Welcome to our first episode recorded at the London Trauma Conference 2024.

In this episode, hosts Iain Beardsell and Natalie May are joined by Matt Hooper from Adelaide to discuss his unique career path, from emergency medicine to pre-hospital and retrieval medicine, intensive care, and more recently, palliative and end-of-life care.

The conversation centres around the principles of end-of-life care, particularly in acute and traumatic scenarios, and how these can be integrated with life-saving efforts. Key points include the challenges of shifting focus from survival to quality of death, the importance of recognizing and supporting witnesses and caregivers, and the concept of 'compassionate resuscitation.'

Practical tools such as the 'pause' are also explored, aiming to humanize highly charged medical environments and potentially prevent burnout and PTSD among healthcare providers.

00:00 Introduction and Guest Welcome

01:00 Key Messages on Death and Palliative Care

02:12 Challenges in End-of-Life Care

03:20 Improving Quality of Death and Relationships

04:32 Emotional Impact on Care Providers

06:41 Navigating End-of-Life Conversations

12:17 Practical Applications in Intensive Care

16:41 The Pause: A Tool for Reflection 21:58 Conclusion and Final Thoughts

The Guest - Matt Hooper

Matt is an accomplished intensive care specialist with a diverse background in emergency medicine, prehospital & retrieval medicine, and palliative care.

Notable for his leadership in developing critical care service models, he founded South Australia’s MedSTAR Emergency Medical Retrieval Service. He has also co-authored a highly regarded case-based text book and held key teaching and examining roles nationally and internationally in prehospital and retrieval medicine.

With a strong focus on high-performance teams working within high acuity, high consequence environments, Matt's expertise has also extended to human factors in healthcare, cardiothoracic intensive care, ECMO, and clinical ultrasound. More recently however, he has pivoted towards palliative and end of life care, pursuing a Master's degree at Cardiff University and consulting at Mary Potter Hospice in Adelaide. He is passionate about exploring new and innovative ways to prevent potentially avoidable suffering and enhance end of life outcomes for patients in acute care clinical environments.

In this episode of the St Emlyn's podcast, Iain Beardsell and Natalie May reflect on their experiences at the London Trauma Conference, a four-day event covering various aspects of trauma and pre-hospital care.

They discuss key takeaways from sessions on cardiac arrest, including talks on perioperative cardiac arrest and the prognostication of cardiac arrest patients.

The episode also delves into wellness in the medical field, featuring insights from senior emergency physician Rod McKenzie and pre-hospital expert Matt Hooper on practical psychosocial care. Additionally, the podcast highlights advancements in trauma care, defibrillation strategies, and the importance of correct pad placement and basic practices.

The episode underscores the holistic approach to patient care and the significance of personal well-being for medical professionals.

00:00 Welcome to the St Emlyn's Podcast

00:52 Highlights from the London Trauma Conference

01:13 Cardiac Arrest Symposium Insights

03:53 Prognostication After Cardiac Arrest

06:44 Defibrillation Strategies and Basics

08:29 Wellness and Mental Health in Emergency Medicine

11:10 Palliative Care in Pre-Hospital Settings

12:32 Trauma Conference Highlights and Innovations

16:48 Poster Presentations and Stand-Up Science 17:58 Key Takeaways and Reflections

18:43 Closing Remarks

In this episode of the St Emlyn's podcast, hosts Iain Beardsell and Liz Crowe are joined by Chris Bishop, a clinical research fellow at the Centre for Trauma Sciences at Queen Mary University of London. Chris discusses his PhD research on veno-arterial ECMO support for cardiogenic shock following major trauma haemorrhage and explains the principles and applications of ECMO, particularly in trauma patients. The conversation covers the current practices, challenges, and future directions in the use of ECMO for trauma care, including multidisciplinary decision-making, patient selection criteria, and pioneering techniques like selective aortic arch perfusion and emergency preservation and resuscitation.

00:00 Introduction

01:12 Understanding ECMO and Its Applications

02:20 ECMO in Trauma Patients

04:17 Challenges and Resistance in ECMO Adoption

05:36 Current Research and Practices

11:31 Future Directions in Trauma Resuscitation

13:28 Conclusion

Welcome to the St Emlyn's Monthly Podcast, your go-to source for the latest insights, developments, and discussions in emergency medicine and critical care. Each month, Simon and Iain will bring you in-depth analysis, evidence-based practices, and practical advice to enhance your clinical practice and professional development. 

In this round-up of May 2024, we talk about a wide range of issues relating to emergency medicine, including highlights from the RCEM conference, including the future management of head injury, crowding, RATing and what it takes to be an awesome ED for training. There's also advice on how to be a epic Emergency Physician In Charge, as well as discussion about the use of ChatGPT for medical exams, serratus anterior blocks for rib fractures, whether first pass success matters and the return of measles.

Thank you for joining us, please do like and subscribe wherever you get our podcasts.

After a long, hot and relaxing summer (!) Simon and Iain return with all the content from the St Emlyn's blog in July and August. They discuss four papers in detail, including the ARREST trial about cardiac arrest centres, whether clinical examination can identify life threatening injuries in trauma, the TOP-ART study looking at a novel agent in trauma management and the use of REBOA. 

Please do like and subscribe and get in touch if you would like to contribute to the blog site. 

Our monthly round up of all from the St Emlyn's blog. We discuss pathways into emergency care research, pad positioning in cardioversion of AF and possible gender differences in the presciption of TXA in trauma.

We also chat about travel in Lithuania, memories of defibrillating with hand held paddles and Simon's recent forst infection with COVID.

We mention a post on Lyme disease which you can read here (especially if you live near the New Forest...)

A bumper edition of the podcast where Iain and Simon discuss TXA (twice), antibiotics in appendicits, VTE, Blood products in trauma, use of ultrasound in cardiac arrest and plasma in traumatic brain injury. Oh, and COVID19 (but not for long)...

An evidence based cornucopia of aural pleasure.

Please like and subscribe (as all podcasters seem to say).

Take care,

Iain

This excellent epsiode of Crackcast covers all you need to know about head injury in the ED.

Iain is back on the podcast with Simon to talk through the best of the blog from January 2020.

This talk focuses on how we can optimise our psychological performance in critical care situations, the type of situations that Simon describes as Time Critical, Information light. The Audio is available below, or watch the full presentation above.

Don't forget to watch the video on the St Emlyn's site http://www.stemlynsblog.org

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St. Emlyn's Podcast: Key Insights from May in Emergency Medicine

As we transition into the warmer months, it's an opportune time to reflect on recent discussions and developments within the field of emergency medicine, particularly those highlighted in the latest episode of the St. Emlyn's podcast. This episode covered a wide range of topics, from workplace safety to advancements in pediatric care and innovative approaches in patient management. Below is a comprehensive summary of the key points discussed.

Workplace Safety: A Pressing Concern

The podcast began with a reflection on a recent violent incident at Newham Emergency Department (ED), which served as a stark reminder of the dangers healthcare professionals face daily. Emergency departments, by their very nature, are open and accessible, making them vulnerable to violent incidents. This recent attack has prompted a nationwide reassessment of safety measures, with many EDs enhancing their protocols to protect staff.

The conversation emphasized that violence in the workplace should never be normalized. It’s crucial that healthcare professionals feel safe and supported in their working environment. Leadership within departments plays a critical role in this, not only by implementing robust safety protocols but also by fostering a culture of solidarity and mutual support among staff. The incident at Newham underscores the need for constant vigilance and proactive measures to ensure the safety of everyone working in emergency medicine.

Leadership in Education: Simon Carley’s New Role

In more positive news, Simon Carley’s recent appointment as the CPD (Continuing Professional Development) lead for the college was discussed. This role is a significant milestone, not just for Simon but also for the integration of modern educational approaches within formal medical education. Simon’s involvement with St. Emlyn's has long been focused on innovative, social media-driven education, and this new role offers an opportunity to bring these methods into a broader educational framework.

The appointment highlights the value of combining traditional education with the dynamic, accessible formats offered by the #FOAMed (Free Open Access Meducation) community. It’s a recognition that medical education can benefit from new perspectives and that the integration of these ideas can enhance the learning experiences for healthcare professionals.

Pediatric Status Epilepticus: Evaluating Second-Line Agents

The discussion moved to a detailed analysis of pediatric status epilepticus, focusing on the findings from two key trials: the Eclipse trial and the ConSEPT trial. These studies compared the efficacy of levetiracetam (Keppra) and phenytoin as second-line agents for stopping seizures in children.

The trials found no significant difference between the two drugs in terms of their effectiveness, which has led to debate within the medical community about whether to switch from phenytoin to levetiracetam. While levetiracetam is perceived as easier to administer and safer, the lack of a clear superiority has left the decision somewhat open. However, the ease of use and safety profile of levetiracetam make it an appealing option, and some institutions are considering making the switch.

For clinicians, the takeaway is that while both drugs are viable options, the choice may ultimately come down to individual preferences and institutional protocols. The trials underscore the importance of continuous evaluation of treatment options, particularly in complex cases like pediatric seizures.

Understanding Clinical Trials: The Importance of Statistical Literacy

Simon Carley also highlighted the importance of understanding the statistical nuances in clinical trials, particularly the difference between demonstrating a difference between treatments and establishing their equivalence. This distinction is crucial for accurately interpreting research findings and making informed clinical decisions.

The discussion emphasized that clinicians must be cautious in how they interpret trial results, particularly when it comes to determining whether treatments are genuinely equivalent or if the lack of a significant difference merely reflects the study’s design. This level of critical appraisal is essential for ensuring that new research is applied correctly in clinical practice.

Prolonged Field Care in the ED: Learning from Military Medicine

Another topic discussed was prolonged field care, a concept borrowed from military medicine that is becoming increasingly relevant in emergency departments due to overcrowding and delays. Rich Carden introduced the HITMAN mnemonic—Hygiene and Hydration, Infection, Tubes, Medication, Analgesia, and Nutrition—as a framework for managing patients who are stuck in the ED for extended periods.

The HITMAN approach ensures that patients' fundamental needs are met even when resources are stretched. This method helps prevent complications and improves patient outcomes, even in less-than-ideal conditions. The approach is particularly relevant in today’s healthcare environment, where EDs are often overwhelmed and patients may wait longer than usual for admission or transfer.

Atrial Fibrillation: Reassessing Cardioversion Strategies

Atrial fibrillation (AF) management was another key topic. A recent study in the New England Journal of Medicine compared immediate cardioversion with a wait-and-see approach in patients with new-onset AF. The study found that a wait-and-see approach was non-inferior to immediate cardioversion, with 69% of patients in the wait-and-see group spontaneously cardioverting within 48 hours.

This finding challenges the traditional approach of immediate cardioversion and suggests that in many cases, a more conservative approach may be just as effective. However, the decision should be made through shared decision-making with the patient, taking into account their preferences and the specific circumstances of their condition. This patient-centered approach ensures that treatment decisions are made collaboratively and with the patient’s best interests in mind.

Traumatic Cardiac Arrest: Reevaluating Chest Compressions

The podcast also touched on the evolving management of traumatic cardiac arrest, particularly the role of chest compressions. Recent studies, including one involving porcine models, suggest that in cases of hypovolemic traumatic cardiac arrest, chest compressions may not be beneficial and could even be harmful. Instead, the focus should be on addressing the underlying cause, such as restoring circulating volume.

This shift in practice highlights the importance of understanding the specific etiology of cardiac arrest and tailoring resuscitation efforts accordingly. Communicating these changes to the entire resuscitation team is crucial, as there may be resistance to deviating from traditional protocols. Ensuring that everyone is on the same page and understands the rationale behind the approach is key to successful implementation.

Virtual Reality in Pain Management: An Emerging Tool

Virtual reality (VR) is emerging as a promising tool in pain management, particularly in pediatric patients undergoing painful procedures. A recent study discussed in the podcast found that children who used VR experienced less distress during procedures compared to those who received standard care.

VR offers an innovative, accessible method for managing pain and anxiety, and its use is likely to expand in the coming years. The ability to create immersive environments that distract patients during procedures has the potential to improve patient experiences and outcomes, not just in children but potentially in adults as well.

The Power of Peer Review: Enhancing Clinical Practice

Finally, Simon Carley discussed the importance of peer review in clinical practice. Peer review is a valuable tool for continuous improvement, allowing clinicians to receive feedback from colleagues on their performance. While it can be challenging to create a culture where feedback is welcomed and constructive, the benefits are significant.

Peer review helps clinicians avoid complacency, stay up-to-date with best practices, and continually refine their skills. It’s a simple, cost-effective way to ensure that healthcare professionals are delivering the highest standard of care. Creating a supportive environment where feedback is seen as an opportunity for growth rather than criticism is essential for the success of peer review initiatives.

Conclusion

The discussions in this month’s St. Emlyn's podcast highlight the complexities and challenges of working in emergency medicine, from ensuring workplace safety to staying current with evolving practices. By engaging with new research, embracing innovative tools like virtual reality, and fostering a culture of continuous improvement through peer review, we can continue to advance the field and improve patient care. As always, the St. Emlyn's blog and podcast remain valuable resources for staying informed and connected with the latest developments in emergency medicine.

The Evolution of Traumatic Cardiac Arrest Management: Military Insights and Civilian Applications

Traumatic cardiac arrest (TCA) is a critical and often fatal condition encountered in both military and civilian emergency medicine. Historically, the prognosis for patients with TCA has been poor, leading many to believe that resuscitation efforts are largely futile. However, recent developments, particularly those arising from military experience, are challenging this perspective. In this post, we explore insights shared by Dr. Jason Smith, a consultant in emergency medicine and a seasoned military doctor, about the evolving understanding of TCA, including the role of chest compressions and the application of military practices in civilian settings.

Traumatic Cardiac Arrest: Insights from Military Experience

TCA is relatively rare in civilian settings, with major trauma centres like Plymouth seeing a case every one to two months. However, in military environments, where high-velocity injuries are more common, TCA occurs more frequently. Dr. Jason Smith’s experience in Afghanistan revealed that traumatic cardiac arrests happened as often as three to four times a week. This stark contrast has driven the development of specific management protocols in military settings, where hemorrhagic shock is the leading cause of TCA.

In these high-intensity environments, the focus is on immediate and aggressive interventions. These protocols, developed on the battlefield, have significantly improved outcomes and are now being adapted for civilian trauma centres, where they continue to challenge the longstanding belief that TCA is nearly always fatal.

From the Battlefield to the Emergency Room: Evolving TCA Management

Over the past decade, the management of TCA has undergone significant evolution, largely influenced by military practices. Dr. Smith’s team in Afghanistan developed a "bundle of care" designed to rapidly and effectively address the key factors leading to TCA. This bundle includes:

1. External Hemorrhage Control involves ensuring that tourniquets are properly applied and functioning, alongside other measures to control external bleeding.
2. Oxygenation and Ventilation: Rapid intubation and ventilation to maintain oxygen delivery to vital organs.
3. Bilateral Thoracostomies: Decompressing the chest on both sides to manage potential tension pneumothorax.
4. Rapid Volume Replacement: Administer warm blood and blood products intravenously or intraosseously to quickly replace lost volume.
5. Pelvic Binding: Applying a pelvic binder in cases of blunt trauma to reduce pelvic volume and control bleeding.
6. Consideration of Thoracotomy: In specific cases, such as penetrating trauma to the chest, thoracotomy is considered as a life-saving intervention.

This structured approach, honed in military contexts, has led to outcomes that are significantly better than those reported in civilian literature at the time. These practices are now being adapted for civilian use, where they are helping to improve survival rates for TCA patients.

Challenging Old Assumptions: New Data on TCA Survival

One of the most significant shifts in the perception of TCA has come from recent data showing that survival rates are not as dismal as previously thought. In military populations from Iraq and Afghanistan, survival rates from TCA have been reported at around 10.6%. Even more compelling is data from the UK’s TARN database, which indicates a 7.5% survival rate for civilian TCA cases, including those caused by blunt trauma.

These figures are comparable to survival rates for non-traumatic cardiac arrest, leading to a reassessment of TCA management. The traditional view that resuscitation in TCA is futile is increasingly being challenged by evidence that with the right interventions, survival is possible.

The Controversy Around Chest Compressions in TCA

One of the most hotly debated topics in TCA management is the role of closed chest compressions. In standard Advanced Life Support (ALS) protocols, chest compressions are a fundamental part of resuscitation. However, in the context of TCA, particularly hemorrhagic TCA, their effectiveness has been called into question.

Dr. Smith’s research has played a pivotal role in this debate. He observed that during resuscitation in Afghanistan, the use of a Belmont rapid infuser often resulted in alarms indicating that chest compressions were creating too much pressure inside the thorax, preventing effective blood transfusion. This led to the hypothesis that chest compressions might be not only ineffective but potentially harmful in hemorrhagic TCA.

To explore this hypothesis, Dr. Smith and his colleagues at DSTL Porton Down developed an animal model using swine to simulate TCA. The study aimed to replicate the conditions seen in hemorrhagic TCA by bleeding the animals to a mean arterial pressure (MAP) of 20 mmHg. The animals were then divided into groups to compare the outcomes of different resuscitation strategies, including chest compressions alone, blood transfusion alone, and combinations of the two.

Key Findings: Prioritizing Blood Over Compressions

The study’s results were revealing. Animals that received blood transfusions without chest compressions had significantly better outcomes than those that received chest compressions alone or in combination with blood transfusion. Specifically, all animals that received only chest compressions were dead by the end of the study, while those that received blood alone showed signs of return of spontaneous circulation (ROSC).

Moreover, when chest compressions were combined with blood transfusion, the results were mixed. While some animals achieved partial ROSC, the overall survival was lower than in the group that received blood alone. This led to the conclusion that in hemorrhagic TCA, chest compressions might be not only unnecessary but potentially detrimental.

These findings, while based on animal models, have significant implications for clinical practice. They suggest that in cases where haemorrhage is the primary cause of TCA, the focus should be on rapid volume replacement with blood and blood products rather than on chest compressions.

Translating Research into Practice

While Dr. Smith’s study provides compelling evidence, applying these findings to human practice requires careful consideration. The study’s limitations, including its reliance on animal models and the specific conditions of hemorrhagic TCA, mean that more research is needed to fully understand how these findings apply to diverse patient populations.

However, the study does provide a strong foundation for re-evaluating current protocols. In situations where haemorrhage is identified as the primary cause of TCA, emergency teams might consider prioritizing volume replacement over chest compressions, especially in environments where rapid blood transfusion is possible.

The challenge, as Dr. Smith noted, lies in training and protocol development. Chest compressions are deeply ingrained in resuscitation practice, and changing this mindset requires robust training and clear guidelines. Emergency departments and trauma centres need to prepare their teams for scenarios where the traditional approach might not be the best one, ensuring that all members are aligned in their approach to TCA management.

Conclusion: A New Paradigm for Traumatic Cardiac Arrest

The management of traumatic cardiac arrest is evolving, driven by insights from military medicine and supported by emerging data from civilian practice. While challenges remain, particularly in shifting entrenched practices around chest compressions, the future of TCA management looks promising. Survival rates once thought to be negligible, are improving as we better understand the mechanisms at play and refine our interventions accordingly.

For emergency medicine practitioners, staying informed about these developments is crucial. As more data becomes available and as we continue to learn from both military and civilian experiences, the protocols for TCA will undoubtedly continue to evolve. The days of viewing traumatic cardiac arrest as a futile scenario are fading. With the right approach, training, and tools, we can offer these patients a fighting chance at survival.

In summary, putting science into the argument has been a game-changer, and continuing to blend evidence with practice will be key to improving outcomes in this challenging area of emergency medicine.

Highlights from March 2019: Key Insights and Updates

Welcome to the St Emlyn's podcast. I'm Simon Carley and today; I'll be taking you through the highlights from our blog in March 2019. This was a busy month filled with exceptional content, insightful trips, and significant conferences. Let's dive into the details and explore some key topics, starting with adult congenital heart disease, top trauma papers, and the importance of responsible volunteering.

Management of Adult Congenital Heart Disease

March kicked off with an important post on the management of adult congenital heart disease (ACHD). This topic is particularly close to my heart as the hospital I work at is a level two centre for ACHD in the UK. Services have become centralized, and surgical components are now managed at a few specialized centres, with Liverpool being the hub for my region.

Despite this centralization, we still encounter a large population of ACHD patients in our area. These patients often present complex medical histories and unique pathologies that can be challenging to manage in emergency settings. The guidance available typically focuses on chronic and surgical management, but emergency care for these patients requires a different approach.

Common Issues in ACHD Patients

ACHD patients commonly present with dysrhythmias, which can be particularly challenging to manage. Chest pain is also prevalent, although the incidence of ischemic heart disease isn’t significantly higher in ACHD patients, except for those who have undergone certain procedures like the switch operation. Other common issues include:

• Cyanotic patients: Those with single ventricle physiology and right-to-left shunts.
• Endocarditis: A rare but serious complication.
• Non-cardiac problems: Managing ACHD patients with conditions like appendicitis or pneumonia can be complex due to their unique circulatory dynamics.

The bottom line is that these patients often require specialized management strategies. When ACHD patients present with cardiac complications, we consult our local cardiologist or the ACHD centre. However, non-cardiac issues in ACHD patients also warrant discussion with the ACHD centre to ensure comprehensive care.

Key Takeaways for Emergency Physicians

Emergency physicians should familiarize themselves with the unique aspects of Fontan circulation, which relies on venous return based on venous pressure. Aggressive interventions like CPAP, bagging, and diuretics can be detrimental. Understanding these nuances is crucial for providing optimal care.

A Deeper Dive into Fontan Circulation

The Fontan procedure, a surgical intervention for single ventricle defects, creates a unique circulatory system that can be difficult to manage in emergency settings. Unlike normal circulation, Fontan physiology depends heavily on passive blood flow from the veins to the lungs. This means that increasing intrathoracic pressure through methods like CPAP or bagging can reduce cardiac output and worsen the patient's condition.

Fontan patients are particularly vulnerable to fluid shifts and pressures, making careful management of intravenous fluids and medications essential. Understanding these dynamics can be life-saving in the ED. For example, while diuretics might seem a reasonable choice for a patient with fluid overload, they can lead to dangerously low preload and cardiac output in a Fontan patient.

Top Trauma Papers from the Trauma UK Conference

Next up, we revisited some of the top trauma papers presented at the Trauma UK conference. These papers covered a range of topics, from the use of bougies in the ED to bag-mask ventilation during hypertensive resuscitation. Here are some key highlights:

The PAMPer Trial

The PAMPer trial examined the use of prehospital plasma in trauma patients and found significant survival benefits. This trial has important implications for trauma care protocols, emphasizing the potential of early plasma administration to improve outcomes.

The trial showed that administering plasma before hospital arrival can reduce mortality rates in severely injured patients. This finding supports the concept of damage control resuscitation, aiming to stabilize patients early and prevent coagulopathy, acidosis, and hypothermia—the lethal triad in trauma.

Bougie Use in the ED

Another focal point was the utility of bougies in emergency airway management. Evidence suggests that bougies can significantly improve first-pass success rates in difficult intubations, making them a valuable tool in the ED.

A study highlighted at the conference demonstrated that the use of a bougie, even in routine intubations, could increase the success rates for first-pass intubations. This is particularly important in prehospital settings and emergency departments where difficult airways are common.

Late Presenting Head Injury Patients

A paper from Hull explored the management of patients presenting with head injuries more than 24 hours post-injury. The findings indicated that these patients have a significant incidence of important findings on CT scans, suggesting that delayed presentations should not be underestimated.

This study challenges the conventional exclusion of late-presenting head injury patients from acute imaging protocols. It suggests that significant injuries can still be present and warrant immediate attention, even if the patient presents days after the initial trauma.

The Zero Point Survey

The Zero Point Survey, which emphasizes situational awareness, team dynamics, and environmental control before initiating the primary survey, was also highlighted. This approach can significantly enhance resuscitation efforts, ensuring a more organized and effective response.

The Zero Point Survey encourages clinicians to prepare mentally and physically before patient contact. By assessing the situation, assembling the right team, and ensuring the environment is conducive to optimal care, clinicians can improve outcomes and reduce errors in high-stress scenarios.

Responsible Volunteering Overseas

One of the most thought-provoking posts of the month came from Stefan Brisions, discussing the need for responsible volunteering overseas. Volunteering in low and middle-income countries can be incredibly rewarding, but it’s essential to approach it with the right mindset and framework.

The Ethics of Volunteering

Stefan emphasized the importance of volunteering within a system that has sustainability and benefits for all parties involved. There have been concerns about individuals volunteering for personal gain rather than genuine altruism. It’s crucial to ensure that our efforts are focused on creating lasting, positive impacts.

Volunteering should always aim to build local capacity rather than create dependency. This means working with local healthcare providers to enhance their skills and infrastructure, ensuring that the benefits of volunteering continue long after volunteers have left.

Volunteering Responsibly

If you're considering volunteering abroad, it’s vital to engage with established organizations that have a clear mission and ethical framework. This ensures that your contributions are meaningful and aligned with the needs of the local community. Our discussions with experts like Shweta Gidwani, Hooling Harrison, Jennifer Hulls, and Najee Rahman offer valuable insights into this complex issue.

Case Study: Volunteering in South Africa

Kat Evans, who works in Mitchell’s Plain in South Africa, shared her experiences at St Emlyn’s Live. Kat discussed the challenges of working in a resource-limited environment, particularly in managing trauma and toxicology cases.

Her insights into managing trauma in a high-volume, low-resource setting were eye-opening. Kat also shared fascinating details about the use of high doses of atropine for poisoning cases, highlighting the unique medical practices required in such environments.

Kat’s presentation underscored the value of structured volunteer programs that integrate volunteers into local healthcare systems, providing both valuable learning experiences and much-needed support to local healthcare providers.

The Future of SMACC: CODA

March also marked the end of an era with the final SMACC conference in Sydney. SMACC has been a cornerstone for many in the emergency and critical care communities, offering unparalleled opportunities for learning and networking. However, the spirit of SMACC lives on in its successor, CODA.

CODA: A New Beginning

CODA aims to build on SMACC's successes while addressing broader health issues such as vaccination, climate change, and healthcare inequality. The goal is to leverage the engaged community SMACC created to drive meaningful change on a global scale.

CODA plans to tackle these global health issues by bringing together a diverse group of professionals, including those outside the traditional medical fields. This interdisciplinary approach aims to create innovative solutions to some of the world’s most pressing health challenges.

Looking Ahead

While we bid farewell to SMACC, we look forward to the new opportunities CODA will bring. Its emphasis on tackling significant health challenges aligns with the evolving needs of the global healthcare community, promising an exciting future.

What to Expect from CODA

CODA will continue the tradition of high-quality content and dynamic presentations that SMACC was known for. However, it will also incorporate new elements focused on global health advocacy and interdisciplinary collaboration. Expect to see more discussions on how healthcare professionals can contribute to solving broader societal issues.

Additional Highlights from March

Critical Appraisal Nuggets (CANS) on P-values

We also introduced a mini podcast series called Critical Appraisal Nuggets (CANS) focusing on p-values, featuring myself and Rick Body. P-values are a common topic in exams and critical appraisal, and understanding them is crucial for interpreting medical research.

This less-than-ten-minute podcast provides a concise overview of p-values, helping clinicians and students alike grasp this important concept. By demystifying p-values, we aim to enhance our audience's critical appraisal skills, enabling better evidence-based practice.

Dual Coding in Medical Education

Nick Smith, a recent addition to the St Emlyn's team and a brilliant clinical educator, shared insights on dual coding. Dual coding involves using both verbal and visual information to enhance learning and retention.

Nick’s post emphasized how our brains struggle to process multiple streams of information simultaneously. Effective teaching and communication require a balance between verbal explanations and visual aids, ensuring that learners can absorb and retain information without being overwhelmed.

The Impact of Reboa in Trauma Care

Zaf Qasim, a great friend of ours over in the US, examined the impact of Resuscitative Endovascular Balloon Occlusion of the Aorta (Reboa) in trauma care. This post, based on a paper published in JAMA Surgery, analyzed Reboa success rates in civilian trauma using a US database.

The findings suggested that Reboa was associated with higher mortality rates compared to similar patients who did not receive Reboa. This raises important questions about patient selection and the overall benefits of Reboa in trauma care.

Zaf’s post highlighted the need for ongoing research and evidence to determine Reboa's true value. While there are compelling pathophysiological arguments for its use, the clinical outcomes must be scrutinized to ensure it is applied appropriately and effectively.

The Role of Evidence-Based Practice

At St Emlyn's, we prioritize evidence-based practice in all aspects of emergency medicine. The discussions around Reboa, p-values, and dual coding all reinforce the importance of using high-quality evidence to guide clinical decisions and educational strategies.

Final Thoughts

March 2019 was a month of incredible learning and growth. From managing complex ACHD patients to discussing the ethics of volunteering and exploring cutting-edge trauma research, we covered a wide range of topics that are crucial for emergency medicine professionals.

Stay Connected

As we move forward, we encourage you to stay connected with St Emlyn’s for more insights, updates, and discussions. Follow our blog, participate in our events, and join the conversation on social media. Together, we can continue to advance the field of emergency medicine and make a difference in the lives of our patients.

Thank you for joining us this month. Enjoy your practice, and we’ll be back with more great content in April. Have fun, stay safe, and keep learning!

Last year we were honoured to bring Kat Evans to Manchester to talk at the #stemlynsLIVE conference. We've covered emergency medicine in South Africa before on the blog, but there is no substitute to hearing about it from someone who actually works there.

Five strategies to improve your resuscitations.

1. Zero point survey

2. Peer review

3. 10 in 10

4. Hot debriefs

5. Fly the patient

You can read about these strategies, watch the video and learn about the background on the St Emlyn's blog here https://www.stemlynsblog.org/stemlynslive-five-free-strategies-to-improve-your-resuscitation-practice-st-emlyns/ 

Understanding Devastating Brain Injury: Key Insights and Guidelines

In a recent episode of the St Emlyn's podcast, Simon Carley hosted experts Dan Harvey and Mark Wilson to discuss the intricacies of managing devastating brain injury (DBI). The conversation covered new guidelines, the challenges in prognostication, ethical considerations, and practical approaches in clinical settings. This blog post provides a comprehensive summary of their insights, focusing on the importance of standardized care, ethical decision-making, and the role of family involvement.

Defining Devastating Brain Injury

Devastating brain injury encompasses severe brain damage that often leads to significant long-term impairment or death. These injuries can result from various causes, including trauma, subarachnoid hemorrhage, hypoxic brain injury, and intracerebral hematomas. The term "devastating" highlights the severity of these injuries, but as discussed, the perception of devastation can vary, complicating management and prognostication.

The Challenge of Prognostication

One of the core issues in managing DBI is the variability in clinical practice across different healthcare settings. This inconsistency can lead to different outcomes depending on where the patient is treated. Dan Harvey emphasized that the new guidelines aim to standardize care, providing a consistent approach regardless of location. The guidelines recommend an observation period of up to 72 hours to gather comprehensive clinical data, crucial for making informed decisions.

Mark Wilson highlighted the difficulty in early prognostication, noting that initial presentations can be misleading. Factors such as intoxication, medication effects, or pre-existing conditions can obscure the true extent of brain injury. The term "perceived devastating brain injury" underscores the subjective nature of these assessments, stressing that what appears catastrophic on imaging may not always align with clinical outcomes.

The Role of Radiology and Clinical Assessment

Radiological findings, while essential, must be interpreted alongside clinical assessments. A severe CT scan may not always correlate with poor clinical outcomes, and vice versa. The discussion stressed the importance of not rushing to judgment based solely on initial imaging or clinical presentation. Recent studies, including those by Hanni Marcus and Mark Wilson, have shown that some patients with poor prognostic indicators can recover better than expected, particularly those with extra-axial hematomas.

Ethical Considerations and Family Involvement

Ethical considerations are paramount in managing DBI. The definition of a "good recovery" can vary widely among patients and families. For example, elderly patients with significant impairments may still value life, even with extensive care needs. The guidelines emphasize the importance of involving families in discussions about prognosis and treatment, ensuring decisions align with the patient's values and preferences.

Understanding the patient's and family's perspectives is crucial in determining the appropriate course of action. This holistic approach ensures that care decisions are not only medically sound but also ethically and personally appropriate. The discussion also highlighted the need for clear communication, helping families navigate complex and emotionally charged situations.

The Importance of Time and Observation

The guidelines advocate for a period of observation to avoid hasty decisions based on incomplete information. This period, typically up to 72 hours, allows for the identification and management of reversible factors, collection of comprehensive medical history, and better communication with the family. The aim is to reduce the risk of prematurely withdrawing life-sustaining treatment.

Practical Decision-Making

Determining the level of care for DBI patients involves deciding whether to transfer them to neurocritical care units or manage them in general ICUs. While specialized care offers advanced interventions like intracranial pressure (ICP) monitoring, evidence does not conclusively show that these measures always improve outcomes. The discussion acknowledged the limitations of resources and the importance of considering logistical factors, such as proximity to the patient's family.

The guidelines encourage clinicians to make informed decisions based on available evidence and specific case circumstances. They stress that not all DBI patients require transfer to specialized centers, especially when prognosis remains uncertain. The focus should be on providing essential life-saving therapies and monitoring the patient's condition.

Transitioning to Palliative Care

When recovery is deemed unlikely, transitioning to palliative care becomes a compassionate and appropriate choice. The guidelines stress the importance of clear communication with the family, ensuring they understand the prognosis and rationale behind limiting or withdrawing aggressive treatment. Palliative care focuses on symptom management, comfort, and supporting the patient and family, addressing not only physical but also emotional and psychological needs.

Organ Donation Considerations

Organ donation is an important consideration for DBI patients when the prognosis is poor. The guidelines recommend discussing this option with the family as part of end-of-life care planning. These discussions should be handled sensitively, providing clear information and respecting the family's wishes. Organ donation can provide hope and purpose in the face of tragedy, potentially saving other lives.

Conclusion and Key Takeaways

The St Emlyn's podcast episode on devastating brain injury provides crucial insights into the complexities of managing this challenging condition. The newly published guidelines offer a structured approach, emphasizing comprehensive assessment, ethical considerations, and family involvement.

Key Takeaways:

1. Standardize Practice: Reduce variability in DBI management by adhering to standardized guidelines, ensuring consistent and high-quality care.

2. Comprehensive Assessment: Utilize both clinical and radiological assessments to inform prognosis. Avoid premature conclusions based on incomplete data.

3. Ethical and Family Considerations: Engage with families to align treatment decisions with the patient's values and wishes. Provide clear, compassionate communication throughout the process.

4. Observation Period: Allow an appropriate observation period to clarify the patient's condition and potential for recovery.

5. Palliative Care: Transition to palliative care when necessary, prioritizing patient comfort and dignity.

6. Organ Donation: Discuss organ donation as part of end-of-life planning, handling these conversations with care and respect.

By following these guidelines, healthcare professionals can navigate the complexities of managing DBI with greater confidence and compassion, ultimately improving patient outcomes and supporting families through challenging times. For more detailed information and resources, visit the St Emlyn's blog and stay updated with the latest in emergency and critical care.

In this episode of the St Emlyn's podcast, Ian Beardsell and Simon Carley review the top 10 trauma papers of the year, highlighting key findings and their implications for trauma care. The selection includes significant studies published in high-profile journals such as The Lancet and the New England Journal of Medicine, offering valuable insights for healthcare professionals in emergency and trauma medicine.

1. Whole Body CT Scanning: REACT-2 Study

The REACT-2 study explored the impact of whole-body CT (WBCT) scanning on trauma patients, particularly its effect on mortality rates. The study involved 1400 patients and found no significant difference in mortality between those who received WBCT and those who underwent more selective CT scanning. The difference in radiation exposure was minimal, suggesting that WBCT's comprehensive imaging might be more beneficial than harmful, especially in elderly patients where missed injuries can complicate outcomes. This study reassures trauma team leaders that current scanning practices are appropriate and highlights the importance of a patient-centred approach based on clinical presentation.

2. Impact Brain Apnea (IBA)

Impact brain apnea, characterized by apnea and a catecholamine surge following a severe head blow, has been increasingly recognized in trauma care. The paper, co-authored by John Hines and Mark Wilson, provides a detailed explanation of IBA's pathophysiological mechanisms. This condition can lead to cardiac arrest if not promptly addressed, emphasizing the need for immediate intervention in cases of traumatic brain injury (TBI). Understanding IBA helps emergency care providers identify and treat potentially life-threatening conditions that may not be immediately apparent.

3. Decompressive Craniectomy for Raised ICP: RESCUE-ICP Trial

The RESCUE-ICP trial examined the outcomes of decompressive craniectomy in patients with refractory intracranial pressure (ICP) due to severe TBI. The study found that while the procedure increased survival rates, many survivors experienced significant disability. This raises ethical considerations about the quality of life post-intervention. The trial underscores the importance of informed consent and discussions about potential outcomes with patients' families, aligning treatment with patient values.

4. STITCH Trial: Surgery Timing for Intracranial Bleeds

The STITCH trial focused on the timing of surgical intervention in patients with traumatic intracranial bleeds. Although the trial faced recruitment challenges and was terminated early, results suggested better outcomes with early surgery. This finding, while not statistically conclusive, supports the notion that timely intervention can reduce mortality and improve recovery. Emergency physicians and neurosurgeons should consider these findings when deciding on surgical timing in TBI cases.

5. Traumatic Cardiac Arrest: Epidemiology and Outcomes

Using data from the Trauma Audit and Research Network (TARN), this study examined traumatic cardiac arrest (TCA) cases, revealing a 30-day survival rate of 7.5%. This rate, similar to medical cardiac arrests, challenges the perception that TCA is almost always fatal. The study highlights the importance of aggressive resuscitation efforts and underscores the need for ongoing training to retain skills in managing these rare but critical events.

6. Open vs. Closed Chest Compressions in TCA

The effectiveness of open chest (thoracotomy) versus closed chest compressions in TCA was explored, with findings indicating similar outcomes in terms of end-tidal CO2 levels, a marker for effective CPR. This challenges the notion that thoracotomy should always be performed in TCA cases. The study suggests that standard advanced life support (ALS) protocols may suffice in certain scenarios, especially where thoracotomy is not practical.

7. Rocuronium vs. Succinylcholine for RSI in Severe Brain Injury

The choice between rocuronium and succinylcholine for rapid sequence intubation (RSI) in severe brain injury remains debated. An observational study found no significant overall difference in mortality between the two drugs, though succinylcholine was associated with higher mortality in severe head injury cases. This suggests a possible preference for rocuronium in such scenarios, though the evidence is not strong enough to mandate a change in practice.

8. Intraosseous Needle Length in Obese Patients

As obesity becomes more prevalent, appropriate intraosseous (IO) needle length is crucial for effective vascular access. The study recommended using longer yellow IO needles for patients with a BMI over 43, as standard blue needles may not reach the marrow. This is particularly important in emergency situations where IV access is difficult, ensuring proper drug administration and preventing complications like compartment syndrome.

9. Optimal Site for Needle Decompression in Tension Pneumothorax

A systematic review recommended the anterior axillary line as the preferred site for needle decompression in tension pneumothorax, aligning with standard chest drain placement. The review also noted significant complication rates associated with needle decompression, suggesting that alternative methods like thoracostomy may be necessary in certain cases. This finding emphasizes the need for precise technique and careful consideration in managing tension pneumothorax.

10. Weekend Effect in Major Trauma Care

The study examined the "weekend effect" in major trauma care, finding no significant difference in mortality between weekend and weekday admissions. This suggests that well-resourced, consultant-led trauma care can provide consistent outcomes regardless of the day. The findings advocate for the 24/7 availability of senior emergency physicians and trauma teams, ensuring high-quality care at all times.

Conclusion

This year's top trauma papers provide valuable insights into current practices and emerging trends in trauma care. While there may not have been groundbreaking changes, the studies reinforce the importance of evidence-based decision-making, ongoing training, and ethical considerations in patient management. As the field evolves, staying informed about the latest research is crucial for improving patient outcomes and delivering high-quality trauma care. For further details and access to the studies, visit the Sentemlin site and related FOAMed resources.

Navigating Major Trauma in South Africa: An Unforgettable Experience

Introduction

Simon Cowie and Robert Lloyd bring a special episode from Cape Town, South Africa, at the International Conference of Emergency Medicine (ICEM). The focus is on Robert's profound experiences working in South Africa’s emergency departments, particularly dealing with major trauma in challenging environments like Khayelitsha Hospital. This blog post recounts Robert's transformative journey, offering insights into managing severe trauma cases and coping with intense psychological stress.

Experiencing Major Trauma in South Africa

Robert’s elective stint in South Africa aimed to deepen his expertise in major trauma, a specialty for which the country is well-known due to its high rates of violence-related injuries. He worked in New Somerset Hospital in the city and Khayelitsha Hospital in the township, where he faced a staggering volume of trauma cases, especially during "payday weekends"—a time marked by increased violence and accidents due to heightened alcohol consumption.

On his first night shift, Robert encountered an overwhelming number of severe cases, including 32 stab wounds to the chest, seven to the neck, and eight fatalities, six of whom were minors. This immediate immersion into high-stakes trauma care was a stark contrast to his previous experience in Australia and underscored the unique challenges faced by healthcare professionals in South Africa.

The Reality of Community Assaults

A particularly harrowing aspect of Robert’s experience was dealing with the aftermath of community assaults, where residents, in the absence of adequate police presence, took justice into their own hands. This vigilante justice often resulted in severe injuries, adding to the already heavy burden on emergency departments. Patients frequently presented with blunt trauma and crush injuries, showcasing the harsh realities of community-based violence and the critical need for comprehensive emergency care services.

Psychological Impact and Stress Management

The sheer volume and severity of cases led Robert to experience an acute stress reaction, referred to as "Condition Black," a term popularized by Dave Grossman in "On Combat." This state represents a high level of stress-induced impairment, where cognitive and physical functions degrade. Robert felt overwhelmed, his heart racing, hearing muffled, and hands shaking—making even simple medical procedures challenging. This response highlighted the necessity of managing psychological stress to maintain effective performance in high-pressure situations.

Strategies for Overcoming Psychological Barriers

To cope with the intense stress and improve his performance, Robert employed several strategies: overlearning essential skills, engaging in mental rehearsal, and fostering relentless positivity.

1. Overlearning Essential Skills: This involved practicing critical procedures like fast scanning and intercostal drain insertion until they became automatic. He also mastered surgical hand tying, crucial in the resource-limited setting of Khayelitsha Hospital, where suture instruments were often unavailable. This preparation ensured he could perform these tasks effectively, even under stress.

2. Mental Rehearsal: Robert used this technique to visualize and mentally practice the steps of critical procedures, such as rapid sequence intubation (RSI) for severe head injuries. This repeated mental walkthrough helped reduce anxiety and built confidence, making the actual procedures feel familiar and more manageable.

3. Relentless Positivity: Drawing from his experience as a competitive tennis player, Robert cultivated a positive mindset by replacing negative thoughts with positive affirmations. This approach helped him maintain focus and confidence, essential for handling the unpredictable and high-pressure nature of emergency medicine.

The Importance of Stress Inoculation Training

Robert’s experience underscored the value of stress inoculation training (SIT) in medical education. SIT involves gradually exposing individuals to stress in a controlled environment, helping them build resilience and improve their ability to handle high-pressure situations. This training is particularly beneficial for medical professionals, preparing them to remain calm and make sound decisions under stress. Incorporating SIT into medical simulations provides a safe yet realistic training ground for emergency scenarios, enhancing preparedness and performance.

Conclusion

Robert’s journey through South Africa’s emergency medicine landscape was a profound learning experience, highlighting the importance of comprehensive preparation in handling severe trauma cases. His strategies for managing psychological stress—overlearning, mental rehearsal, and maintaining positivity—proved invaluable. These methods not only improved his technical skills but also built the mental resilience needed to thrive in high-pressure environments.

The experience also highlighted the critical need for training programs like SIT to better prepare medical professionals for the realities of emergency medicine. Whether working in high-trauma settings like South Africa or less extreme environments, the lessons learned from managing stress and psychological preparedness are universally applicable.

Call to Action

For further insights into emergency medicine, visit Robert’s blog, Pondering EM, and follow him on Twitter @ponderingem. For those interested in exploring stress management in high-pressure situations, "On Combat" by Dave Grossman is a highly recommended read. Thank you for joining us on the St. Emlyns Podcast. Please subscribe and leave us a review to help us continue bringing valuable content to the medical community.

Ross Fisher, consultant paediatric surgeon and lead for TARNlet joins Simon Carley at the London Trauma Conference to discuss the challenges in managing paediatric trauma in the UK.

Iain Beardsell joins Tim Coats, chair of the UK Trauma Audit Network, to discuss the role of trauma units within major trauma networks.

Simon and Ross Fisher from Sheffield discuss the emerging role of paediatric surgeons in trauma. This podcast was recorded at the London Trauma Conference (so sorry for a bit of background noise at times).

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Greetings from the London Trauma Conference!

As has become our pre-Christmas custom, Iain and I have been hanging out at the fabulous London Trauma Conference, hearing about advances and controversies in trauma care and tracking down some of the speakers to find out exactly what they really think (and recording it, for podcasts we'll release in due course).

The conference extends over four days, incorporating the Air Ambulance and Prehospital Day and the Cardiac Arrest Symposium; unfortunately we can't stick around for those but our colleagues over at the RCEM FOAM network will be podcasting from those days too, so keep an eye on their site and podcast feed too.

We are truly honored to listen and learn from Dr Youri Yordanov from Paris. Youri was the senior emergency physician on duty on the 13/11/15 during the brutal and terrifying terrorist attacks in Paris. Here he joins St.Emlyn's to discuss how they managed a mass casualty incident with lessons for us all.

There is no doubt that without the skills, preparation and response of Youri, his ED team, the wider hospital and the emergency service in general the death rate would have been much worse.

Thanks Youri for your wisdom and reflections.

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A first podcast with Simon Laing from the RCEMFOAMed team. We look back at influential trauma related papers from 2014-2015.

Iain interviews the wonderful Tim Draycott on the management of the Obstetric patient with trauma.Tim is a consultant Obstetrician from Bristol and is a great speaker on this rather terrifying topic!

A short podcast updating the UK Advanced Paediatric Life Support (APLS) course guidelines for the management of trauma in children.

Don't forget to read the blog post here. APLS Updates: New kids on the block,

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Understanding Impact Brain Apnea: A Revolutionary Insight into Trauma Care

Today, we delve into a fascinating and crucial topic in trauma care: impact brain apnoea. We recently had the privilege of attending the London Trauma Conference and caught up with Dr. Gareth Davis, a leading figure in trauma care and pre-hospital emergency medicine in the UK. Dr. Davis shared his insights into impact brain apnoea, a phenomenon that, while not widely recognized, has significant implications for patient outcomes.

The Unseen Danger: What is Impact Brain Apnoea?

Impact brain apnoea refers to a sudden cessation of breathing due to a blow to the head. This phenomenon, although not commonly discussed, has been a subject of intrigue for trauma professionals for many years. Dr. Davis explained that this condition occurs when an impact to the brain stem interrupts normal breathing, potentially leading to severe consequences if not promptly addressed.

This condition's significance lies in its subtlety and the challenges it poses in pre-hospital care. Many trauma incidents involve high-impact forces, such as car accidents, where a patient may suffer head injuries. Understanding the mechanics behind impact brain apnea can be the key to differentiating between minor and severe trauma cases, potentially saving lives.

The Historical Context and Research Challenges

The concept of impact brain apnoea isn't new, but it has been challenging to prove and widely accept due to a lack of concrete evidence. Gareth emphasized that the inconsistency in patient outcomes—where one individual might suffer severe consequences while another escapes with minor injuries—sparked curiosity among trauma specialists. Over time, through a combination of clinical observations and literature reviews, the medical community has started to piece together a more comprehensive understanding of this condition.

A significant barrier in researching impact brain apnoea is the timing of medical intervention. Most pre-hospital care teams arrive at the scene minutes after an incident, often too late to observe the initial apnea phase. This delay makes it challenging to gather real-time data, leaving a gap in understanding the immediate physiological responses post-trauma.

Physiological Mechanisms: The Dual Threat

Dr. Davis highlighted two critical physiological responses following a head injury that contributes to the complexity of treating impact brain apnea: the immediate cessation of breathing and a subsequent catecholamine surge.

1. Apnea and Hypoxia: The primary response is an apnea caused by the impact on the medulla oblongata, the brain's breathing control centre. This apnea leads to hypoxia (low oxygen levels) and hypercarbia (increased carbon dioxide levels), which can quickly deteriorate the patient's condition.

2. Catecholamine Surge: Following the initial apnea, the body releases a significant amount of catecholamines—hormones like adrenaline—that flood the system. This response, while a natural reaction to stress, can be detrimental, especially when the heart is already struggling due to hypoxia. The combination of these factors can lead to traumatic cardiac arrest, a situation where the heart fails due to trauma-induced physiological stress rather than direct injury.

Understanding these mechanisms is crucial for emergency responders. Recognizing the signs of impact brain apnea and addressing them promptly can be the difference between life and death.

The Clinical Conundrum: Diagnosing and Treating Impact Brain Apnea

One of the most challenging aspects of dealing with impact brain apnea is the clinical presentation. Patients may not exhibit obvious signs of severe trauma, such as external bleeding or visible injuries, making it difficult to diagnose based solely on physical examination. Gareth discussed the importance of thorough history-taking and observing indirect signs—akin to observing the "echo" of a particle, like in the Higgs boson analogy.

The lack of direct evidence means clinicians often rely on a combination of observational data, patient history, and situational awareness. For example, if a patient presents with persistent hypotension without a clear source of bleeding, clinicians might consider central shock—a term used to describe shock due to central nervous system dysfunction rather than volume loss.

The Role of Public Education and Pre-Hospital Care

Gareth emphasized the crucial role of public education and pre-hospital care in managing impact brain apnoea. The public's ability to provide immediate aid, such as opening an airway and administering ventilatory support, can significantly affect outcomes. He pointed out that while there is a global trend to focus on chest compressions in cases of cardiac arrest, for patients with traumatic injuries, addressing airway and breathing is paramount.

In London, initiatives like the GoodSAM app are helping bridge the gap by connecting trained responders with emergencies in real-time. This app allows people with medical training to provide critical first aid before professional services arrive, potentially mitigating the effects of impact brain apnea by ensuring the patient's airway is open and they are breathing adequately.

Navigating the Future: Research and Education

The conversation with Dr. Davis also highlighted the future directions for research and education. The medical community needs to invest more in understanding and validating the concept of impact brain apnea. This investment includes funding for clinical studies and fostering an environment where healthcare professionals can share their observations and experiences.

Podcasts, blogs, and medical conferences are valuable platforms for disseminating information about new medical phenomena like impact brain apnea. Dr. Davis encouraged medical professionals to remain curious, continue their education, and be open to emerging concepts that may not yet have robust evidence but have practical significance in clinical settings.

Key Takeaways and Clinical Pearls

1. Recognition and Belief: Clinicians need to recognize and believe in the concept of impact brain apnea. Even if direct evidence is scarce, understanding the physiological mechanisms and potential clinical presentations can guide effective treatment.

2. Focus on Airway and Breathing: In cases of traumatic injury, especially with suspected head trauma, the immediate focus should be on ensuring the airway is clear and the patient is breathing. This intervention can prevent the cascade of negative physiological responses that lead to traumatic cardiac arrest.

3. Role of Bystanders and First Responders: Public education and the involvement of trained responders are critical. Tools like the GoodSAM app can play a significant role in ensuring timely intervention.

4. Continuous Learning and Adaptation: The medical field must remain adaptive, incorporating new research findings and adjusting treatment protocols as more is understood about conditions like impact brain apnea.

Conclusion

Impact brain apnoea is a critical yet under-recognized phenomenon in trauma care. Through continued research, education, and public awareness, we can improve patient outcomes and provide better care in pre-hospital and clinical settings. 

London Trauma Conference Day 2: Comprehensive Summary

Welcome back to the St. Emlyn’s blog. I'm Iain Beardsell, joined by Natalie May, here to recap the second day of the London Trauma Conference at the Royal Geographical Society in Kensington. The day was filled with insightful talks and valuable teaching points, which we’re eager to share with you.

Elderly Trauma: Addressing Under-Triage

The day began with Marius Reigns focusing on the challenges of elderly trauma. Reigns highlighted the growing number of elderly patients in emergency departments and the critical issue of under-triage. Studies indicate that almost 50% of elderly trauma cases are under-triaged, compared to about 20% in younger patients. This leads to missed opportunities to reduce morbidity and mortality. Reigns emphasized the need to recognize the unique factors in elderly trauma, including multiple medical conditions, medication use, and systemic disadvantages in trauma management.

Pediatric Trauma: A Unique Approach

Ross Fischer, a favorite at St. Emlyn’s, delivered an outstanding presentation on pediatric trauma. He stressed the importance of not managing pediatric trauma with the same principles as adult trauma. Children have different injury mechanisms and often require different management strategies. For example, splenic injuries in children are less likely to need surgical intervention compared to adults. Fischer called for more research in pediatric trauma, emphasizing the rarity of these cases and the need for collaborative efforts to determine best practices. He also highlighted the importance of simulation in maintaining skills, noting that emergency physicians might only see one or two cases of pediatric trauma annually.

Obstetric Trauma: Critical Four-Minute Window

Tim Draikot followed with a humorous yet insightful talk on obstetric trauma. He reiterated the critical four-minute window for resuscitation in traumatic maternal cardiac arrest, after which a paramortum C-section should be performed. Draikot emphasized that this procedure is vital for the survival of both mother and child. He stressed the importance of this cognitive protocol—looking at the clock and acting decisively. Draikot’s engaging style made this crucial message resonate, reminding us that swift action can save lives.

Coaching Principles in Emergency Medicine

Tom Evans, a pre-hospital physician and rowing coach, shared fascinating insights on applying coaching principles to emergency medicine. He discussed the importance of clear mental models, focused teamwork, and having a defined endpoint. Evans drew parallels between coaching an elite athlete and managing a trauma team, emphasizing the need to strive for excellence. He posed the thought-provoking question: "What is our Olympics?" Evans’ talk encouraged us to find our own goals and work towards giving 100% in our practice.

The Future of ATLS: Evolving Beyond the Basics

Matt Walsh challenged the current status of Advanced Trauma Life Support (ATLS) in his talk. He argued that ATLS should now be considered a basic rather than an advanced course. Walsh proposed the idea of creating local trauma courses tailored to specific systems and teams, incorporating the latest evidence from conferences and social media. This approach aims to improve patient care by adapting training to local needs and continuously updating it with current best practices.

Afternoon Highlights: Forensic Pathology and Quick Hits

The afternoon session featured the Peter Baskett Memorial Lecture by forensic pathologist Stephen Lead-Beater. Lead-Beater provided a unique perspective on trauma through post-mortem examinations, offering insights that can inform and improve clinical practice. His lecture was both enjoyable and enlightening, adding a valuable dimension to the conference.

In the quick hits session, several key points were discussed:

• Cooling in Isolated Head Injuries: Currently, there's insufficient evidence to support this practice, but further research is anticipated.
• Calcium in Shocked Trauma Patients: It's advisable to consider calcium administration in hypovolemic patients, particularly those with calcium levels below 0.9 mmol/L. For massive transfusion protocols, administering 10 ml of 10% calcium chloride for every four units of blood is recommended.
• IO Access: While intraosseous (IO) access remains a vital option, especially for rapid sequence intubation (RSI), it's not the ultimate solution. The debate continues on whether IO can effectively deliver blood due to potential hemolysis issues.
• FAST Scanning: The role of FAST (Focused Assessment with Sonography for Trauma) scanning in stable patients is diminishing. Operator dependence and declining performance outside research centers are concerns. However, ultrasound's evolving role in assessing general shock remains significant.
• Social Media in Trauma Care: Connor Deasy highlighted the importance of social media in trauma care, with St. Emlyn’s receiving notable mentions for its contributions.

Conclusion and Looking Ahead

The second day of the London Trauma Conference has been immensely rewarding, offering a wealth of knowledge and practical insights. From the challenges of elderly and pediatric trauma to the critical timelines in obstetric emergencies, the talks have reinforced the need for continuous learning and adaptation in emergency medicine.

As we look forward to day three, focusing on air ambulance work and pre-hospital care, we hope you’ve found these recaps useful. Follow the discussions on Twitter for real-time updates and join us again tomorrow for more highlights.

Thank you for reading, and stay tuned for our next update from the London Trauma Conference. Take care and keep striving for excellence in your practice.

London Trauma Conference 2024: Day One Highlights

Welcome to the St Emlyn's blog! I'm Iain Beardsell, and I'm Natalie May. We’re excited to share insights from the London Trauma Conference 2024, held in the glamorous heart of Kensington, London. This year’s conference has brought together national and international experts, offering a wealth of knowledge on trauma care. Here, we’ll take you through some of the key highlights from day one, hoping to give you a feel for the event and perhaps persuade you to join us for the remaining days.

Karen Bray’s Dynamic Talk on Trauma Dissection

One of the standout sessions was Karen Bray's talk on trauma dissection. Her dynamic presentation, complemented by stunning slides, provided numerous take-home messages. For those following us on Twitter, you might have seen some key points and visuals already.

Karen’s discussion was particularly poignant given the recent tragic events in Australia involving Phil Hughes. Her ability to weave current events into her presentation added a layer of immediacy and relevance. We’ll delve deeper into her insights in a separate podcast, but suffice it to say, her talk was both enlightening and thought-provoking.

Pediatric Trauma and Research Challenges

Ian McConaughey addressed the perennial issue of pediatric trauma, emphasizing the inconsistencies in pre-hospital assessments. He pointed out the challenges due to the lower incidence of pediatric trauma compared to adults, which hampers research efforts. Ross Fisher from Sheffield built on this, discussing potential pathways to overcome these barriers in pediatric trauma research.

In line with these discussions, Ian Bailey from Southampton raised critical points about the evolution of trauma surgery in the UK. He highlighted the need to attract young doctors to general and trauma surgery, questioning why this isn’t currently a structured career path. His candid approach to addressing these “elephants in the room” was refreshing and necessary for future improvements in trauma care.

The Helmet Debate: To Mandate or Not?

One of the liveliest sessions featured a debate between Mark Wilson and Karim Brohi on the use of cycling helmets. This debate sparked significant discussion on Twitter. The crux of the debate was whether making helmets mandatory would reduce cycling participation and thereby negate the overall health benefits. Ultimately, Karim won with the argument that helmets should remain a choice rather than a mandate, but the conversation is far from over.

Impact Brain Apnea: A New Mechanism

We also had a compelling discussion with Gareth Davies on impact brain apnea—a newly recognized mechanism where a head injury can temporarily stop breathing. This simple yet critical understanding could reshape how we manage head trauma in the initial stages. Stay tuned for an upcoming podcast where we’ll explore this topic further.

Chris Moran on the Future of Trauma Care

Professor Chris Moran, a leading figure in trauma care in England, provided an insightful talk on the progress of major trauma centers over recent years. He also addressed the contentious issue of whether the focus should shift from in-hospital care to pre-hospital phases or rehabilitation. Surprisingly, he advocated for greater emphasis on rehabilitation, sparking a gut reaction among many attendees. However, upon reflection, the audience began to see the merit in his argument. Rehabilitation, though less glamorous than pre-hospital interventions, plays a crucial role in patient recovery and long-term outcomes.

Practical Insights on Chest Trauma and Rib Fractures

Doug West, a cardiothoracic surgeon from Bristol, delivered a practical talk on chest trauma, particularly the management of rib fractures. He highlighted the disparity in practices across centers, with some performing rib fixation regularly and others not at all. This variation underscores the need for standardized protocols and further research.

Tim Moll on Trauma in Motorsport

Tim Moll gave an entertaining and informative presentation on trauma in motorsport, a field with a historically high injury rate. He focused on the unique challenges of managing injuries in this sport, emphasizing the importance of understanding the specialized gear and protocols involved. This talk was enhanced by the presence of John Hinds, a veteran motorsport doctor, who added his invaluable perspective.

The Complex Relationship Between Shock and Blood Pressure

Tim Harris’s session on shock was another highlight. He challenged the traditional view that blood pressure is a direct surrogate for shock, emphasizing instead that shock is defined by inadequate oxygen delivery to tissues. This nuanced understanding is critical for trauma team leaders in managing hypotensive patients more effectively.

Looking Ahead: Day Two at the London Trauma Conference

As we wrap up day one, we’re looking forward to another full day of insightful sessions. Tomorrow’s program includes talks focused on patients requiring special consideration—such as the elderly, pediatric trauma cases, and trauma during pregnancy. These sessions promise to provide valuable knowledge for tailoring trauma care to these vulnerable populations.

Additionally, there will be master classes and breakaway sessions on remote critical care and core topics in trauma, as well as a full day dedicated to motorsport medicine. If you’re in the area, it’s not too late to join us. Turn up at the door, and you might find a space available.

Engage with Us

We’re the slightly tired but enthusiastic team running around Kensington, usually attached to our mobile phones or computers. If you see us, please say hello! We’d love to meet our listeners and readers. If you have any questions for the speakers, reach out to us, and we’ll try to include them in a special follow-up podcast.

From the beautiful, Christmassy setting of Kensington, the St Emlyn’s team at the London Trauma Conference wishes you a good evening. We’ll be back with more updates tomorrow. Thank you for listening and following along.

Exciting Collaboration Between St Emlyns and the London Trauma Conference

Welcome to the latest St Emlyns podcast! I'm Iain Beardsell, and alongside Natalie Mace, we are thrilled to announce an exciting new collaboration between the St Emlyns team and the London Trauma Conference. This esteemed conference will take place in London next week, and we've been honored with the opportunity to attend as members of the press. We will be interviewing some of the prominent speakers participating in the event, marking a significant first for our team at St Emlyns.

The London Trauma Conference: Dates and Highlights

The London Trauma Conference is scheduled from Tuesday, December 9th to Thursday, December 11th. This three-day event promises a stellar lineup of speakers from the Trauma World, including sessions on Trauma Surgery, Trauma Nursing, and a dedicated day for trainees. There’s even a special Thoracotomy day planned. This comprehensive program ensures there’s something for everyone in the field of trauma care.

Why Attend the London Trauma Conference?

We are not just attending to listen; our goal is to bring you the inside stories and insights from the speakers after their sessions. We aim to ask the questions you want answers to, making this conference more interactive and engaging for all of us. Whether you are a seasoned professional or a trainee, this conference offers invaluable knowledge and networking opportunities.

If you’re considering attending, we highly encourage it. You can find all the details and register at www.londontraumaconference.com. There are still places available, so don’t miss out on this exceptional event.

Engaging with the Conference Online

For those who can't make it to London, there are still plenty of ways to stay involved. Follow along on Twitter using the hashtag #ltc2014. We will be tweeting live updates from the sessions, and you can tweet your questions to us. We’ll do our best to catch up with the speakers and get your questions answered.

Getting Ready for Trauma Week

To get in the mood for the upcoming trauma week, we recommend listening to "The Fight for Life," a program by Kevin Fong on BBC Radio 4. This enlightening show traces the origins of trauma care and brings it up to the modern day. Kevin speaks with James K. Steiner, the American orthopedic surgeon who designed the ATLS course after his family was involved in a tragic air accident. The program is both moving and inspiring, highlighting the importance of coordinated trauma care.

Meet the Speakers: Friends of St Emlyns

We are excited to reconnect with many friends of St Emlyns at the conference. Among the notable speakers are Mark Wilson, a renowned neurosurgeon from London, and Karen Brodie, a respected vascular and trauma surgeon. Ross Fisher, a pediatric surgeon from Sheffield, will be discussing pediatric trauma. Additionally, our colleagues from Sydney Hems, including Cliff Reed and Brian Burns, will also be presenting. The lineup reads like a who's who of UK and international trauma medicine, ensuring a wealth of knowledge and experience will be shared.

Our Mission at St Emlyns

At St Emlyns, we are dedicated to spreading trauma care education as widely as possible. None of our team members have any financial interest in the conference; our goal is purely educational. We hope to learn and share valuable insights with you, our community, to enhance our collective understanding and capabilities in trauma care.

Welcoming New Doctors to Emergency Medicine

This week is particularly special as it marks the arrival of new doctors in our emergency departments across the UK. This transition happens four or five times a year, bringing fresh faces, enthusiasm, and, understandably, a bit of nervousness. We urge everyone to extend kindness and support to these junior doctors. Our emergency departments thrive on a culture of learning and collaboration, and it’s essential to make our new colleagues feel welcome and valued.

If you are one of these new doctors, make sure to check out our induction blog posts and podcasts. They are available on the St Emlyns blog at stemlynsblog.org and on our iTunes podcast feed. These resources are designed to help you navigate the initial challenges and embrace the exciting journey ahead in emergency medicine.

The Importance of Continued Learning in Emergency Medicine

As we see from the current news, it’s a challenging time for UK emergency medicine. However, at St Emlyns, we are committed to bringing you the best resources, insights, and inspiration to help you continue delivering exceptional care to your patients. Our collaboration with the London Trauma Conference is just one example of our efforts to enhance the education and support available to all healthcare professionals in our community.

Conclusion

We are incredibly excited about this new venture and look forward to sharing our experiences and learnings from the London Trauma Conference with you. Whether you join us in person or follow along online, we hope this event will be as enlightening and inspiring for you as it promises to be for us.

Thank you for being a part of the St Emlyns community. Please continue enjoying your work in emergency medicine, and we’ll be back with more updates and insights very soon. Take care and thanks for listening!