The St.Emlyn’s virtual hospital podcast

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August 7, 2014  

Understanding Troponin Part 2. St.Emlyn’s

Recently we published part one of our series on cardiac troponins.  If you haven't checked it out yet, you can find it here.    In the second part, we're going to take a look at high sensitivity troponins and some of the more advanced areas around understanding cardiac troponin and its use in practice.  We'll give you a quick run down on the troponin lingo - the language you need to be able to speak in order to fully understand how to use high sensitivity troponin in your practice, including terms like the limit of blank, limit of detection, co-efficient of variation and 99th percentile.

We'll also ask whether Joe Lex had a point when he stirred up controversy around these assays with this legendary tweet:

So, check out the associated BLOG POST here and listen to the podcast. There is more on diagnostics and troponin to come very soon.


Hope you enjoy! Please keep the feedback, questions and comments coming. As always, we'd love to hear from you.

Rick

DOI: Much of my research work involves HsT. To help with this I have received reagents from companies who make HsT assays, but I not received any other financial benefit or gifts in kind as part of my work and have no financial ties to any companies.

August 6, 2014  

Exeter CEM conference with Adam Reuben

Adam Reuben is a super chap. A rugby playing, friendly, engaging, hard working, researching, teaching emergency physician from Exeter in the lovely county of Devon.
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In addition to being generally awesome he is also the convener of this year's College of Emergency Medicine conference in Exeter from the 9th to the 11th of September 2014. There is still time to come and the program looks really good and features some fantastic presenters.

#AWESOME ALERT - CLIFF REID WILL BE THERE - YOU HAVE TO BE TOO!!!!

I'll be there with many others from St.Emlyn's so if you see me say hi.

You can see the program here

vb

S

July 27, 2014  

Understanding Troponin Part 1. St.Emlyn’s

Do you remember when it took three days to 'rule in' or 'rule out' an acute myocardial infarction (AMI)?  When I was a medical student doing my first clinical attachments, I remember doing ward rounds on the CCU seeing patients with suspected AMI.  The way they were managed is a million miles from what we do now.  Back then, patients would have serial ECGs and then be admitted for cardiac enzyme evaluation over the course of the next 3 days.  We'd measure CK, AST and LDH.  'CK' was the so-called 'early marker', which would rise early after the start of an AMI.  Today we use CK as a marker of skeletal muscle damage (e.g. rhabdomyolysis).  AST and LDH (today we think of these as liver function tests, I know) were the 'late markers' - and by late I really mean late - we might see a rise on days 2 and 3.

Could you imagine for a second, in today's world, ruling out AMI because their CK and LFTs were normal?  It's completely unthinkable.  That's how much cardiac troponin has changed our practice.  We rely on it so completely to diagnose AMI.  And yet, it's one of the most misunderstood tests in medicine.  Given how much we use it, I guess we feel that we all should know lots about this test.  But doctors still have so many questions.  Here are just a few:

  • What is cardiac troponin?
  • Why is it a marker of AMI?
  • What else causes a raised troponin and how?
  • Should we be doing troponins at 3 hours, 6 hours, 12 hours?  What's the difference and what's the evidence?
  • What is a 'delta troponin'?
  • What do you need to 'rule in' AMI?
  • How do you use cardiac troponin in patients with renal failure?

This is just a brief list.  With the research I do in this area and my experience developing protocols/guidelines, people get in touch to ask questions like this quite a lot.  There are loads of questions that people ask - but there are lots of themes in common.  We thought it was about time we produced a handy run down in the true spirit of #FOAMed.

Take a listen to Part 1 of our troponin podcast.  While Simon and Iain have been prolifically churning out spectacular stuff for some time now, this is my debut on the St. Emlyn's podcast.  I really enjoyed talking about troponin with Iain - and I hope we covered some useful stuff.

We'll cover more in part 2, when we'll move on to discussing high sensitivity troponins, what they are, how to use them and how to speak the troponin lingo.  Please get in touch if there's anything we haven't covered that you'd like us to, or if there's anything you'd like us to elaborate on some more!

Rick

July 21, 2014  

Induction to EM. Staying safe in your first job. St.Emlyn’s

If you're starting out in EM then it can be a scary time. Iain and Simon talk through some of the initial anxieties and ask what you need to know to be safe, sensible and super.

Remember our top ten tips...
  1. Respect those around you and value their opinion
  2. The History is everything
  3. There are 4 key treatments we give in the ED – think whether every patient you see needs any of these and you will save lives and relieve pain
    1. Oxygen
    2. Fluids
    3. Analgesia
    4. Antibiotics
  4. Think ‘What difference have I made to this patient?’. Always try to make a difference, however small (it may “just” be getting them an extra blanket)
  5. No patient (almost) wants to be in the ED. They really don’t. It wasn’t what they planned for their day.
  6. Spend twice as long with patients you don’t like or don’t get on with.
  7. Look the part. Be smart. Behave in the way you would expect anyone to behave towards you.
  8. Be on time. Always. Ansd leave on time if at all possible.
  9. Take your breaks – eat when you can and drink water when you can’t.
  10. Enjoy yourself…
 
July 17, 2014  

Archery in the ED. What can we do about targets? St.Emlyn’s

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It is a little known fact that to be successful as an emergency physician in the UK it is vital to take a three month rotation in Archery. Archery is a key skill for us all dating back to Medieval times when we introduced the longbow into warfare. This devastating tool could cause panic in opposing forces, scattering them into many wide and ineffective directions. In short they were an effective tool to cause and disruption inthe opposition ranks whilst the noble English armies of old strode forward with their visions of the future. Soldiers trained using targets to hone their skills and to focus on the aim - meeting the target.

Of course these days we do not have real bows and arrows in the emergency department, but archery remains alive and well. In the modern NHS we still train our troops in archery, or at least in the principle aim of archery - to meet the target.

With our long history of target setting and target hitting it is therefore no suprise that we are world leaders in standards/targets/indicators....., whichever term you prefer in fact and it has to be said that a target culture in the NHS has been criticised widely, even being blamed for the exodus of trainees to Southern climes, but there is arguably more to it than that.

In last weeks episode we touched on new targets around trauma care in the UK and that raised many questions and opened a debate on twitter. This week we want to take those thoughts further and ask what we, as the archiest of arch archers across the entire NHS can do with these externally set targets.

What we forgot to say in the podcast is the absolute need to work alongside a short stay admissions unit under the ED umbrella. Without that you would really struggle to deliver safe and efficient care. We both work in units with short stay admission units that allow us to deliver safe diagnostic and therapeutic interventions to our patients.

So, with some trepidation Iain and I ask whether all targets are a bad thing....

vb

S

July 8, 2014  

Trauma Team Leadership - the 30min CT target. St.Emlyn’s

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Iain and Simon discuss the challenges of getting our trauma patients to the CT scanner within 30 minutes of arrival.

The 30 minute target is a UK standard, and we did not set it! All UK trauma centres are judged against the target and (rightly or wrongly) it has become a real issue for many centres.

We would be really be interested in what our International colleagues think about the target and the resultant strategies outlined by the team. There's more on this at the St.Emlyn's website.

As always, we'd love to hear your comments.

vb

S

June 29, 2014  

Delving into the Number Needed To Treat, RRR and ARR. Why we love natural frequencies. St.Emlyn’s

Iain and Simon chat about how we can start to translate research findings in to natural frequency summaries that help clinicians and patients alike understand the value of therapeutic interventions.

The NNT site we mention is just fantastic. Visit them here http://www.thennt.com/
Great revision page here by the amazing LITFL crew http://lifeinthefastlane.com/education/ccc/risk-and-numbers-needed-to-treat/

The NNT for tranexamic acid is 67 not 50.

S

June 26, 2014  

SMACC Back-Back on What to believe and when to change.

spockkirk.jpegHopefully you will have already seen and listened to my SMACC talk on 'What to believe and when to change'. If not then please whizz over to the site now and have a listen. I really enjoyed exploring the uncertainties that exist around when we decide to adopt or abandon therapies.

My belief is that it's really difficult to define the perfect moment and that it's only in retrospect that we can define it.

Since appearing on the ICN network and St.Emlyn's, Scott Weingart, one of the best and most innovative clinicians I know has come back and argued for early adoption. You can check out his rationale on his site and see what you think.

I actually agree with many of the things he tells us, although he has confined himself to one side of the argument. In terms of a defence of early adoption he makes a good case, but like all debates there needs to be another side to the story, so sit back and listen to why we must reflect hard on the decisions we make in deciding what we do, why we do it, and most importantly when.

vb

S

June 22, 2014  

Understanding diagnostics 3. Why prevalence helps us stay in practice. St.Emlyn’s

Iain and Simon tackle the effect of prevalence on diagnostic performance. Mrs Trellis of North Wales makes a return appearance to discuss the delicate issues of sensitivity and Rick Body joins us by mail to raise concerns about the difficulties of missing patients with myocardial disease.

Listen and enjoy, visit the blog site and keep in touch.

Don't forget to subscribe to the podcast via iTunes, to subscribe to the blog site and to like us on facebook.

vb

S

June 10, 2014  

Understanding diagnostics 1. SNout SpIn and Probability. St.Emlyn’s

A podcast discussing sensitivity and specificity of diagnostic tests and how we can use this in our everyday medical care of patients. 

This article from the Centre for Evidence Based Medicine is also useful. 

June 4, 2014  

SMACC Chicago. St.Emlyn’s

The St.Emlyn's choirmaster has asked Iain and Simon to deliver a sermon on the importance of attending the SMACC Chicago conference in May 2015. After their pilgrimages to Australia in 2013 and 2014 they came back enthused and at times rather annoying about how jolly marvellous it all was. 

We felt that it was important for them to share their thoughts and to ask if anyone wishes to join them on their planned trip to the Northern Americas next year. AS Choirmaster at St.Emlyn's I have reluctantly decided to give them some air time.
I have the honour to be, as always, your most dutiful servants.
Yours etc.
The St.Emlyn's Choirmaster
May 25, 2014  

Marginal Gains in the ED. St.Emlyn’s

A short podcast on the reasons why it's the little things that matter. Sure, we all love the latest shiny kit, but that's not what always matters and it's not how to move a system to excellence. In this short podcast we talk about why it's good to sweat the small stuff.

See the related blog post here.

http://stemlynsblog.org/ed-need-matt-parker-st-emlyns/

April 21, 2014  
April 21, 2014  

Balanced sedation in the ED

A short version from the blog post on balanced sedation on the St.Emlyn's blog. Link here http://stemlynsblog.org/2012/10/balanced-sedation-in-the-ed-st-emlyns/

 

In summary, if you are going to be good at procedural sedation you need to evaluate the needs of the patient assess their needs and then select the appropriate drugs to tailor their effects to what the patient requires.

Remember

  1. Analgesia
  2. Sedation
  3. Anxiolysis
  4. Amnesia
October 27, 2012  

Sample Size: The basics

This podcast links to the blog post on the main St.Emlyn's website. It's a bit old now but hopefully will help you grasp the basics of sample size calculation. It should be very helpful to anyone considering the critical appraisal component of the FCEM exam.

vb

S

July 17, 2012  

Ring removal trick

Visit http://stemlynsblog.org/the-undertakers-ring-method/ for more information.

This is the undertakers trick. If you have arrived here then don't forget to visit the StEmlyns blog as well for more posts on EM topics.

2 caveats about this....I say that I've never cut a ring off. Sort of true as others have done it for me in two circumstances. 1. If there is a deep wound to the finger distal to the ring this is not a great method 2. If the ring did not come off before the injury due to bony (i.e. fixed) enlargement distally then clearly this won't work. However, if they were able to get the ring off that morning, and now they cannot because of soft tissue swelling, and they can tolerate the discomfort of the procedure then this is a great technique.

Check out the better explanation here http://stemlynsblog.org/the-undertakers-ring-method/

And obviously, this is best done by someone who knows what they are doing, and you try it at your own risk.

vb

S

November 3, 2011  

Statistics 2

More on basic interpretation of statistics for the critical appraiser. No maths, no formulas, no hard calculations. Just the tools to make the interpretation of results easier.

This week we look at relative risk (RR), absolute risk reduction (ARR) and number needed to treat (NNT). Are they different or the same?

You'll find that NNT is much more useful for the reader, things like relative risk have their place for statisticians and researchers who are seeking to understand their data. However, for clinicians and readers we would be better served by expressing data as NNT (or NNH).

S

November 3, 2011  

Statistics 1

This is not a stats lecture!

What I want to get across is that with very little knowledge you can have a really good go at interpreting the stats in the papers you read. No calculators, no maths, no hard sums, just an appreciation of whether it looks as though the authors did the right sort of thing.

In this podcast we look at different types of data, what p-values are and how do we define confidence intervals.

October 27, 2011  

Study design: Diagnostic tests

A short podcast on the basics of diagnostic test design. Hope you like it.

You may find these links useful.

http://www.stard-statement.org/

http://emj.bmj.com/content/22/3/180.abstract

http://www.cebm.net/index.aspx?o=1025

S