We start with the RSI trial — ketamine versus etomidate. A study that generated a lot of noise, and perhaps more certainty than it deserved.

We move through trauma team leadership. Not as a checklist, but as a set of decisions made under pressure — when to call a Code Red, how to structure a handover, and what it means to lead a team that hasn’t worked together before.

There’s a discussion about trauma units. Not the big centres. The places where most patients go. Fewer resources. Different pressures. The same expectations.

We talk about spinal cord injury and blood pressure targets. Numbers are useful. But they’re still just numbers.

And then corridor care. Not a new problem. But one we may have started to accept in ways that should make us uneasy.

We discuss:

• What the RSI trial actually showed — and what it didn’t • Why secondary outcomes should make you pause, not pivot practice • How and when to activate a massive haemorrhage protocol • Why early senior decision-making matters more than perfect diagnosis • What good trauma handover looks like — and why it often doesn’t happen • How trauma teams function differently in trauma units • The limits of blood pressure targets in spinal cord injury • Why corridor care is not just operational — but ethical

This is not a guideline episode. It’s a conversation about practice. About judgement. About the small decisions that shape outcomes long before the data catches up.

If you’re listening after a shift, you’ll recognise most of it.

If podcasts are part of how you learn, you can log your listening, reflect, and build CPD through MedPod Learn. It works across podcasts, not just this one.

As always, thanks for listening.

these ideas are tested in practice.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.

In this episode, recorded at Trauma 2030 at the Royal College of Surgeons, I sit down with one of St Emlyn's own, Rich Carden — former emergency physician, now intensive care trainee and PhD graduate in trauma sciences — to explore what shock actually means beyond the blood pressure reading.

We discuss:

• Why shock is fundamentally about oxygen delivery and utilisation at a cellular level • The difference between pressure and perfusion • The concept of the “dose” of shock — magnitude and duration • Why haemorrhage may only be the first phase • How trauma patients transition between haemorrhagic, inflammatory, vasoplegic and septic states • The glycocalyx — and why losing it matters • The risks of early vasopressors in an empty system • Why doing the basics exceptionally well remains our best intervention

This is not a protocol episode. It’s a physiology conversation. A systems conversation. A reminder that restoring a number is not the same as restoring oxygen to mitochondria.

If you’re interested in pre-hospital and trauma systems thinking, do take a look at Tactical Trauma — spaces where these ideas are tested in practice.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.

Trauma 2030

TRAUMA 2030 united experts and innovators to shape the future of trauma care. Over two days, it explored breakthroughs in science, systems, and frontline practice, fostering collaboration across disciplines. The symposium aimed to inspire research, inform policy, and build a bold roadmap for trauma care worldwide.

As always, thanks for listening.

In this episode, we talk to Sheldon Cheskes about the evolving science of cardiac arrest, with a focus on refractory and recurrent ventricular fibrillation. We explore the evidence behind double sequential external defibrillation (DSED), how it compares to standard defibrillation, and what the DOSE VF trial has changed in practice.

This is not just about adding another shock. It’s about understanding why defibrillation fails, how vector and energy delivery matter, and when a different approach might improve outcomes.

We also discuss:

• The difference between refractory and recurrent VF — and why it matters

• What DSED and vector change actually do in physiological terms

• Why guidelines have been slow to move despite emerging evidence

• The role of antiarrhythmics, adrenaline, and sequence of care

• Practical considerations for introducing DSED into real systems

• What comes next — from smarter detection to post-arrest recovery

This is a conversation grounded in real-world resuscitation. It challenges current practice without overselling the evidence.

• Refractory VF (persistent after multiple shocks) and recurrent VF (returns after ROSC) are distinct clinical problems with different implications

• Double sequential external defibrillation (DSED) may improve outcomes in refractory VF by altering current pathways and myocardial depolarisation

• Timing matters — waiting too long to escalate may reduce the chance of success

• Current guidelines remain cautious, reflecting the balance between evidence and implementation risk

• Defibrillation strategy is only one part of a complex system that includes high-quality CPR, drug therapy, and post-resuscitation care

Cardiac arrest survival remains low.

Small improvements in early resuscitation can have large system-wide effects. Understanding when standard care is failing — and what to do next — is where expertise matters.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection.

The app is free to download, includes a one-month free trial, and offers globally adjusted pricing. If you are already listening, you may as well make it count.

But it isn’t really about any single topic - It’s about where emergency medicine is heading. And whether we are ready for it.

This is our November and December 2025 round-up, and revisits the blog posts from the end of last year. A pause. A reset. A chance to look again at ideas that still matter on shift.

We explore

• The Medical Education Training Review and what it might mean for emergency medicine in the UK
• Flexibility, bottlenecks, and the portfolio route
• Why culture and team matter more than workload alone
• Trauma Team Leader tips — from missed wounds to managing presence in the room
• Ondansetron in paediatric gastroenteritis — symptom control or over-medicalisation?
• The SNAP protocol for paracetamol overdose in children
• How long it can take for good data to become everyday practice
• AI in the consultation room — and what happens when patients arrive with ChatGPT

What this means for trainers, medical schools, and the future of clinical judgement

This episode closes Season 12 of the St Emlyn’s podcast. Season 13 is coming — including London 2030 content and more from recent conferences.

Upcoming events

Tactical Trauma returns 2–4 November in Sundsvall, Sweden. It remains one of the most focused and practical trauma meetings in Europe — small faculty, serious discussion, no fluff. If you are interested in pre-hospital and in-hospital trauma care, it is worth your time.

IncrEMentuM is approaching fast, with limited places remaining. If you’ve heard us talk about it before, you’ll know why people come back.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection.

The app is free to download, includes a one-month free trial, and offers globally adjusted pricing. If you are already listening, you may as well make it count.

More conversations from recent meetings — including Trauma 2030 — will follow in upcoming episodes.

Thanks for listening

Recorded at Trauma 2030 at the Royal College of Surgeons, this episode explores a shift in mindset in pre-hospital trauma care — away from maximal intervention on scene and towards rapid recognition of the patient who cannot be fixed pre-hospital.

I’m joined by Harriet Tucker — consultant at London’s Air Ambulance, HEMS Governance Lead at Air Ambulance Kent Surrey Sussex, and Trauma Team Leader at St George’s Major Trauma Centre — to talk about damage control pre-hospital care.

We discuss:

• Using time as a treatment

• Recognising non-compressible haemorrhage

• Why one line may be enough

• Moving interventions into the ambulance

• Changing the pre-alert

• The “pit stop” resus

• Taking patients straight to theatre

• Cultural resistance to doing less

• Governance, debrief, and looking after teams

This approach focuses on a small but critically unwell group of patients — often penetrating trauma with rapidly exsanguinating haemorrhage — where the only definitive treatment is surgical control of bleeding.

The key intervention is speed.

Harriet also discusses the governance work behind this change, the importance of reviewing every case, and how to bring ambulance services and in-hospital teams along with the shift in thinking.

This episode is part of a series recorded at Trauma 2030. More conversations from the meeting will follow in upcoming episodes. 

Upcoming events

Harriet will be speaking at Tactical Trauma, 2–4 November, Sundsvall, Sweden.

IncrEMentuM is now only eight weeks away, with limited tickets remaining.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.

Trauma 2030

TRAUMA 2030 united experts and innovators to shape the future of trauma care. Over two days, it explored breakthroughs in science, systems, and frontline practice, fostering collaboration across disciplines. The symposium aimed to inspire research, inform policy, and build a bold roadmap for trauma care worldwide.

This is a conversation about Helicopter Emergency Medical Services (HEMS) — but not in the way you might expect.

It’s not really about aircraft. It’s about people.

Nigel talks us through the long, often uncomfortable journey to building Air Ambulance Northern Ireland. From early fundraising attempts in the 2000s, through the influence and legacy of Dr John Hinds, to the eventual partnership between charity and the statutory ambulance service that made a doctor–paramedic HEMS model possible.

We explore:

• Why the helicopter isn’t the intervention — the team is • The charity–NHS partnership model in Northern Ireland • Geography, rurality, and the realities of serving 1.9 million people • Dispatch challenges and the use of video triage (including the GoodSAM platform) • Cross-border working with the National Ambulance Service of Ireland • The cultural work required to convince colleagues that HEMS is not a “Cinderella service” • Humility, leadership, and the people who quietly build systems

We also reflect on John Hinds's legacy and how his passion catalysed change, including the significance of the Delta 7 callsign.

This is a thoughtful conversation about system design, pre-hospital care, and what it actually takes to introduce enhanced critical care capability into a region that has never had it before.

If you enjoy thinking about pre-hospital medicine, trauma systems, and the future of emergency care, you may also want to look at: the IncrEMentuM Conference and Tactical Trauma

And if you want to go deeper into the evidence behind the conversations we have on this podcast, explore MedPod Learn — now hosting nearly 5,000 medical podcast episodes with linked multiple-choice questions to support structured learning.

As always, thanks for listening.

This is a calm, evidence-led discussion of a rare, high-stakes intervention that most clinicians will encounter once, if at all — and still need to get right.

• Why the term resuscitative hysterotomy has replaced perimortem caesarean section

• The physiological rationale: relieving aortocaval compression to improve maternal resuscitation

• What the evidence actually shows about timing, maternal survival, and neonatal outcomes

• Findings from Caroline’s systematic review of out-of-hospital cardiac arrest in pregnancy

• Why the “4–5 minute rule” does not reflect real-world pre-hospital care

• Neonatal survival at far longer timelines than traditionally taught

• Practical decision-making in pre-hospital and emergency department settings

• Who should perform the procedure, and why speed matters more than seniority

• Aftercare challenges: open abdomen, placenta management, bleeding (or lack of it)

• Team cognitive load, role allocation, and when termination at scene is appropriate

• The emotional and professional impact on clinicians and families

• Maternal survival after out-of-hospital arrest is rare, but not zero

• Neonatal survival is higher than often appreciated, even with prolonged timelines

• Delaying purely to reach hospital or a specialist may reduce benefit

• The hardest part is not the incision — it is the decision, coordination, and aftermath

• Training should focus as much on judgement and communication as on technical skill

This episode is not about heroics. It is about realism, evidence, and being prepared for one of the most confronting moments in emergency care.

MedPod Learn is a medical podcast player designed to help turn listening into structured learning, with tools to support reflection, CPD, and appraisal.

Available on the App Store and Google Play.

IncrEMentuM was born to revolutionise how we approach emergency medicine. It’s not a traditional conference — it’s an immersive experience that pushes professionals to act, think, and make decisions in real time.

Our mission is to bring together healthcare providers, experts, and emergency personnel from around the world to share experiences, train in realistic scenarios, and test their skills under extreme pressure.

In 2026, we return with an even more intense and lifelike edition — all with one clear goal: to prepare you for what cannot be predicted.

This is an international conference covering various aspects of working in high-stakes environments, primarily related to pre-hospital trauma and critical care, with a tactical twist.

Our program is rich and diverse, featuring state-of-the-art lectures from world-class speakers. We aim to bring together all organisations working with pre-hospital trauma in tactical/hostile environments, including physicians, HEMS, EMS, police anti-terror units, military, fire and rescue services and more.

The discussion moves across trauma, analgesia, cardiac arrest physiology, emergency department systems, and antimicrobial stewardship—less about novelty, more about what actually holds up on shift.

The episode opens with a discussion of the FIRST-2 trial, examining fibrinogen concentrate and prothrombin complex concentrate versus fresh frozen plasma in severe traumatic haemorrhage. Despite promising physiological theory, the trial shows no meaningful reduction in blood product use compared with standard care, reinforcing the ongoing role of FFP in early trauma resuscitation.

The team explore the SUPERB trial comparing supraclavicular brachial plexus blocks with Bier’s blocks for upper limb reductions. Both techniques provide excellent analgesia. The conversation reflects on changing practice, procedural sedation pressures, ultrasound access, and how physical space—not evidence—often dictates what we do.

Three recent cardiac arrest papers are reviewed, focusing on physiological markers rather than new devices:

• End-tidal CO₂ as a CPR quality target

• Ventilation strategies during arrest, including chest-compression-synchronised ventilation

• Cerebral oximetry as a potential prognostic signal

These are not definitive answers, but they point towards cardiac arrest management that is more physiological and less ritualistic.

A reflective discussion on “designer repair” challenges the idea that emergency departments need constant transformation. Instead, the focus shifts to recognising and supporting the clinicians quietly holding fragile systems together every day—and why fixing small, broken things often matters more than grand redesigns.

The episode closes with a critical look at broad-spectrum antibiotic use in suspected sepsis. Observational data suggest significant overtreatment and real harm, reinforcing the need to pause, think, and choose the right antibiotic—not just the fastest one.

This episode is a reminder that good emergency medicine is rarely about silver bullets. It’s about judgement, physiology, and paying attention to what actually works in the real world.

MedPod Learn is a medical podcast player designed to help turn listening into structured learning, with tools to support reflection, CPD, and appraisal. Available on the App Store and Google Play.

Short, practical, and deliberately focused, these are the moments that make you stop and think: “That’s useful — I want that in my head.”

There’s minimal commentary and no deep dives. Each clip stands on its own as a clear takeaway, designed to be listened to in one go or dipped back into when needed.

• Practical triage language that lowers thresholds and prompts earlier action

• Time-critical decision-making in pre-hospital thoracotomy

• Resuscitation physiology and why diastolic pressure matters

• Intraosseous access and the reality of long-term complications

• Analgesia strategies for rib fractures, including posterior injuries

• Hydrofluoric acid burns and why improvised treatment is a trap

• Recognising and acting on decompression illness

• Cognitive HALOs and preparing for rare, high-load decision moments

• Building excellence in teams, not just avoiding failure

• Compassionate resuscitation and the value of the pause

This episode is designed to be saved, revisited, and shared — the kind of learning that pays off later.

Clips in this episode are taken from the following full St Emlyn’s episodes:

• Episode 257 — Ten Second Triage with Sean Brayford-Harris

• Episode 270 — Insights on Cannabis Edibles, Pre-Hospital Thoracotomy and more

• Episode 266 — Monthly Round Up (February 2025): Skills Fade and Resuscitation Targets

• Episode 260 — Monthly Round Up (December 2024): IO Access and Chest Trauma

• Episode 268 — Top Papers of 2024 from The Big Sick Conference

• Episode 275 — Targeted Resuscitation and Hydrofluoric Acid Burns

• Episode 263 — Hyperbaric Medicine with Jeff Kerrie

• Episode 277 — Cognitive HALOs and Advanced Simulation Training

• Episode 264 — High Performance Teams with Dan Dworkis

• Episode 258 — Compassionate Resuscitation with Matt Hooper

All full episodes are available in the podcast feed.

MedPod Learn is a medical podcast player designed to help turn listening into structured learning, with tools to support reflection, CPD, and appraisal. Available on the App Store and Google Play.

This final episode in the Best Bits of 2025 series is the “file it away” collection: rare, high-stakes situations where preparation is largely cognitive, decisions are time-critical, and there may be no second chance.

The clips in this episode are drawn from full St Emlyn’s episodes released during 2025 and focus on recognition, decision-making, and human factors in uncommon but consequential scenarios.

• How community response and live video have changed what happens before patients reach hospital

• Recognising and acting on decompression illness, even when presentations are subtle

• Cognitive HALOs — what happens to our thinking in rare, high-acuity situations

• Junctional haemorrhage and the role of the abdominal aortic junctional tourniquet

• Human decision-making under extreme pressure, illustrated through aviation medicine

This episode is designed to be listened to slowly, and returned to when needed — the kind of learning that pays off long after you first hear it.

Clips in this episode are taken from the following full St Emlyn’s episodes:

• Episode 262 — GoodSAM Update with Mark Wilson (London Trauma Conference)

• Episode 263 — Hyperbaric Medicine with Jeff Kerrie (London Trauma Conference)

• Episode 277 — Cognitive HALOs and Advanced Simulation Training with Halden Hutchinson-Bazely (BASICs)

• Episode 273 — Abdominal Aortic Junctional Tourniquet with Ed Barnard

• Episode 276 — Ejection Seats and the Injured Pilot with Phil Lucas (BASICs)

All full episodes are available in the podcast feed.

MedPod Learn is a medical podcast player designed to help turn listening into structured learning, with tools to support reflection, CPD, and appraisal. Available on the App Store and Google Play.

This third episode in the Best Bits of 2025 series focuses on how improvement actually works in emergency and acute care — and how to do it in a way that is realistic, sustainable, and kind to the people doing the work.

The clips in this episode are drawn from full St Emlyn’s episodes released during 2025 and reflect some of the most practical conversations about learning, feedback, and professional development from the year.

In this episode, we explore

• Why clinical skills fade faster than most of us realise — and why teaching is not the same as training

• How debriefing and video review can drive learning safely, when the culture is right

• The impact of artificial intelligence and algorithm-driven information on how clinicians learn and make decisions

• Why conferences, community, and being “in the room” still matter in medical education

This episode is designed for listening on the way to work, on the way home, or during a quieter moment when you’re thinking about how to improve practice without adding more weight.

Clips in this episode are taken from the following full episodes:

• Episode 259 — Skills Fade with Nathalie Pattyn (Tactical Trauma 24)

• Episode 265 — Excellence in Debriefing with Richard Lyon (London Trauma Conference)

• Episode 267 — Social Media and Artificial Intelligence in Medicine with Peter Brindley

• Episode 274 — What Medical Conferences Offer in 2025 and How They’ve Changed

All full episodes are available in the podcast feed.

MedPod Learn is a medical podcast player designed to help turn listening into structured learning, with optional tools to support reflection, CPD, and appraisal.

Available on the App Store and Google Play.

This second episode in the Best Bits of 2025 series focuses on the human side of emergency medicine: culture, moral injury, compassion, and the small but meaningful behaviours that help clinicians stay grounded when work is relentless.

The clips in this episode are drawn from full St Emlyn’s podcast episodes released during 2025 and reflect some of the most thoughtful conversations of the year.

• What a genuine learning culture looks like on shift — and why it matters more than workload

• Moral injury in emergency and prehospital care, and how it differs from day-to-day moral distress

• Compassionate resuscitation and “the pause” after a death

• Why small, practical actions can counter hopelessness, even when systems are broken

• The EPICC framework and the role of self-compassion in clinical practice

This episode is designed for listening on shift, on the way home, or during a quieter moment over Christmas and New Year.

Featured episodes

Clips in this episode are taken from the following full St Emlyn’s episodes:

• Episode 256 — Monthly Update (November 2024): Learning culture in emergency medicine

• Episode 261 — Moral Injury with Caroline Leech (recorded at Tactical Trauma 24)

• Episode 258 — Compassionate Resuscitation with Matt Hooper (London Trauma Conference)

• Episode 264 — High Performance Teams with Dan Dworkis (Tactical Trauma 24)

• Episode 271 — Monthly Update (April and May 2025): EPICC and self-compassion

All full episodes are available in the podcast feed.

MedPod Learn is a medical podcast player designed to help turn listening into structured learning, with optional reflection and tools to support CPD and appraisal. Available on the App Store and Google Play.

This first episode in the Best Bits of 2025 series brings together some of the most practically useful moments from the St Emlyn’s podcast this year — focusing on how clinicians make good decisions under pressure, when conditions are far from ideal.

Each clip comes from a full episode released in 2025.

In this episode, we explore:

• How ten-second triage is designed to work on “worst-day” scenarios, not in textbooks

• The uncomfortable truth about why procedures sometimes get done — and why that matters

• Why time, not technique, is often the limiting factor in resuscitative thoracotomy

• The case for earlier invasive monitoring in the sickest patients

• Where thinking around double sequential defibrillation may be heading

This episode is designed to be useful on shift, in the car, or during a quiet moment before the next job.

Featured episodes

Clips in this episode are taken from the following full St Emlyn’s episodes:

• Episode 257 — Ten Second Triage with Sean Brayford-Harris (Tactical Trauma 24)

• Episode 269 — Monthly Round Up (January 2025): Decision-making and prehospital RSI

• Episode 270 — Insights on Cannabis Edibles, Pre-Hospital Thoracotomy and more

• Episode 266 — Monthly Round Up (February 2025): Targeted resuscitation and arterial lines

• Episode 268 — Top Papers of 2024 from The Big Sick Conference

All full episodes are available in the podcast feed.

MedPod Learn is a clinician-built medical podcast player designed to turn listening into structured learning, with optional MCQs, reflection prompts, and saved activity for appraisal and CPD. You can find it on the App Store and Google Play.

The discussion highlights the emphasis on speed in damage control resuscitation, the ongoing debate on 'scoop and run' versus 'stay and play' approaches, and the nuanced use of resuscitative thoracotomy.

The episode delves into advanced therapies like ECMO, their expanding role in trauma care, and the importance of relentless self-evaluation in medical practice.

Discover how London's focused approach can provide broader lessons for trauma care and the potential for innovative treatments to become more widespread.

Look out for more podcasts from Trauma 2030 over the coming weeks, where we will talk about team leadership in pre-hospital teams, more on damage-control pre-hospital care, nuancing the management of traumatic cardiac arrest, the increasing use of ECMO, and the shocked trauma patient.

The Institute of Pre-Hospital Care

The Institute of Pre-Hospital Care is part of London’s Air Ambulance Charity, focused on advancing pre-hospital care. They train clinicians, use case studies to guide our priorities, develop new clinical interventions and conduct research. They are also proud to educate and inspire the next generation of pre-hospital care experts through our two degree programmes, co-convened with Queen Mary University London (QMUL).

Through the training and education of The Institute of Pre-Hospital Care, they ensure their unique team of doctors and paramedics are there for London, today, tomorrow, always.

Listen on MedPod Learn

MedPod Learn is a new app that turns medical podcasts into structured learning. Alongside the audio, you get concise learning points, exam-style MCQs, and short reflection prompts — with listening time and activity logged automatically for CPD and appraisal. If you already learn through podcasts, this is a way to make that learning count.

Available now on iOS and Android.

Hutch describes a traumatic cardiac arrest he encountered alone, with no warning and no crewmate to share the load. He explains how he recognised cognitive overload and used simple strategies — “lighting a flare”, “norming the abnormal”, and dropping tasks he couldn’t safely achieve — to regain decision-making space.

The discussion links this experience to his work on the ATACC course and the emerging SPEAR programme, exploring how realistic, human-centred simulation prepares clinicians to function when the stakes and stress are highest.

MedPod Learn turns trusted FOAMed podcasts into structured CPD, adding concise learning notes, single-best-answer questions, and role-specific reflection prompts to thousands of episodes. Everything you do — listening time, MCQs, reflections — is saved automatically and downloadable in one click for appraisal. The app is free to download, with a one-month trial of the full learning tools. Just search MedPod Learn on the App Store or Google Play.

Phil explains: • Why the aviation environment is so hostile to humans and how aerospace medicine supports aircrew • How modern ejection seats work – from canopy jettison and rocket firing to parachute deployment and landing • The decision making required to eject in a matter of seconds, and how pilots are trained to be “mentally ready” • Typical injury patterns after ejection, how technology has reduced spinal compression injuries, and where the remaining risks lie • Practical considerations for ED and pre-hospital teams when a pilot presents after ejection, including spinal precautions and safe removal of flight equipment • The psychological impact of surviving a crash or ejection, how support needs can change over months, and what helps people return to flying • Aviation medicine as a career path, including the role of the RAF Centre of Aerospace Medicine, the diploma in aviation medicine, and how this can sit alongside general practice or emergency care

This conversation draws strong parallels between aviation and emergency medicine: human factors, training under pressure, using simulation and mental rehearsal, and the importance of honest, individualised psychological support after critical incidents.

Topics covered include the physiological-targeted resuscitation, arterial line placements during cardiac arrest, the PECan abdominal trauma rule in pediatric emergency care, intra-arrest stellate ganglion blocks, hydrofluoric acid burns treatment, and pediatric status epilepticus. They also delve into the evidence trial on moving patients with refractory out-of-hospital cardiac arrest to hospitals for specialised care, and review discussions on moral injury among emergency responders. Additionally, they mention the upcoming Geckos Global Health and Emergency Care Research Summit and explore the potential future of emergency medicine by 2038.

00:00 Introduction and Conference Highlights

02:55 Arterial Line Placement During Cardiac Arrest

05:27 Pediatric Abdominal Trauma Rule

10:25 Intra-Arrest Stellate Ganglion Blocks

14:35 Moral Injury in Emergency Responders

23:22 Hydrofluoric Acid Burns Treatment

25:38 Ketamine for Pediatric Status Epilepticus

28:57 Refractory Out-of-Hospital Cardiac Arrest

33:59 Global Health and Emergency Care Research

35:09 Conclusion and Future Episodes

• Why in‑person conferences still matter in a post‑COVID world.

• What formats work now: short talks, interviews, demos, strong hosting.

• How to turn “a great day out” into Monday‑morning change.

Guests

• David Carr — EM physician (Toronto). Leads the Annual Update in EM at Whistler. Focus: inclusive, high‑energy, “hard‑core EM” content.

• Haney Mallemat — EM & Critical Care (South Jersey/Philadelphia). Founder of ResusX; designs short, high‑engagement sessions that feel like live conversations.

Key themes

• Why travel when content is online? Being in the room changes attention, reflection, and recall. Learning happens in corridors, evening sessions, and next‑day conversations.

• From lectures to experiences. Shift to shorter talks, couch discussions, live demos, and deliberate hosting. Format follows audience and venue.

• Programme design starts with the audience. Build for how people learn now. Coach faculty. Pick speakers for delivery and credibility.

• Strong hosting is part of pedagogy. Good chairs manage flow, time, and psychological safety so the audience can relax and learn.

• Social learning drives change. Purposeful social time and small‑group evening sessions create the “stickiness” that leads to projects and practice updates.

Practical takeaways for clinicians

• Arrive with intent: bring 1–2 real patient problems to solve.

• Choose your format: prioritise short talks, interviews, and hands‑on if your attention is fragmented.

• Make it stick on Monday: debrief with a colleague, write one practice change, set a review date. Present a short “what I learned” to your team.

• Borrow authority wisely: take clear, referenced points (e.g., contrast allergy/nephropathy policies) back to local committees.

Practical takeaways for organisers

• Audience first: define who you serve; let that drive length, tone, and format.

• Shorten and vary: fewer bullet‑heavy lectures; more interviews, panels, and no‑slide formats when it helps educators shine.

• Coach and curate: select speakers for content and delivery; build a pipeline for new voices.

• Invest in hosting: treat chairs as educators; they safeguard pacing, transitions, and safety.

• Design the socials: plan purposeful evening micro‑teaching and cross‑disciplinary meet‑ups.

• Measure impact: mandate feedback tied to CPD; analyse themes and close the loop next year.

Risks and tensions

• Edutainment vs evidence: keep the energy without losing rigour.

• Access and equity: budgets, visas, disability, and caring responsibilities exclude many; amplify content post‑event.

• “Too innovative?” Novel formats can struggle with recognition and funding; meet audiences halfway and iterate.

How conferences translate to patient care

• Prioritise topics that solve common bottlenecks.

• Put change agents on stage with take‑home resources (e.g., clear radiology guidance on contrast “allergy” and nephropathy).

• Encourage attendees to form local groups to implement one change within two weeks.

The conversation traces the problem of non-compressible haemorrhage, the leading cause of potentially survivable trauma death. Conventional limb tourniquets, pelvic binders and packing can’t reach these deep bleeding sites. The AAJT offers a radical alternative: external aortic compression to buy a few crucial minutes until surgical control or REBOA is possible.

Ed explains the mechanism — an inflatable, ratcheted belt that can occlude the aorta or major junctional vessels — and the evidence so far. Laboratory and volunteer data show that it can stop flow, but pain and tissue ischaemia make it difficult to tolerate for long. Clinical experience remains limited to small case series, mostly in military or research settings, and no human trials yet demonstrate a survival benefit.

The discussion is candid about risk and realism. The AAJT is a last-resort device, to be used only within strict governance, with clear time limits and immediate plans for definitive haemorrhage control. It’s not something you reach for on a normal shift — it’s something you might need once in a career, and only if every other option has failed.

Ed shares insights from ongoing research, including its potential role as a bridge to REBOA, and the governance frameworks that should surround any trial use. The episode ends with a look to the future: how civilian and military collaboration might refine indications, training, and data collection for this rare but potentially life-saving intervention.

Surgeon Captain Ed Barnard

Surgeon Captain Ed Barnard is a Consultant in Emergency Medicine at Addenbrooke’s Hospital, Cambridge, and a Professor of Emergency Medicine with the Defence Medical Services. He also serves with East Anglian Air Ambulance as a HEMS doctor (having had many years as a BASICS responder). His academic work focuses on prehospital and military trauma care, with a portfolio spanning clinical trials, blood product innovation, and trauma system development.

Ed’s academic work focuses on improving survival from catastrophic bleeding, particularly non-compressible and junctional haemorrhage. He has published and presented widely on trauma resuscitation, traumatic cardiac arrest, and the evolving role of devices such as the abdominal aortic and junctional tourniquet (AAJT) and REBOA. He is a co-author of the 2025 BMJ Military Health systematic review examining the utility of the AAJT-S in military practice.

He is also an experienced educator, contributing to trauma training for BASICS, HEMS, and Defence Medical Services, and continues to combine clinical work with research aimed at translating lessons from military to civilian trauma care.

About BASICS: The British Association for Immediate Care (BASICS) is a UK charity uniting clinicians dedicated to pre-hospital emergency medicine. Founded in 1977, it supports regional immediate-care schemes, delivers national training, and hosts the annual BASICS Pre-Hospital Care Conference, bringing together experts in trauma, retrieval, and critical care — like this conversation with Dr Ed Barnard.

They also highlight the growing issue of nitazenes, a new class of synthetic opioids, and their implications for emergency medicine. Lastly, they emphasise the importance of staying updated on toxicology to effectively manage high-acuity, low-occurrence events such as drug-induced hyperthermia.

00:00 Introduction

01:35 Upcoming Conferences

03:41 Med Pod Learn

05:09 Serotonin Syndrome Deep Dive

10:22 Urgent and Emergency Care Plan

18:04 Salbutamol for Renal Colic

22:07 Hypothermia in Toxicology Emergencies

27:04 Nitazines: A Growing Problem 

Discussions cover content from recent emergency medicine research, the importance of compassion and patient-centred care, and operational strategies to avoid emergency department overcrowding. Insights are also shared from fieldwork in South Africa on emergency thoracotomies and their impressive survival rates.

Topics include the Sub 30 Feasibility Study on pre-hospital ECMO, comparisons of pre-hospital versus in-hospital emergency anaesthesia, variations in maintenance of pre-hospital anaesthesia in trauma patients, and the effectiveness of physician-led pre-hospital teams.

They also discuss the economic implications of advanced pre-hospital interventions and highlight reviews from the London Trauma Conference.

00:00 Introduction and January Recap

01:58 Pre-Hospital ECPR Study: The Sub 30 Study

07:09 Emergency Anaesthesia: Pre-Hospital vs. Emergency Department

13:55 Maintenance of Pre-Hospital Anaesthesia: Variations in Practice

16:57 Physician-Led Pre-Hospital Teams: Do They Improve Outcomes?

22:12 Additional Insights and Upcoming Content

They also delve into double sequential external defibrillation in refractory out-of-hospital cardiac arrest and provide a rapid-fire review of additional critical papers discussed at the conference. Notable mentions include the HEMOTION trial, PRE OXI trial, BLING III, and PARAMEDIC-3, among others.

A must-listen for those passionate about evidence-based medicine in emergency and pre-hospital care.

You can read more about all the trials, including links to all the papers here (part 1) and here (part 2)

00:00 Introduction and Conference Highlights

01:51 Non-Invasive vs. Arterial Pressure Monitoring

03:28 Intra-Arrest Blood Pressure and ROSC

05:34 Serratus Anterior Plane Blocks for Rib Fractures

08:38 Micro Axial Flow Pump in Cardiogenic Shock 10:49 Double Sequential Defibrillation in Cardiac Arrest

13:17 HEMOTION Trial

15:01 PRE OXI and BLING III Trials

17:08 Fluid Management in Septic Shock

18:37 Expedited Transfer vs. On-Scene Resuscitation

20:39 Intraosseous vs. Intravenous Access

21:48 Conclusion and Final Thoughts

Dan Dworkis, MD, PhD, FACEP is the Chief Medical Officer at the Mission Critical Team Institute, the founder of The Emergency Mind Project, a board-certified emergency medicine physician, and an assistant professor at the Keck School of Medicine at USC.

His work focuses on the optimal development of mission critical teams in and out of emergency departments. He completed the Harvard Affiliated Emergency Medicine Residency at Massachusetts General Hospital / Brigham Health, and also earned an MD and PhD in molecular medicine from Boston University School of Medicine. Dr. Dworkis is the author of The Emergency Mind:  Wiring Your Brain for Performance Under Pressure.

For the last three years, Jeff Kerrie has served as the Island Health Medical Director of Quality, Safety, and Ethics. Dr. Kerrie has a master’s degree in clinical bioethics from Clarkson University/Icahn School of Medicine at Mt. Sinai in New York. Over the last six years, Dr. Kerrie helped build the Island Health ethics program, where he has provided ethics consultations and teaching to staff, patients, and families.

Dr. Kerrie underwent medical training at the University of Manitoba before completing residency in Internal Medicine at UBC. He practices as a general internist in Victoria, and is an Assistant Clinical Professor with the University of British Columbia and the University of Victoria. Other medical work has included medicine in atypical environments (including dive/hyperbaric medicine, ski patrol, and high altitude environments), obesity medicine, and international health. Dr. Kerrie is also a graduate of the Physician Quality Improvement program at Island Health.

In his spare time Dr. Kerrie enjoys aviation, skiing, and SCUBA diving.

He am a Clinical Professor specialising in Brain Injury at Imperial and Honorary Professor of Pre-Hospital Care (the Gibson Chair) at the Faculty of Pre-Hospital Care, Royal College of Surgeons, Edinburgh. 

His specialist areas are acute brain injury (mostly traumatic brain injury) and its very early management. He is co-director of the Imperial Neurotrauma Centre and am co-founder of GoodSAM, a revolutionary platform that alerts doctors, nurses, paramedic and those trained in basic life support to emergencies around them. 

Mark have worked extensively overseas (India, Nepal, South Africa, as a GP in Australia, Researcher for NASA and as an expedition doctor on Arctic and Everest expeditions). He also wrote The Medics Guide to Work and Electives Around the World. His research is mainly into the brain in trauma and in hypoxia (using it as an injury model) in humans.

They highlight a randomized control trial on early exercise in blunt chest wall trauma, revealing its limited impact on recovery outcomes. Additionally, they explore the long-term safety of intraosseous access based on new evidence from Denmark.

The episode also provides insights into updated imaging guidelines for paediatric trauma and broad considerations on the growing role of AI in healthcare, especially in emergency settings. There are closing remarks on recent blog posts about toxic alcohol poisoning and the Difficult Airway Society meeting, while looking forward to upcoming conferences in Spain and Vienna.

00:00 Welcome to St Emlyn's Podcast

00:31 Exploring the Big Sick Conference in Zermatt

01:25 Evidence-Based Medicine: Early Exercise in Blunt Chest Wall Trauma

04:30 Intraosseous Access: Long-Term Complications

06:37 Imaging Decisions in Pediatric Trauma

09:17 The Promise and Perils of Artificial Intelligence in Healthcare

13:10 Toxic Alcohol Poisoning: A Critical Review

16:17 Conference Highlights and Future Events

19:19 Season 11 Finale and Looking Ahead to Season 12

Nathalie discusses her extensive background in medicine, psychology, and neuroscience, and shares insights from her research on how skills can deteriorate during low workload deployments, such as her 15-month clinical stint in Antarctica.

They delve into the lack of systemic measures to address returning to practice after long absences, how cognitive and psychomotor skills are affected by skill fade, and the contrast between teaching technical skills and ensuring they become automatic and stress-resilient.

The conversation highlights the need for evidence-based guidelines to ensure healthcare professionals maintain their proficiency, which ultimately benefits patient care and the healthcare system.

00:00 Introduction and Guest Introduction 00:13 Natalie's Background and Expertise 00:38 Skills Fade in Emergency Medicine

01:01 Personal Experience with Skills Fade

02:14 Regulations and Policies on Skills Maintenance

04:19 Imposter Syndrome vs. De-skilling

06:42 Aviation vs. Medical Field: Skills Certification

08:27 Aging and Cognitive Decline in Medical Skills

09:57 Teaching vs. Training in Medical Education

12:42 Future Directions and Systemic Solutions

14:31 Conclusion and Contact Information

Nathalie Pattyn, MD, MPsy, PhD, received a degree in medicine from the Université Libre de Bruxelles (magna cum laude, 2001), a Master in Clinical Psychology from the Vrije Universiteit Brussel (cum laude, 2004), a PhD in Psychological Sciences from the Vrije Universiteit Brussel (2007) and a PhD in Social and Military Sciences from the Royal Military Academy (2007).

She also holds a postgraduate degree in Aerospace Medicine; a postgraduate degree in Emergency Medicine; a postgraduate degree in General Practice ; a postgraduate degree in Disaster Medicine ;and a Master in Global and Remote Healthcare.

She completed her Junior Officer Course with the Belgian Defense College in 2005, and her Staff Officer Course in 2008. She has a mixed clinical, research and operational background, having been deployed as a medical officer in various Middle Eastern and African countries, and having completed missions in Antarctica for a total duration of more than two years.

Her longest deployment was 15 months to the Halley VI Research Station in Antarctica, where she worked as the station physician while setting up a new biomedical research laboratory for the European Space Agency. She is currently still working as an emergency physician and a flight surgeon.

Her research interests include the psychophysiological measures of performance in elite populations; and Human Factors approach to isolated and confined environments, ranging from space to submarines.

In 2010, she founded a research unit within the Royal Military Academy, dedicated to the multidisciplinary study of human performance in operational environments. This led her to be the project manager for designing a tailored Human Performance Program for the tier one unit of the SOF community in Belgium.

She is currently an Associate Professor in Physiopathology at the Vrije Universiteit Brussel and in Human Performance at the Royal Military Academy.

You can read Nathalie's excellent book "Handbook of Mental Performace" for free here.

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

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.

They discuss its creation and implementation, including collaboration with the Metropolitan Police and other emergency services. Key points include the shortcomings of the previous 'sieve and sort' system, the challenges of developing a simplified tool, and the benefits of this new approach for non-medical first responders.

The episode emphasizes the importance of cross-team collaboration in emergency scenarios and the potential impact of the tool on reducing distress and improving outcomes for both responders and patients.

00:00 Introduction

00:37 Background on Major Incident Triage

01:01 Challenges with Existing Triage Systems

01:15 Designing the 10 Second Triage Tool

05:16 Implementing the Triage Tool

06:50 How the 10 Second Triage Tool Works

13:48 Real-World Applications and Benefits

18:54 Conclusion and Final Thoughts

They highlight the upcoming Big Sick Conference in Zermatt and the IncrEMentuM in Spain, noting their potential benefits for networking and education.

Simon emphasizes creating a psychologically safe environment and fostering curiosity, growth, and knowledge-sharing among emergency department staff. They also review a range of medical studies, including those on small bore vs. large bore chest tubes for haemothorax, intra-arrest arterial blood pressure monitoring, and the new GLP-1 receptor antagonists for obesity treatment.

Lastly, they address the importance of handling bad behavior in the team and maintaining kindness and professionalism, even during high-stress periods.

00:00 Introduction and New Year Greetings

00:35 Current State of Emergency Departments

01:17 Upcoming Conferences: The Big Sick and IncrEMentuM

03:43 Building a Learning Culture in Emergency Medicine

12:24 Pre-Hospital ECPR and ECMO

13:58 Small Bore vs Large Bore Chest Tubes

17:37 Intra-Arrest Arterial Blood Pressure Monitoring 24:01 New Drugs and Toxicology

24:47 Care in the Hot Zone

27:12 Addressing Bad Behaviour in Emergency Departments

30:42 Conclusion and Future Plans for St Emlyn's

Rick and Greg also discuss Bayesian reasoning and how pretest and post-test probabilities are used in practice.

00:00 Introduction to the Podcast

00:34 Understanding Likelihood Ratios

02:05 Practical Example: Chest Pain Case

03:53 Calculating Likelihood Ratios

07:17 Applying Bayesian Reasoning

09:50 Recap and Conclusion

They also explore the Green ED project and the impact of climate change on healthcare. Additionally, they delve into recent research on ventricular fibrillation pad positions, the use of tranexamic acid (TXA) in trauma care, and the importance of maintaining a positive outlook amidst winter challenges by seeking small wins and engaging in enjoyable aspects of emergency medicine. The episode offers valuable insights and updates for emergency medicine professionals.

00:00 Welcome and Introduction

01:27 Highlights from the Royal College of Emergency Medicine Conference

01:50 Toxicology Insights: High Potency Opioids and Benzodiazepines

05:11 Climate Change and Healthcare: The Green ED Project

08:23 Medical Conferences: A Phoenix from the Ashes

10:38 Ventricular Fibrillation and Pad Position: New Insights

17:22 Tranexamic Acid (TXA) in Trauma Care

24:01 Maintaining Positivity in Challenging Times

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

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

Key findings from recent research highlight that even subtle actions like eye-rolling can negatively affect patient safety as much as overt harassment. The speaker emphasises the importance of psychological safety, trust, competence, authenticity, consistency, and empathy in maintaining a healthy team environment. Practical advice includes assessing one's own behaviour and seeking honest feedback from colleagues and loved ones.

Comprehensive show notes are available here

00:00 Introduction: Addressing Bad Behaviour

01:18 Defining Bad Behaviour

01:49 Impacts of Bad Behaviour

03:15 Psychological Safety and Team Dynamics

04:24 Personal Experiences and Observations

05:46 Types of Bad Behaviour

07:19 Research Findings on Workplace Behaviour

09:10 Self-Awareness and Behavioural Impact

14:21 The Karpman Drama Triangle

17:29 Conclusion and Final Thoughts

They highlight a study on patient experience in emergency departments, focusing on issues like loss of autonomy, unmet expectations, and vulnerability. Suggestions for improvement include better communication, effective signage, and patient comfort.

The podcast also covers a 'dirty adrenaline drip' study from Australia, emphasizing remote inotrope management.

Discussions include the use of arterial blood pressure monitoring in pre-hospital settings and the merits of CT scans beyond the traditional six-hour window for diagnosing subarachnoid haemorrhage.

The episode wraps up with reflections on the positives of emergency medicine and the importance of maintaining enthusiasm and mastery in the field.

The episode delves into the implementation and logistics of pre-hospital eCPR (Extracorporeal Cardiopulmonary Resuscitation) by SAMU in Paris. Alice shares insights from her PhD research on refractory cardiac arrest and discusses the use of therapeutic hypothermia, including experimental approaches like total liquid ventilation.

Key topics include team composition, decision-making for patient eligibility, real-time management strategies, bypassing traditional emergency rooms for specialized facilities, and the challenges of scene management, family communication, and post-event debriefing.

This conversation offers a comprehensive look at the latest innovations that could transform pre-hospital emergency medical services.

Read more here...

00:00 Introduction and Guest Introduction

01:29 eCPR in Paris: Current Practices

02:35 Dispatch and Response Protocols

03:32 On-Scene Procedures and Challenges

04:23 Decision Making and Scene Management

05:53 Training and Handling Difficult Situations

06:59 Challenges of eCPR Decision-Making

08:07 Importance of Team Debriefing

08:52 Post-Resuscitation Procedures

10:12 Operational Logistics and Success Rates

11:20 Innovative Research in Therapeutic Hypothermia

13:13 Future of Pre-Hospital Cooling Techniques

13:46 Conclusion and Final Thoughts

They explore 'Goldilocks moments' for executing life-saving procedures in critical care, emphasizing optimal timing for interventions like thoracotomies. The episode also discusses innovative training methods like shadowboxing to enhance decision-making in high-stress medical scenarios. In addition, they review a significant trial on smoking cessation in emergency departments, highlighting its potential role in broader public health initiatives, including sexual health and HIV screening.

Discussions also cover various pain management strategies, such as the use of intranasal vs. intravenous Ketorolac for renal colic. The hosts critique the traditional peer review process in medical research and advocate for open peer review to support equitable and accessible scientific publishing.

00:00 Introduction and Catching Up

02:07 The Goldilocks Moment in Critical Care

05:25 Training and Decision-Making in Emergency Procedures

07:23 Smoking Cessation in Emergency Departments

10:07 Challenges in Implementing Preventive Health Strategies

10:38 Successful Public Health Projects in Emergency Medicine

11:19 Exploring Alternative Interventions in Emergency Departments

11:52 Highlights from the Premier Conference

12:54 Intranasal Ketorolac for Pain Management

15:46 The Future of Peer Review in Medical Research

20:09 Concluding Thoughts and Upcoming Content

Key takeaways include the concept of intelligent failure, reducing cognitive overload for medical staff, and the creation of efficient medical environments. Moreover, the episode delves into the significant improvements achieved through simulation, such as a 50% reduction in blood delivery times, and the integration of performance data to enhance CPR and clinical space design. Emphasizing the importance of using data to drive improvements, the conversation explores the implementation of roles like a CPR coach and the scalable application of these practices across individual, team, and systemic levels.

Listeners are encouraged to view failures constructively and leverage simulations and data for better patient outcomes and team performance.

00:00 Introduction to Simulation in Emergency Medicine

01:05 A Real-Life Trauma Case

02:18 Identifying Systemic Issues

02:46 Implementing and Testing Solutions

05:45 The Concept of Intelligent Failure

09:41 Scaling and Impact of Simulation

10:22 The Power of Simulation in Experimentation

10:56 Data Integration in Healthcare and Sports

11:29 Evaluating CPR Quality Through Simulation

12:14 Using Data to Improve Clinical Performance

13:47 Designing Clinical Spaces with Simulation Data

15:28 Scaling Impact with Simulation

18:02 Efficient Team Communication in Trauma Bays

19:04 Broadcasting and Recording Simulations for Education

19:39 Conclusion and Future Directions

Dr. Andrew Petrosoniak is an emergency physician and trauma team leader at St. Michael’s Hospital and an Assistant Professor in the Department of Medicine at the University of Toronto. He has completed a Master of Science in medical education where he focused on the use of in situ simulation (practice in the actual workplace) in procedural skill acquisition.

Andrew’s field of research includes in situ simulation and simulation-based technical skill acquisition. His work focuses on usability testing and the identification of personnel- and systems-based safety threats within acute care medicine. He is the principal investigator of the TRUST study (Trauma Resuscitation Using in Situ simulation for Team Training) that includes a partnership with human factors experts to evaluate systems and processes during high-stakes trauma simulations.

Key Themes:

1. Handling Failure in High-Pressure Situations: Kevin discusses a significant incident where a hostage was killed by his SWAT team during a rescue attempt, describing it as the “epitome of failure.” This tragic event not only made national news but left an indelible mark on the team. The podcast dives into the lessons learned from this event and how the team used it to drive growth and improvement. In healthcare, much like in policing, failure can feel devastating and highly public, but it’s also a critical aspect of development for teams and leaders.

2. Visible Leadership and Unwavering Support: In the aftermath of a traumatic event, Kevin emphasizes the importance of leadership being present and supportive. He recounts how he and his commanding officer went to visit the officers involved in the shooting immediately after the event, providing what he calls “unwavering support.” In healthcare, leaders should adopt similar strategies, offering visible and sustained support to their teams in the immediate aftermath of difficult cases.

3. Sustained Support Over Time: While initial support following a traumatic event is crucial, Kevin points out that it’s often after 48 hours, or even weeks later, that people start feeling isolated. Leaders must continue to check in with their teams weeks after the event, when the immediate crisis may have passed, but the emotional toll is still present. This ongoing visibility and emotional support are key to retaining staff and ensuring their well-being in both law enforcement and healthcare.

4. Debriefing to Learn, Not to Blame: Kevin advocates for a debriefing process that focuses on learning from failure rather than assigning blame. After their tragic event, his team didn’t just move on; they dissected the event to understand what went wrong and how to prevent similar failures in the future. In healthcare, this process is equally valuable—debriefs should aim to identify learning opportunities and reinforce positive actions, not to point fingers.

5. The Role of Organizational Culture: Kevin touches on how organizational apathy, or a lack of emotional and psychological support, can cause more damage than the actual traumatic event itself. He highlights the importance of developing a high-trust environment where team members feel safe to express vulnerability. In healthcare, fostering a culture of open communication and mutual support is essential to prevent burnout and moral injury.

6. The Value of Failure in Team Growth: One of the most profound insights Kevin shares is the idea that failure is a necessary part of growth. Three years after their tragic hostage situation, his team was called to a similar event, but this time they were successful in rescuing both hostages. Kevin attributes this success directly to the lessons learned from their earlier failure, emphasizing that failure, when handled correctly, can lead to transformational change.

7. Selection and Resilience in High-Performance Teams: Kevin discusses the importance of selecting team members with high emotional intelligence and the humility to ask for help when needed. He explains how his team differentiates between rank and role, giving autonomy to those with the most subject matter expertise, regardless of their rank. In healthcare, this is a critical point—leaders must recognize that true leadership isn’t just about authority, but about empowering others to take charge when appropriate.

8. Managing Expectations and Mental Health: The episode also delves into how individuals in high-stakes roles, whether in policing or healthcare, cope with the psychological aftermath of traumatic events. Kevin explains how his team has shifted from the belief that emotional support is unnecessary to recognizing the value of helping team members process their experiences in a healthy way. This parallels the increasing focus in healthcare on preventing burnout and ensuring emotional well-being through proactive support.

Key Takeaways:

- Failure is Inevitable: In high-stakes environments like policing and healthcare, failure will happen. What matters is how teams respond to failure—learning from it, growing stronger, and preventing future mistakes. Leadership Requires Visibility: Leaders must be present, especially in the aftermath of failure. Showing unwavering support and maintaining visibility over time is crucial for maintaining team morale and trust.

- Debriefing to Learn: After a failure, it’s essential to have structured debriefs that focus on learning and improving, rather than blaming. This helps teams identify areas of improvement and ensures they grow stronger from difficult experiences.

- Long-Term Support is Critical: Immediate support after a traumatic event is important, but equally important is sustaining that support over time, checking in with team members weeks or even months later to ensure their well-being.

- Resilience through Humility: Teams should be built on trust and humility, where members can ask for help when needed and offer help to others. Selecting individuals with high emotional intelligence is key to creating a resilient team.

- Failure Leads to Growth: When handled correctly, failure can drive transformational change within teams. It allows for the development of new skills and ensures that teams are better prepared for future challenges.

Quotes:

- “Failure is a necessary part of growth. It’s not just something to get over, it’s something you get better from.” - “Visible leadership and unwavering support are critical in the immediate aftermath of failure. Your team needs to know you’re there with them.” - “Debriefing to learn, not to blame, is essential. We must focus on what went well, what went wrong, and how to improve next time.” - “In high-pressure environments, we can’t control every variable, but we can control how we respond to them and how we prepare for the future.”

The main topics include a systematic review on the Manchester Acute Coronary Score (MACS) and its application in emergency departments, the potential influence of AI in diagnosing occlusive myocardial infarctions through ECGs, and guidelines for managing non-fatal strangulation cases. Additionally, they touch on the feasibility of using lidocaine patches for elderly patients with rib fractures and the role of partial REBOA in pre-hospital care for exsanguinating subdiaphragmatic haemorrhage.

They also highlight informative segments from the premier conference on pediatric emergency medicine, covering topics such as eating disorders, hybrid closed-loop insulin pumps, and button battery ingestion. Finally, they emphasize the importance of understanding medical statistics and using diagnostic tests effectively in emergency medicine practice.

00:00 Introduction and Summer Updates

00:55 Upcoming Conferences and Events

01:44 Manchester Acute Coronary Score (MACS) Review

05:30 AI in ECG Analysis with Steve Smith

08:18 Non-Fatal Strangulation Awareness

10:45 Reboa: Pre-Hospital Use and Insights

14:11 Pediatric Emergency Medicine Highlights

14:36 Eating Disorders and Diabetes Management

19:00 Lidocaine Patches for Rib Fractures

21:46 Critical Appraisal and Medical Statistics

24:28 Button Battery Ingestion Dangers

26:12 Conclusion and Farewell

The study examines acute severe headache presentations in the ED and the diagnostic approach to ruling out subarachnoid haemorrhage, a critical and often feared diagnosis among emergency physicians. Conducted through the Trainee Emergency Research Network (TURN), the study included over 3,600 patients from 88 UK EDs with acute severe headaches reaching maximum intensity within one hour and no focal neurology. Data collection included CT scans, lumbar puncture results, and 28-day follow-up to identify missed cases of subarachnoid hemorrhage.

Key findings from the study revealed a 6.5% prevalence of subarachnoid haemorrhage, with a significant number presenting within six hours of headache onset. The sensitivity of CT scans remained high beyond the traditional six-hour window, suggesting that CT alone could safely rule out subarachnoid haemorrhage up to 18 hours in many cases, potentially reducing the need for lumbar puncture. The risk of missing an aneurysmal subarachnoid haemorrhage after a negative CT was found to be extremely low, around 1 in 1,000.

These findings challenge the routine use of lumbar puncture in patients presenting beyond six hours if the CT scan is negative, potentially changing ED practice and reducing unnecessary invasive procedures. The discussion also emphasized the importance of shared decision-making and recognizing that diagnostic testing is about managing probabilities, not certainties. For clinicians, the episode highlights the need to expedite CT scans for patients with acute severe headaches, especially those presenting within 10 minutes of onset, as they are more likely to have significant pathology. Emergency physicians are encouraged to own the decision-making process for ruling out serious causes of headaches and not defer solely to 'specialists'.

The SHED study supports extending the diagnostic window for CT scans in ruling out subarachnoid hemorrhage up to 18 hours, reducing the need for lumbar puncture in many cases. This data empowers emergency clinicians to make informed decisions, manage patient expectations, and streamline ED processes. 

For more information, listeners are encouraged to read the SHED Study in the Emergency Medicine Journal and explore the related blog post on the St Emlyn’s website. Emergency clinicians are also invited to connect with TERN to get involved in future research opportunities. 

This episode provides valuable insights for clinicians in managing acute severe headaches, emphasizing a more nuanced approach to subarachnoid hemorrhage diagnosis and the importance of clinical decision-making in the ED.

There is more detail on the full blogpost here. 

This podcast was recorded live at the Hope Church in Winchester as part of the PREMIER conference. We are grateful to the organizing team for hosting us and allowing us to use the audio. The PIER and PREMIER websites are full of amazing resources for anyone working in Paediatric Emergency Medicine, and we highly recommend them.

Ed is a Speciality Trainee in Emergency Medicine in Wessex and a trainee Critical Care Practitioner with Dorset and Somerset Air Ambulance. Ed is also the co-founder and Managing Director of Enhanced Care Services, a Southampton-based company delivering enhanced and critical care to the event medical sector, providing frontline ambulance services across Hampshire and clinical education at all levels, employing over 200 clinicians. Ed holds the Diploma in Immediate Medical Care (RCSEd) and, having promised to not take on any more work, is currently undertaking a Masters in Resuscitation, Pre-hospital and Emergency Medicine at QMUL.

Enhanced Care Services' mission is to provide and influence excellent patient care, irrespective of injury, illness or location, through the delivery of high-quality clinical operations and education. Founded in 2015, ECS now provide frontline ambulance operations across the South, delivers extensive medical cover to some of the most prestigious events across the UK and provides education from its bespoke education centre in Southampton and beyond.

The episode begins by clarifying what paediatric palliative care truly involves. Contrary to common misconceptions, palliative care is not about withdrawing care but rather enhancing the quality of life for children from the point of diagnosis, whether the condition is present from birth or develops as the child deteriorates. This proactive approach often involves increasing the level of care and support as the child’s needs evolve.

As the number of children with life-limiting conditions continues to rise, EDs are encountering more medically complex cases, including children who are technology-dependent and require high levels of care at home. These challenges are compounded by the evolving expectations of parents, who are often better informed and more involved in their child's care decisions. Post-COVID, community services have struggled to recover, particularly in nursing support, making the role of the ED even more critical.

The episode provides practical tips for ED professionals to better manage these cases. Key strategies include:

1. Recognising Life-Limiting Conditions: With over 400 recognized life-limiting conditions and many more undiagnosed, it’s crucial to assess whether a child might have palliative care needs.

2. Listening to Families: Families often have an intimate understanding of their child’s unique medical baseline. Listening deeply to their insights, even when they seem unusual, is essential for providing appropriate care.

3. Building Rapid Rapport: Quickly establishing a connection with the family is vital, as these children can deteriorate rapidly. Acknowledging the child’s presence, summarizing the situation, and validating the family’s experience can help build trust.

4. Understanding the Child Beyond Their Illness: Families worry that healthcare professionals only see their child when they are unwell. Taking the time to learn about the child’s life outside of the hospital can lead to better care decisions.

5. Reading the Advanced Care Plan: If available, review the child’s advanced care plan before discussing the case with the family. This ensures that the family doesn’t have to recount their entire journey and that care decisions are based on the most current information.

The episode also addresses the importance of being aware of unconscious prejudice. Healthcare professionals must ensure that decisions are based on the child’s specific needs rather than assumptions about their quality of life due to their disability.

In conclusion, the episode emphasizes that while caring for children with life-limiting conditions in the ED is challenging, it is also deeply rewarding. The key to providing excellent care lies not just in medical interventions but in being present, listening, and supporting the family through difficult times. Whether things go as planned or not, your presence and compassion are what families remember most.

This episode is a must-listen for anyone involved in pediatric care, offering valuable insights into the critical role of the ED in supporting children with life-limiting conditions and their families. There is more detail on the blogpost here. 

In this round-up of Month Year, we talk about a wide range of issues relating to emergency medicine, including nebulised ketamine for analgesia in the ED, risky intubations, presentation skills, more about the DOSE VF trial and analysis of the much-hyped PREOXI trial about preoxygenation before tracheal intubation.

We're excited to announce our participation in two upcoming conferences. The Tactical Trauma Conference in Sweden this October promises to delve into pre-hospital emergency medicine, offering sessions from renowned speakers. It's a fantastic opportunity to learn and network, with flights to Sweden being relatively affordable. The event takes place just north of Stockholm, providing a chance to explore the beautiful city.

In March next year, we look forward to the Incrementum Conference in Murcia, Spain. This is a significant event as emergency medicine has recently been recognized as a specialty in Spain. The conference will feature an impressive lineup of speakers from the FOMED world, including Scott Weingart, Ken Milne, Hany Malamatt, and Slim Resie , among others. Our very own Simon Carly will also be presenting. We'll be there to conduct interviews and gather exclusive content for our listeners.

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

Button batteries are ubiquitous and come in various types and sizes. There are about 85 different kinds available or in use in the UK alone, found in everything from toys to hearing aids. The most notorious is the CR2032, which is about 20 millimeters in diameter and 3.2 millimeters thick. It contains lithium manganese oxide, and while its small size makes it convenient for electronics, it poses a significant risk if ingested.

The danger with button batteries lies in their potential to cause severe injuries when lodged in the esophagus. They can cause necrosis, which is essentially tissue death, due to a strong alkaline substance produced by the battery. This substance acts like a potent oven cleaner, rapidly causing damage. The esophagus has three natural narrowing points where these batteries often get stuck, increasing the likelihood of injury. The situation becomes critical very quickly, often within two hours of ingestion.

One of the most concerning aspects of these incidents is that button battery ingestions are rarely witnessed. Children might present with vague symptoms like drooling, difficulty swallowing, or even just being generally unwell. These can easily be mistaken for other common illnesses, leading to delays in diagnosis. In one particularly harrowing case, a child presented multiple times with symptoms of a respiratory infection, only for an x-ray to reveal a button battery lodged in the esophagus. By then, the damage was extensive.

When ingestion is suspected, immediate action is crucial. Getting a chest x-ray is the first step, and if necessary, a lateral x-ray can confirm the presence of a button battery by revealing a characteristic double rim or halo sign. Pre-hospital measures can include giving honey or jam, depending on the child’s age, to help mitigate the damage. However, these should never delay getting the child to the hospital.

Once at the hospital, the primary goal is to remove the battery as quickly as possible to prevent further injury. Depending on the location of the battery and available specialists, either ENT surgeons or paediatric surgeons may perform the removal. Post-removal care involves monitoring for complications like perforations or fistulas, which can develop days or even weeks later. In severe cases, these injuries can lead to life-threatening conditions, such as aorto-esophageal fistulas, which require immediate surgical intervention.

In summary, button battery ingestion is a serious and often underappreciated risk. Even in homes where precautions are taken, accidents can happen. The key is quick recognition and action. As parents and caregivers, we need to be vigilant about keeping these small, dangerous objects out of children's reach. And if an accident does occur, immediate medical attention is essential to minimize the risk of serious injury. 

More details are available on the blogpost here. 

Positive predictive value (PPV) and negative predictive value (NPV) are essential tools for understanding the effectiveness of diagnostic tests. PPV helps us determine the likelihood that a patient with a positive test result actually has the condition, whereas NPV helps us gauge the probability that a patient with a negative test result does not have the disease. These values are crucial for making informed clinical decisions, particularly when considering the prevalence of a condition in the population. Today, we’ll delve into these concepts, their practical applications, and why it's important to consider both PPV and NPV alongside sensitivity and specificity.

You can find more about this on the St Emlyn's Blog and please don't forget to like and subscribe.

With NICE's recent technology appraisal advocating for universal access to hybrid closed loop systems for all type 1 diabetes patients, it's crucial to understand these devices. Over the next few years, you'll likely encounter these systems frequently. We'll cover the essentials of how these pumps work, their benefits, and potential issues that might arise, such as connectivity problems, cannula issues, and handling intercurrent illnesses.

Join us as we explore the revolutionary impact of hybrid closed-loop systems, which offer better glucose control and significantly improve the quality of life for those with type 1 diabetes.

Dr Nicola Trevelyan has been the Clinical Lead for the Paediatric Diabetes Service in Southampton for the last 20 years. During this time, she has seen huge changes in the management of CYP with diabetes.  She has been involved in several large multicentre trials for paediatric diabetes,  helping to better our understanding of how best to use new technologies in diabetes management in children and move forward access to new treatment technologies.  She was one of the founding committee members for the Assoc of Children's Diabetes Clinicians (ACDC) in 2006 and has been on working parties for BSPED helping evidence base and re-write the national DKA guidelines in 2020 and for the National Paediatric Diabetes Audit.  For the last 4 years, she has been on the Clinical Advisory Group for the RCPCH Quality Improvement Programme for Paediatric Diabetes. 

In this special episode of the St Emlyn's podcast, we explore the concept of occlusive myocardial infarction (OMI) and its distinctions from ST elevation myocardial infarction (STEMI). Dr. Smith discusses his extensive work and experience in emergency medicine, spanning over three decades, and his development of Dr. Smith's ECG blog. The conversation dives into the limitations of traditional STEMI criteria and the benefits of adopting the OMI paradigm. Additionally, they discuss the revolutionary potential of artificial intelligence in ECG interpretation, particularly through the Queen of Hearts program developed in collaboration with Powerful Medical. Dr. Smith shares compelling studies and real-world applications demonstrating the efficacy of AI in diagnosing ECGs, ultimately offering a promising future for enhanced patient outcomes.

00:00 Introduction

01:43 Steve Smith's Journey in Emergency Medicine and ECGs

02:45 The Evolution of ECG Diagnosis: From STEMI to OMI

03:55 Challenges and Resistance to the OMI Paradigm

07:10 Key Indicators of Occlusive Myocardial Infarction

09:25 The Role of Artificial Intelligence in ECG Diagnosis

11:03 Development and Implementation of the Queen of Hearts AI

14:28 Clinical Studies and Real-World Applications

21:10 Future Prospects and Final Thoughts

A comprehensive blog post with references is available here

00:00 Introduction to the Podcast

01:03 The Deadly Nature of Eating Disorders

02:23 Medical Complications of Eating Disorders

05:08 Cardiovascular and Other Systemic Effects

07:22 Risk Assessment and MEAD Guidance

10:23 Communication and Management Tips

15:24 Conclusion and Final Thoughts

Comprehensive notes can be found here

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.

The sudden death of anyone is a tragic event, but even more so a child, particularly when it comes completely unexpectedly. We've all seen stories in the papers or even been involved in caring for these young people. In this podcast Harshil Dhutia talks about the common causes fo sudden cardiac death, and gives a roadmap for the investigation of young people with worrying symptoms and ongoing care for their families.

There are more details in the comprehensive post on the St Emlyn's blog site

This podcast was recorded live at the Hope Church in Winchester as part of the PREMIER conference. We are grateful to the organising team for hosting us and allowing us to use the audio. The PIER and PREMIER websites are full of amazing resources for anyone working in Paediatric Emergency Medicine and we recommend them highly.

Harshil Dhutia is a consultant cardiologist at Glenfield Hospital, University Hospitals of Leicester the lead for inerited cardiac conditions service in the region, providing specialist care for patients with genetic heart diseases and their family members. He is a International Board of Heart Rhythm Examiners certified heart rhythm specialist for all aspects of cardiac device implantation and management including pacemakers, defibrillators and cardiac resynchronisation therapy. He is an expert in sports cardiology and has extensive clinical and research interests in the management of competitive and recreational athletes with cardiovascular disease. He is the medical lead for the Joe Humphries Memorial Trust, a Leicestershire based charity that raises awareness of sudden cardiac death in young people and provides cardiovascular resuscitation and AED training in schools, sports clubs and to members of the community.

You can find an in-depth set of shownotes on St Emlyn's. Please do also like and subscribe, wherever you get your podcasts.

This month's content includes...

Premier Conference - 11th-12th June 2024, Winchester

Tactical Trauma 24 - 7th-9th October, Sundsvall, Sweden

RCEM Annual Scientific Conference

Conor Crowley, Justin Salciccioli, Wei Wang, Tomoyoshi Tamura, Edy Y. Kim, Ari Moskowitz, The association between mechanical CPR and outcomes from in-hospital cardiac arrest: An observational cohort study, Resuscitation, 2024, 110142, ISSN 0300-9572, https://doi.org/10.1016/j.resuscitation.2024.110142.

Roussel M, Teissandier D, Yordanov Y, Balen F, Noizet M, Tazarourte K, Bloom B, Catoire P, Berard L, Cachanado M, Simon T, Laribi S, Freund Y; FHU IMPEC-IRU SFMU Collaborators; FHU IMPEC−IRU SFMU Collaborators. Overnight Stay in the Emergency Department and Mortality in Older Patients. JAMA Intern Med. 2023 Dec 1;183(12):1378-1385. doi: 10.1001/jamainternmed.2023.5961. PMID: 37930696; PMCID: PMC10628833.

Premier Conference - 11th-12th June 2024, Winchester

Tactical Trauma 24 - 7th-9th October, Sundsvall, Sweden

RCEM Annual Scientific Conference

In Part 2 they discuss papers about major haemorrhage, trauma, cardiac arrest and more. 

In Part 1 they discuss all things airway, including where we should be intubating patients needing immediate haemorrhage control. VL vs DL, the effect of blade size on intubation success, whether small adult ventilation bags are better than larger versions, intubating comatose poisoned patients, and more. 

Jansen JO et al. Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial. JAMA. 2023 Nov 21;330(19):1862-1871. doi: 10.1001/jama.2023.20850. PMID: 37824132; PMCID: PMC10570916.

Davenport R et al. Early and Empirical High-Dose Cryoprecipitate for Hemorrhage After Traumatic Injury: The CRYOSTAT-2 Randomized Clinical Trial. JAMA. 2023 Nov 21;330(19):1882-1891. doi: 10.1001/jama.2023.21019. PMID: 37824155; PMCID: PMC10570921.

PATCH-Trauma Investigators and the ANZICS Clinical Trials Group; Prehospital Tranexamic Acid for Severe Trauma. N Engl J Med. 2023 Jul 13;389(2):127-136. doi: 10.1056/NEJMoa2215457. Epub 2023 Jun 14. PMID: 37314244.

Shepherd JM et al Safety and efficacy of artesunate treatment in severely injured patients with traumatic hemorrhage. The TOP-ART randomized clinical trial. Intensive Care Med. 2023 Aug;49(8):922-933. doi: 10.1007/s00134-023-07135-3. Epub 2023 Jul 20. PMID: 37470832; PMCID: PMC10425486.

Bouzat P et al. Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients With Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial. JAMA. 2023 Apr 25;329(16):1367-1375. doi: 10.1001/jama.2023.4080. PMID: 36942533; PMCID: PMC10031505.

Torres CM, Kent A, Scantling D, Joseph B, Haut ER, Sakran JV. Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and Canadian Adult Civilian Trauma Centers. JAMA Surg. 2023 May 1;158(5):532-540. doi: 10.1001/jamasurg.2022.6978. Erratum in: JAMA Surg. 2023 Apr 5;: PMID: 36652255; PMCID: PMC9857728.

Marsden MER, Kellett S, Bagga R, Wohlgemut JM, Lyon RL, Perkins ZB, Gillies K, Tai NR. Understanding pre-hospital blood transfusion decision-making for injured patients: an interview study. Emerg Med J. 2023 Nov;40(11):777-784. doi: 10.1136/emermed-2023-213086. Epub 2023 Sep 13. PMID: 37704359; PMCID: PMC10646861.

Wohlgemut JM, Pisirir E, Stoner RS, Kyrimi E, Christian M, Hurst T, Marsh W, Perkins ZB, Tai NRM. Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome. Trauma Surg Acute Care Open. 2024 Jan 12;9(1):e001214. doi: 10.1136/tsaco-2023-001214. PMID: 38274019; PMCID: PMC10806521.

Cheskes S, Verbeek PR, Drennan IR, McLeod SL, Turner L, Pinto R, Feldman M, Davis M, Vaillancourt C, Morrison LJ, Dorian P, Scales DC. Defibrillation Strategies for Refractory Ventricular Fibrillation. N Engl J Med. 2022 Nov 24;387(21):1947-1956. doi: 10.1056/NEJMoa2207304. Epub 2022 Nov 6. PMID: 36342151.

Siddiqua N, Mathew R, Sahu AK, Jamshed N, Bhaskararayuni J, Aggarwal P, Kumar A, Khan MA. High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial. Emerg Med J. 2024 Jan 22;41(2):96-102. doi: 10.1136/emermed-2023-213285. PMID: 38050078.

Wilkinson-Stokes M, Betson J, Sawyer S. Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. Emerg Med J. 2023 Feb;40(2):108-113. doi: 10.1136/emermed-2021-212294. Epub 2022 Sep 30. PMID: 36180168.

Patterson T, Perkins GD, Perkins A, Clayton T, Evans R, Dodd M, Robertson S, Wilson K, Mellett-Smith A, Fothergill RT, McCrone P, Dalby M, MacCarthy P, Firoozi S, Malik I, Rakhit R, Jain A, Nolan JP, Redwood SR; ARREST trial collaborators. Expedited transfer to a cardiac arrest centre for non-ST-elevation out-of-hospital cardiac arrest (ARREST): a UK prospective, multicentre, parallel, randomised clinical trial. Lancet. 2023 Oct 14;402(10410):1329-1337. doi: 10.1016/S0140-6736(23)01351-X. Epub 2023 Aug 27. PMID: 37647928.

Issa EC, Ware PJ, Bitange P, Cooper GJ, Galea T, Bengiamin DI, Young TP. The “Syringe Hickey”: An Alternative Skin Marking Method for Lumbar Puncture. J Emerg Med. 2023 Mar;64(3):400-404. doi: 10.1016/j.jemermed.2023.01.013. PMID: 37019501.

In Part 1 they discuss all things airway, including where we should be intubating patients needing immediate haemorrhage control. VL vs DL, the effect of blade size on intubation success, whether small adult ventilation bags are better than larger versions, intubating comatose poisoned patients, and more. 

Check out part 2 for papers about major haemorrhage, trauma, cardiac arrest and more.

Dunton Z, Seamon MJ, Subramanian M, Jopling J, Manukyan M, Kent A, Sakran JV, Stevens K, Haut E, Byrne JP. Emergency department versus operating room intubation of patients undergoing immediate hemorrhage control surgery. J Trauma Acute Care Surg. 2023 Jul 1;95(1):69-77. doi: 10.1097/TA.0000000000003907. Epub 2023 Feb 28. PMID: 36850033.

Prekker et al: Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults August 3, 2023 N Engl J Med 2023; 389:418-429 DOI: 10.1056/NEJMoa2301601

Landefeld KR, Koike S, Ran R, Semler MW, Barnes C, Stempek SB, Janz DR, Rice TW, Russell DW, Self WH, Vonderhaar D, West JR, Casey JD, Khan A. Effect of Laryngoscope Blade Size on First Pass Success of Tracheal Intubation in Critically Ill Adults. Crit Care Explor. 2023 Mar 6;5(3):e0855. doi: 10.1097/CCE.0000000000000855. PMID: 36895888; PMCID: PMC9990830.

Snyder BD, Van Dyke MR, Walker RG, Latimer AJ, Grabman BC, Maynard C, Rea TD, Johnson NJ, Sayre MR, Counts CR. Association of small adult ventilation bags with return of spontaneous circulation in out of hospital cardiac arrest. Resuscitation. 2023 Dec;193:109991. doi: 10.1016/j.resuscitation.2023.109991. Epub 2023 Oct 5. PMID: 37805062.

Freund Y et al. Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial. JAMA. 2023 Dec 19;330(23):2267-2274. doi: 10.1001/jama.2023.24391. PMID: 38019968; PMCID: PMC10687712.

Eastwood G et al, TAME Study Investigators. Mild Hypercapnia or Normocapnia after Out-of-Hospital Cardiac Arrest. N Engl J Med. 2023 Jul 6;389(1):45-57. doi: 10.1056/NEJMoa2214552. Epub 2023 Jun 15. PMID: 37318140.

Downing J, et al. Prevalence of peri-intubation major adverse events among critically ill patients: A systematic review and meta analysis. Am J Emerg Med. 2023 Sep;71:200-216. doi: 10.1016/j.ajem.2023.06.046. Epub 2023 Jun 28. PMID: 37437438

As ever, we hope you enjoy the podcast. Please do like and subscribe, and if you'd like to contribute to St Emlyn's in any way please get in touch. 

Please do get in touch if you would like to contribute to St Emlyn's and as ever do like and suscribe and tell your friends (if you think the podcast is any good). 

Mentioned in the podcast

• Gary Klein - Streetlights and Shadows
• Critical Appraisal Nugget - Semi Structured Interviews
• EMCrit - Shadowboxing
• EMCrit - Interview with Gary Klein
• A Skeptic's Guide to Emergency Medicine
• Life in the Fast Lane - What is AI and How Does it Work
• T-MACS scores
• Homo Deus: A Brief History of Tomorrow by Yuval Noah Harari 
• East Anglia Air Ambulance RAID Conference

All of us at St Emlyn's wish you all, wherever you are on the world a peaceful, happy and restful Christmas. 

Please do like and subscribe and get in touch if you'd like to contribute to our ongoing work. 

Peek GJ, Clemens F, Elbourne D, Firmin R, Hardy P, Hibbert C, Killer H, Mugford M, Thalanany M, Tiruvoipati R, Truesdale A, Wilson A. CESAR: conventional ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure. BMC Health Serv Res. 2006 Dec 23;6:163. doi: 10.1186/1472-6963-6-163. PMID: 17187683; PMCID: PMC1766357.

Stub D, Bernard S, Pellegrino V, Smith K, Walker T, Sheldrake J, Hockings L, Shaw J, Duffy SJ, Burrell A, Cameron P, Smit de V, Kaye DM. Refractory cardiac arrest treated with mechanical CPR, hypothermia, ECMO and early reperfusion (the CHEER trial). Resuscitation. 2015 Jan;86:88-94. doi: 10.1016/j.resuscitation.2014.09.010. Epub 2014 Oct 2. PMID: 25281189.

Belohlavek J, Smalcova J, Rob D, et al. Effect of Intra-arrest Transport, Extracorporeal Cardiopulmonary Resuscitation, and Immediate Invasive Assessment and Treatment on Functional Neurologic Outcome in Refractory Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2022;327(8):737–747. doi:10.1001/jama.2022.1025

Martje M. Suverein, M.D., Thijs S.R. Delnoij, M.D., et al. Early Extracorporeal CPR for Refractory Out-of-Hospital Cardiac Arrest. The INCEPTION trial. N Engl J Med 2023; 388:299-309. DOI: 10.1056/NEJMoa2204511

The Alfred ECPR Role Cards

The Bottom Line ECMO Reviews

Thank you again for listening to the St Emlyn's podcast. Please do like and subscribe and get in touch if there is anything you'd like us to discuss or if you'd like to get involved. 

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

In this episode, Simon and Iain talk about DL vs VL, the PATCH trial, drug pushers, packers and stuffers, the new head injury guidelines from NICE and the AMAX4 algorithm and much more.

If you would like to submit something to St Emlyn's for consideration we'd love to hear from you.

Times are tough in the NHS at the moment, but we hope at St Emlyn's we can remind you of all the best parts of the incredibly important and rewarding job we do.

Take care. 

In this talk, Jilly goes talks through how we can define these events as high and low risk and gives us tools to manage these patients (and their parents)

Along with colleagues, Jilly has written a guideline for BRUE, the full version of which you can find here

Jilly also mentions a flowchart from Peds Cases, which you can find here

There is also this superb blog post from Natalie May on the St Emlyn's website which accompanies this podcast, which goes through some really useful cases.

As a Wessex ST7 in Paediatric Emergency Medicine (RCPCH), Jilly Boden currently works in Queen Alexandra Hospital (Portsmouth).  Her specialist interests include acute stabilisation and transfer of the critically ill patient, having spent a year with the 'Southampton & Oxford Retrieval Team' (SORT) and hopes to find a way of combining this with her future PEM career. Jilly has a passion for education, particularly 'PEM to the non-paediatrician', including international teaching of the tri-service military GPs, and being on the national committee to write a new standardised paramedic paediatric curriculum. In her free time (you know, apart from the kids and all that) she works as part of the track medical team for the 'British Motorcycle Racing Club', providing pre-hospital care to high velocity polytrauma patients in the 'golden hour' following collisions often exceeding 120mph. 

There are three main mechanisms – violence, impalement and self harm, although the first is by far the most common. 

Penetrating injuries are rare but have significant morbidity and mortality. The key is early and accurate diagnosis, and many can be managed conservatively. The distribution of penetrating injuries across the UK differs widely, with most in the London area, although as seen in the news recently can happen anywhere.

Remember how traumatic it is to be a trauma patient. We put you on a bed, cut off your clothes, stick needles in you and take your family away. Some will also just not engage with you (teenage boys particularly) making assessment difficult. Be kind. Don’t get frustrated.

Physiologically there may be a strong vagal response that can hide some of the signs we’d expect. Also, bear in mind the events prior to the injury – the child may have been running a considerable distance (before and after the incident) raising their lactate (but don’t assume this is the cause). Children tend to ‘fall off a cliff’ – they appear well, but can suddenly decompensate – keep the momentum to definitive management going and do not be falsely reassured.

John mentioned a great friend of St Emlyn’s Vic Brazil and we would heartily endorse you have a look at her work.

You can find more information about the Reducing Knife Crime initiative here

Blast injury affects every body cavity, but it is the CABC approach that matters, Doing the basics well is still the key. Bleeding points may not be obvious so apply tourniquets wherever stops the bleeding.

Often patients will not arrive in ones or twos but as a whole group affected by an incident, so it is vital we are prepared. The Paediatric Blast Injury Field Manual is a free resource available to download here and is highly recommended.

Chris Hillman is a Consultant in Emergency Medicine and Paediatric Emergency Medicine, working in Southampton. Serving in the Royal Navy since university, he has deployed on Ships, Submarines and with Commando units globally, and with the Army to Afghanistan and Iraq. He is the outgoing Consultant Advisor in Emergency Medicine and Clinical Director Commando Forward Surgical Group. 

Looking after patients with non-epileptiform seizures are a challenging, and common, event in the Emergency Department. 10% of attendances at paediatric neurology clinics are thought to be 'functional' and a lot of these will also present to the ED. These problems can involve a wide range of physical or sensory manifestations, almost all of wide have significant differentials which we cannot miss.

A large number of these patients can end up with an incorrect diagnosis, some of this due to confirmation bias by clinicians, but also some with psychogenic non-epileptiform seizures may coexist with organic problems.

The history is key and can be helped significantly by watching videos of events. There may be other factors giving a clue to a non-epileptic cause. Sometimes this will only happen in one place, like school, and the history may be inconsistent. Awareness and generalised bilateral movements, with episodes that are different each time all point to a non epileptiform origin. And then there are symptoms just 'not fitting' with our knowledge of dermatomal distribution.

There are Red Flags - Events happening during exercise, neurological signs, unpredictability and patterns to the events all point to a more sinister diagnosis

Management is incredibly difficult, particularly in trhe ED. Don't suggest an organic diagnosis and leave some ambiguity. There is time to get more information and there are few definitive diagnostic tests. EEGs are notoriously unreliable. Self help groups can help.

Steve Warriner has worked as a paediatrician at the QA in Portsmouth for the last 16 years. He trained in various regions in the UK including the Midlands, Yorkshire and the North East of England before working in Somerset for a brief period. He has a particular interest in epilepsy and neurological conditions in children and lead the district epilepsy service in Portsmouth. He teaches on the British Paediatric Neurology Association epilepsy training courses both in the UK and across the world. He was part of the team who designed and implemented the training course (initially in Myanmar) and the method of cascade training has recently been recognised by the World Health Organisation and the course now runs in nearly 30 counties in 3 languages. Steve recently chaired a multidisciplinary working group to update the Advanced Life Support Group guideline for management of prolonged seizures. In his spare time, Steve is a triathlete who qualified for and competed in the World Ironman Championship race in Hawaii in 2022.

In this episode, David James challenges our current practice when we give a 'weaning plan' for children discharged with wheeze. 

There is a plan here that you can review and give to patients and their carers.

More information at these excellent websites

• PIER Network
• Southampton Oxford Retrieval Team
• Healthier Together

David James has been a PEM Consultant at University Hospital Southampton since 2018. His main interests are in training and education, adolescent emergency medicine and Quality Improvement. He is the Divisional Director of Medical Education and a Training advisor on the PEMISAC. He is the acute care lead for Wessex Healthier Together and has led several projects including those around acute wheeze at UHS and regionally. Outside of work he enjoys swimming, cycling and running and is extremely average at triathlons.

Thanks again for listening. Please do like and subscribe here. 

Please do like and subscribe

Each episode has a standard format with a case to set the scene, a set of learning objectives, a discussion, a summary and a case resolution. 

There are comprehensive listening notes on the dedicated website, as well as a growing set of other resources. 

We hope you enjoy listening. The rest of the podcasts can be found on Spotify, or wherever you get your podcasts. 

The music for this series (just as it is for the St Emlyn's Podcast) is composed by Greg Beardsell

With the help of Gregory Yates, an academic doctor based in Manchester, this episode introduces two core concepts: sensitivity and specificity. These are two ways of thinking about the accuracy of a diagnostic test. Knowing the sensitivity and specificity of an investigation will give you a decent idea of how it should be used in the emergency department.

Sensitivity (Sn) describes the chance that a test will be positive if your patient has the condition you're testing for. Some people call it the 'true positive rate' or alternatively the positivity in disease (PID) rate. If you need a hand remembering it, you can always remember that PID is a sensitive issue.

Meanwhile, specificity (Sp) considers the chance of a test being negative if the patient doesn't have the condition you're testing for. It's the 'true negative rate' or alternatively the negativity in health (NIH) rate. There are times when we particularly need a test to have a high sensitivity. This is generally when we want to be particularly confident that a test accurately identifies everyone with the relevant condition because we really don't want to miss it. We need a high sensitivity to rule out disease. (Sn-uff it out). At other times, we need to be confident that a patient with a positive test actually has the disease - for example, if the treatment is unpleasant or involves exposing patients to risk. In that case, we want a high specificity to rule in disease. (Sp-in it in).

In this CAN, we use D-Dimer as an example of a very sensitive investigation: it’s positive in nearly 100% of cases of venous thromboembolism. Specificity describes the likelihood that the test will be negative if your patient does not have the disease. We use HbA1c as an example of a highly specific investigation: it’s rarely used in the emergency department, but if it’s elevated, we can be almost certain that the patient is diabetic. HbA1c is almost never (]]> The latest CAN is one of our brand-new 'revision editions' -- brief podcasts aimed at covering the essentials of critical appraisal for medical students and junior doctors preparing for exams.

With the help of Gregory Yates, an academic doctor based in Manchester, this episode introduces two core concepts: sensitivity and specificity. These are two ways of thinking about the accuracy of a diagnostic test. Knowing the sensitivity and specificity of an investigation will give you a decent idea of how it should be used in the emergency department.

Sensitivity (Sn) describes the chance that a test will be positive if your patient has the condition you're testing for. Some people call it the 'true positive rate' or alternatively the positivity in disease (PID) rate. If you need a hand remembering it, you can always remember that PID is a sensitive issue.

Meanwhile, specificity (Sp) considers the chance of a test being negative if the patient doesn't have the condition you're testing for. It's the 'true negative rate' or alternatively the negativity in health (NIH) rate. There are times when we particularly need a test to have a high sensitivity. This is generally when we want to be particularly confident that a test accurately identifies everyone with the relevant condition because we really don't want to miss it. We need a high sensitivity to rule out disease. (Sn-uff it out). At other times, we need to be confident that a patient with a positive test actually has the disease - for example, if the treatment is unpleasant or involves exposing patients to risk. In that case, we want a high specificity to rule in disease. (Sp-in it in).

In this CAN, we use D-Dimer as an example of a very sensitive investigation: it’s positive in nearly 100% of cases of venous thromboembolism. Specificity describes the likelihood that the test will be negative if your patient does not have the disease. We use HbA1c as an example of a highly specific investigation: it’s rarely used in the emergency department, but if it’s elevated, we can be almost certain that the patient is diabetic. HbA1c is almost never (]]> St Emlyn’s Blog and Podcast false No 683 10 3 full Ep 212 - February 2023 Monthly Round Up https://www.stemlynspodcast.org/e/ep-212-february-2023-monthly-round-up/ https://www.stemlynspodcast.org/e/ep-212-february-2023-monthly-round-up/#comments Mon, 20 Mar 2023 06:00:00 +0000 ebem.podbean.com/b721e1ed-e7cc-3267-b27b-f9ab585d09b3 Our regular monthly round up and chat from the St Emlyn's blog. We talk about the use of artificial intelligence in research and the use of remifentanil instead of neuromuscular blockade in rapid sequence intubation. Plus more about the StEmlynsWILD conference and Simon's new role as Dean of RCEM and how you can get involved. 

In this easily digestible and succinct podcast Rick and Laura Howard go through the pros and cons of setting up semi structured interviews and how these can be used effectively in qualitative research.

In the latest episode, we cover a qualitative research technique: semi-structured interviews. Qualitative research might be out of your comfort zone: we’re generally more comfortable with quantitative measures – numbers and statistics. It’s something they have experience with, having previously published a paper exploring the impact of events that happen at work on the wellbeing of emergency physicians. This was a labour of love for Laura. Laura wrote a powerful blog about it here.

Semi-structured interviews are a great way to get the really rich data we need to understand something in greater depth. They allow us to ask ‘why?’ as well as just ‘what?’, ‘who?’ and ‘when?’. But reading qualitative research papers can be difficult when it takes us out of our comfort zone. In this CAN podcast, Laura and Rick take us through what semi-structured interviews are, why we might use them, how you design and conduct them, and they also have some pearls of wisdom about how to make transcribing them a lot less painful. By the end, we hope that you’ll feel confident with the basics of the technique. And if you want to practice your critical appraisal, why not put their study under the microscope?

Click here to buy tickets for #StEmlynsWILD

We also announced some of the plans for StEmlynsWILD. Look out for booking details and more in the coming weeks. 

Yet we use the term wellbeing to describe a wide variety of different things (often in terms of being the opposite of burnout which it most certainly isn't). 

In this second episode of our series Liz Crowe discusses in detail what the literature says about wellbeing and how we may be able to use this going forward.

Please do like and subscribe. Thanks for listening.

Liz, who be well known to St Emyn's audiences, has just completed her PhD on "Understanding the risk and protective factors for burnout and wellbeing of staff working in the Paediatric Intensive Care Unit: PICU staff wellbeing" and has an unrivalled real world and evidence based experience of what these terms really mean.

In this first in a special series Liz goes into depth describing not only what burnout is, but how it can be measured (and the limitations of this) and most importantly how this is a system issue and not a diagnosis.

In the next episode we will discuss another commonly used term 'wellbeing'.

We think this series is incredibly important and hope you will help us share it far and wide. You can read the accompanying blogpost here.

Iain and Simon chat about batching in EDs, Ossilation in decision making and a whole lot more about trauma (chest drains, extrication, sex and TXA and rib fixation).

Please do like and subscribe and keep an eye out for our new sister website St Emlyn's Medical School and it's podcast series coming soon. 

Lots to think about and discuss. Please do like and subscribe and get in touch if there is anything you'd like us to cover on the blog and podcast, or perhaps you'd even like to write something for publication. 

Listen to Simon and Iain discuss the latest therapies in COVID, particularly Baricitinib, calcium in trauma and how we find balance in our work-life blend.

Please do like and subscribe to the podcast and tell your friends and colleagues. We've lots of exciting stuff coming your way over the next few months.

We hope you enjoy the podcast. Please do like and subscribe on your preferred podcast app and tell your friends and colleagues about us. 

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...)

Thank you again for listening to the St Emlyn's podcast. We really do hope that you enjoy it and have found our witterings over the last 200 episodes useful. 

Hopefully we'll see some of you at the RCEM CPD Conference in Bournemouth next week. 

Please do rate us on iTunes, like, subscribe, tweet and tell you friends about the podcast. 

See https://www.stemlynsblog.org/?s=feedback for more.

Please do like, subscribe and tell your friends about the St Emlyn's podcast. 

Thanks again for listening. Please like and subscribe and all that. We look forward to seeing you next season (in about a month...)

Iain and Simon

We hope all you all have a very happy Christmas and chance over the festive period to relax. Do explore our back catalogue of podcasts for more on wellbeing and grief at Christmas. 

Please do subscribe and rate and review us on your chosen podcast provider. 

Take care all. 

Please see the website for more information and don't forget to subscribe and rate the podcast (if you think it's any good).  

In this episode we discuss Eisenmenger Syndrome, Transposition of the Great Arteries and Coarctation of the Aorta. 

Look out for Part 2, which will be released next week, where we discuss Eisenmenger Syndrome, Transposition of the Great Arteries and Coarctation of the Aorta. 

With advances in paediatric cardiac surgery, more and more patients with complex congenital heart disease are surviving to adulthood: in the 1950s you might expect a survival rate of about 10%, whereas now this is more like 85%. In fact, there are more patients in the adult congenital heart disease population than there are in the paediatric one (with 2.3 million adults vs 1.9 million children in Europe).

Many patients with Adult Congenital Heart Disease are young and able to live a relatively normal life. This means that they can travel and take part in just the same sort of activities as those without ACHD. They may well turn up in your Emergency Department one day, regardless of whether you are a tertiary centre or a district general hospital (DGH).

They are experts, and know their disease well, but this does not abstain you from a responsibility to know about them too! When these patients become unwell, they can go downhill very fast and you may not have the chance to discuss with them their exact lesion and its management.

The anatomy and physiology of these patients is abnormal, so they may present in atypical ways, and may not respond to usual medical interventions: in fact, some of our usual treatments may even be harmful.

However, starting with our usual 'ABC' approach is by far the best way to go, whilst gathering more information and contacting their specialist centre. Many patients will have their last clinic letter and ECG with them (which will also have the direct dial number of their specialist). And if they, or their relative, say there is something wrong you must believe them and do all you can to make sure they are fully investigated.

The presence of scars may give you some clues as to the patient's underlying condition and previous surgical repairs. (BMJ 2016; 354: i3905)

• Do your usual ABC assessment.
• Pay particular attention to the respiratory rate - this should be normal.
• Give oxygen if they look unwell.
• They should have a 'normal' blood pressure - any hypotension should be taken as abnormal and investigated.

This is not a condition in itself, but in fact the resulting circulation after a series of operations that could've been performed due to a number of different underlying conditions:

• Tricuspid Atresia
• Double Inlet Left Ventricle
• Atrio-ventricular Septal Defect – unbalanced
• Pulmonary Atresia
• Hypoplastic Left Heart Syndrome

In essence these patients are born with a single functioning ventricle, that has to be utilised to supply the systemic side of the circulation, whilst the Fontan acts as a passive means of returning blood to the pulmonary circulation.

It was first devised in the early 1970s by Dr Francis Fontan, so the majority of patients with this are in their mid thirties and younger.

As the patient is entirely dependent on their systemic ventricle to work optimally, any disturbance of the delivery into it is very poorly tolerated. Thus, any arrhythmia is life threatening, even a mild atrial tachycardia.

These patients need to be returned to sinus rhythm as quickly as possible and the recommended method for this is DC cardioversion in expert hands.

Fontan patients have an incredibly fragile circulation and any change in their respiratory physiology can be life threatening, especially if it increases their pulmonary pressures (and thus prevents the passive flow within the Fontan circulation). These patients are not candidates for sedation in the ED and should have an experienced anaesthetist to manage them during the procedure.

Beware if the patient comes in and tells you they are fasted! This means they have been in this situation before and needed DC cardioversion.

Over time the patient develops venous hypertension within the Fontan connection. This causes the formation of collateral vessels, that may link into the bronchial arterial tree.

If the patient presents in shock treat them as you would any other patient with emergency blood transfusion.

Any haemoptysis, however small, may herald the beginning of a massive bleed. These patients need further investigation, probably a CT chest with contrast. These vessels may then be coiled by interventional radiology.

If the patient has a non fenestrated Fontan they should have normal oxygen saturations. However, if there is a fenestration there will be shunting and therefore a reduction in oxygenation.

For patients this is trade of between being pink or blue, each of which have complications.

Dr Sam Fitzsimmons is a Consultant Cardiologist in Adult Congenital Heart Disease (ACHD) at the University Hospital Southampton, UK. Sam also subspecialises in pulmonary hypertension and maternal cardiology. Working within a tertiary surgical ACHD centre, Sam delivers an ACHD on call service for emergency admissions, inpatient care, routine outpatient follow-up, intra-operative imaging and post-surgical care, as well as specialist clinics in Pulmonary Hypertension and Maternal Cardiology. Sam holds a Honorary Senior Clinical Lecturer post with the University of Southampton as she is passionate about teaching and in particular, she is enthusiastic about helping demystify congenital heart disease for many non-specialist to improve patient care. Sam is well published in peer review journals, cardiology textbooks and specialist guidelines.

Thanks for listening. Please check out the blogs themselevs at www.stemlynsblog.org and consider subscribing and rating us on iTunes. 

If you'd like to see some more from Peter Brindley you can watch one of his SMACC talks here. 

Simon and Iain also talk about the latest results from the RECOVERY trial, Major Trauma Triage tools, cricothyroidotomy, thromboprophylaxis in COVID19 and the new Medical Licensing Assessment for medical students and the new St Emlyn's Undergraduate Curriculum 

Assessing on-line medical education resources: A primer for acute care medical professionals and others

Peter G Brindley, Leon Byker, Simon Carley, Brent Thoma https://doi.org/10.1177/1751143721999949

Topics discussed this month include tocilizumab in COVID19, TIA risk scores, new Emergency Care standards (targets) and TXA use in epistaxis. We also pay tribute to Dr Cliff Mann, former President of RCEM who sadly died this month. 

Please remember to subscribe to the podcast on iTunes/Google Play and please do leave us some reviews and ratings there.

I’m privileged to be co-leading the COvid-19 National DiagnOstic Research and evaluation programme (CONDOR), which involves a collaboration between amazing teams in Manchester, Oxford, Leeds, Newcastle, London and Nottingham. The programme evaluates diagnostic tests for COVID-19.

We’re extremely lucky to have two very experienced and proactive patient and public representatives as members of our steering committee: Graham Prestwich from Leeds and Val Tate from Oxford.

I recently spoke with Graham and Val to get their thoughts about how we, as clinicians, might effectively communicate with patients during the COVID-19 pandemic. They provide their important insights from a lay perpsective about what they would want from their clinician.

We cover everything from the challenges of communicating while wearing PPE to the way to answer important questions like, “Am I going to die?”, which many of us have, I’m sure, had to answer on a number of occasions over the past 12 months.

I hope that you enjoy the podcast. We realise that 25 minutes wasn’t long enough to cover everything we’d have liked to.We’d really like to know what you think. Are there things that we haven’t covered that you’d like us to? What are your experiences? We’d love you to share your thoughts in the chat!

Rick

Moderna vaccine phase 3 trial - https://www.nejm.org/doi/full/10.1056/nejmoa2022483

Oxford vaccine phase 2/3 - https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)32466-1.pdf

Pfizer vaccine trial - https://www.nejm.org/doi/full/10.1056/NEJMoa2034577

#vaccines #COVID19 #coronavirus

From all at St Emlyn's we hope you have a very happy festive season and we cannot wait to talk to you again in 2021.

Take care,

Simon and all the team

A great listen and lots to learn. 

An evidence based cornucopia of aural pleasure.

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

Take care,

Iain

It's been a relatively quiet on the blog post this month, but we chat through not only blogposts on the REMAP-CAP trial, TXA in Head Injury and the ISARIC COVID Risk prediction tool, but also the situation in the North of England and the recent RCEM Virtual Conference.

The numbers of Lesson Plans available continue to grow. We've had some great feedback following their use in induction. If tyou've not seen them yet, do have a look and let us know what you think. If you're interesed in learning more about Baysian thinking this Lesson Plan is a good place to start.

Take care,

Iain

Blog link here

Welcome to our audio round up of everything on the blog during August. 

As the world continues to be in the grips of the Coronavirus pandemic there have been more papers looking at all aspects of this disease.

Simon reviewed the latest paper on Hydroxychloroquine and Charlie collated some of the top papers covering aspects from aerosol spread and use of CPAP to the effect on vulnerable groups and the effect on staff psychological health

It's not all COVID though. Sepsis is a condition we all want to be able to treat more effectively. Sadly there doesn't seem to be any encouraging news about the use of Vitamin C, Steroids and Thiamine in this latest RCT.

Many of the St Emlyn's group have special expertise in toxicology and Gareth wrote this incredibly informative post about the use of GBL. If you're not sure what "ChemSex" is then this post from a few years ago by Janos is worth a read.

The anonymously written "Look at what they make you give" post really struck a chord with readers, with an astonishing number of views. There are messages here for us all.

The numbers of Lesson Plans available continue to grow. We've had some great feedback following their use in induction. If tyou've not seen them yet, do have a look and let us know what you think.

Coronavirus continues to dominate the medical (and non-medical) headlines, and we discuss the two major results from the RECOVERY trial published recently, one positive and one not so (depending on who you talk to....). Simon also catches up with Roberto Cosentini, who you'll remember from the very powerful podcast at the beginning of the pandemic.

COVID isn't the only EBM circus in town though: we've reviewed HALT-IT and Simon has given a talk about the "Ten Top Trauma Papers" of the last year and Laura reviewed a paper looking at haloperidol for headaches.

We're having to think even harder about how we communicate in the ED, both for clinical care and to deliver education. Two ideas to help learning have been featured this month: The St Emlyn's Lesson Plans and "Background Learning". 

Good luck to all those starting in Emergency Medicine, and a huge thank you to all those who are moving to other areas of medicine or other departments. It's been a curious few months...

Take care,

Iain

*It's actually Get One Free Get Another Free, but whose ever heard of that?

Each lesson plan starts with a descrete learning outcome, to set the scene, as well as details of the RCEM curriculum item(s) that will be covered.

The first tasks are aimed at aquiring some background knowledge and can either be done as part of the session, or beforehand. These utilise the vast "FOAMed" resources (including, but not exclusively, those of St Emlyn's).

Our experience is that time constraints often mean that "background reading" isn't achieved before the session, so would encourage allowing time within it to complete these. They are designed to take about 30 minutes and occupy the first half of the session.

Everything you need for each lesson is included in the plan. We would recommend that each learner has an internet enabled device available (with headphones) to read and listen to the background material at their own pace.

The second half of the session should be facilitated by an expert. This can happen in person, but also online, via any of the interfaces that are now so familiar.

In many plans we have given some case examples, but it would be even better if learners can bring cases of their own for discussion. This element is very much within the control of the facilitator (who should been fully cogniscent of the contents of the knowledge section).

The session finishes off with a summary, this should emphasise again the most important learning points. To really embed the knowledge and skills the particiapants should be encouraged to reflect on what they have learned, and to even talk to thse who were unable to attend about what they missed.

For learners this also gives an opportunity to easily link teaching sessions to their portfolio.

You may want to record the "face-to-face" elements, so that those who were not present are able to access them when they can (and those that did can rewatch to refresh their learning).

Although these plans are designed for delivery in a single centre, there is absolutely no reason why regional (or even national) teaching could take place in this way. The recent COVID19 Journal Clubs have demonstrated beautifully how a group of learners can engage with an online panel.

We would be very happy to receive lessons plans to add to the collection. This is very much a collaborative effort.

Please let us know what you think of these lesson plans and if you are using them in your Department. We'd love to hear your ideas about how we can take medical education forward.

What does this mean for the future of Evidence Based Medicine? Can we really start using a medication when the trial hasn't been peer reviewed and the full dataset not released? 

The blog post by Josh Farkas, that is mentioned in the podcast, is here.

*Professor Simon Carley, Professor of Emergency Medicine at Manchester Metropolitan University and a Consultant in Adult and Paediatric Emergency Medicine at Manchester Foundation Trust, Professor Rick Body Professor of Emergency Medicine in Manchester and Honorary Consultant in Emergency Medicine at Manchester Foundation Trust. Professor Dan Horner, Professor of Emergency Medicine of the Royal College of Emergency Medicine and Consultant in Emergency Medicine and Intensive Care at Salford Royal NHS Foundation Trust.

Keep a look out for the new St Emlyn's Lesson Plans that we hope will help usher in a new era of medical education in a socially distanced world. 

If you would like to donate to the fund in the memory Adel Aziz you can find the link here.

We hope you're finding all of our output useful. Please do subscribe to the website (in the top right hand corner) and rate our podcast on iTunes. 

Take care

Iain

Podcast edited by Izzy Carley

PS You can find the Lesson Plans here. Still a work in progress, but as you've read these "shownotes" you deserve to have a sneak preview... 

The live event took place on Tuesday 26th May.

Today's panel will be hosted by Rick Body The panel includes Prof Paul Klapper (Professor of Clinical Virology), Dr Charlie Reynard (NIHR Clinical Research Fellow), Dr Anisa Jafar, Prof Pam Vallely (Professor of Medical Virology), Ellie Hothershall (Consultant in Public Health), Prof Simon Carley and special guest Kelly Ann Janssens (Emergency Physician in Ireland) to discuss five papers about COVID-19 infection.

This will be the last weekly journal club, but we will be back with more EBM goodness very soon. Do let us know what you like to be included at stemlyns@gmail.com

1. Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for the Treatment of Covid-19 — Preliminary Report. N Engl J Med. Published online May 22, 2020. doi:10.1056/nejmoa2007764
2. Mehra MR, Desai SS, Ruschitzka F, Patel AN. Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis. The Lancet. Published online May 2020. doi:10.1016/s0140-6736(20)31180-6
3. Gray N, Calleja D, Wimbush A, et al. “No test is better than a bad test”: Impact of diagnostic uncertainty in mass testing on the spread of Covid-19. Published online April 22, 2020. doi:10.1101/2020.04.16.20067884
4. Peyrony O, Marbeuf-Gueye C, Truong V, et al. Accuracy of Emergency Department clinical findings for diagnostic of coronavirus disease-2019. Annals of Emergency Medicine. Published online May 2020. doi:10.1016/j.annemergmed.2020.05.022
5. Ludvigsson JF. Children are unlikely to be the main drivers of the COVID‐19 pandemic – a systematic review. Acta Paediatr. Published online May 19, 2020. doi:10.1111/apa.15371

The panel was hosted by Rick Body and included Prof Paul Klapper (Professor of Clinical Virology), Dr Charlie Reynard (NIHR Clinical Research Fellow), Dr Anisa Jafar, Prof Pam Vallely (Professor of Medical Virology), Prof Simon Carley and special guest Liz Crowe (Advanced Clinician Social Worker and PhD candidate in health staff wellbeing in Brisbane) to discuss four papers about COVID-19 infection. We were especially pleased to welcome Liz this week, which enabled us to focus on the important topics of grief, loss and communication during the COVID-19 pandemic.

References

The live event took place on Tuesday 12th May at 11.00am BST (10.00am GMT). 

Today’s panel was hosted by Rick Body The panel includes Prof Paul Klapper (Professor of Clinical Virology), Dr Charlie Reynard (NIHR Clinical Research Fellow), Prof Dan Horner, Dr Anisa Jafar, Prof Pam Vallely (Professor of Medical Virology), Prof Simon Carley and special guest Lauren Westafer (Attending in Emergency Medicine and Co-Creator of the Foamcast blog and podcast) and Ellie Hothershall (head of undergraduate medicine at the University of Dundee and an expert in Public Health) to discuss six papers about COVID-19 infection.

We have seen these samples taken at ever shorter intervals, aiming to discharge low risk patients safely, sooner from the Emergency Department (ED). This has been driven in part by the "Four Hour Emergency Access Target"​ as well as increased crowding in overwhelmed EDs.

In this podcast, internationally renowned researcher Prof Rick Body discusses the latest in troponin research and the recent LoDED study.

The various organisations mentioned by Rick can be found here:

The Innovation Agency Webinar Series

The NHS Accelerated Access Collaborative

The CQUIN that will be implemented later this year (page 15 for the Troponin section)

The Draft NICE recommendations

The live event tool place on Tuesday 5th May at 11.30am BST (10.30am GMT). 

The panel was again be hosted by Rick Body The panel includes Prof Paul Klapper (Professor of Clinical Virology), Dr Charlie Reynard (NIHR Clinical Research Fellow), Dr Anisa Jafar (Academic Clinical Lecturer), Prof Pam Vallely (Professor of Medical Virology), Prof Simon Carley and special guest Justin Morgenstern to discuss six papers about COVID-19 infection.

There will be another COVID 19 Journal Club next week (Tuesday 12th May at 11am).

References

Podcast edited from a live webinar by Izzy Carley 

It's been another busy month at St Emlyn's, with the publication of 15 blog posts and five podcasts, but there does seem to be an awful lot to talk about!

Of course there have been multiple posts and podcasts about COVID-19, and you can fiind all of these on our special St Emlyn's page. Highlights have included the three RCEM/St Emlyn's Webinars which we are delighted to host in podcast form.

It's not just been coronavirus though, we have also dipped out toes into exercise and nutrition, graphic design and horticulture!

Parts of the site have also undergone a bit of a redesign with the curriculum pages now easier to navigate to find that post to fioll an e-portfolio hole.

We hope you're finding all of our output useful. Please do subscribe to the website (in the top right hand corner) and rate our podcast on iTunes.

They'll be much more to come in May I am sure.

Take care

Iain

Podcast edited by Izzy Carley

The live event took place on Tuesday 28th April at 11am BST (10am GMT).

The panel was hosted by Rick Body The panel includes Prof Paul Klapper (Professor of Clinical Virology), Dr Charlie Reynard (NIHR Clinical Research Fellow), Dr Dan Horner (RCEM Professor), Prof Pam Vallely (Professor of Medical Virology), Salim Rezaie (Emergency Physician and Founder of REBEL EM) and Prof Simon Carley (you know him…) to discuss five papers about COVID-19 infection. There will be another COVID 19 Journal Club next week (Tuesday 5th May at 11am).

Edited by Izzy Carley and Iain Beardsell

1. Helms J. High risk of thrombosis in patients in severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Medicine. April 2020:1-21. https://www.esicm.org/wp-content/uploads/2020/04/863_author_proof.pdf.
2. Caputo ND, Strayer RJ, Levitan R. Early Self‐Proning in Awake, Non‐intubated Patients in the Emergency Department: A Single ED’s Experience during the COVID‐19 Pandemic. Acad Emerg Med. April 2020. doi:10.1111/acem.13994
3. Garcia FP, Perez Tanoira R, Romanyk Cabrera JP, Arroyo Serrano T, Gomez Herruz P, Cuadros Gonzalez J. Rapid diagnosis of SARS-CoV-2 infection by detecting IgG and IgM antibodies with an immunochromatographic device: a prospective single-center study. April 2020. doi:10.1101/2020.04.11.20062158
4. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area. JAMA. April 2020. doi:10.1001/jama.2020.6775
5. Metzler B, Siostrzonek P, Binder R, Bauer A, Reinstadler S. Decline of acute coronary syndrome admissions in Austria since the outbreak of COVID-19: the pandemic response causes cardiac collateral damage. Eur Heart J. April 2020. doi:10.1093/eurheartj/ehaa314

The panel was hosted by Rick Body. The panel includes Prof Paul Klapper (Professor of Clinical Virology), Dr Charlie Reynard (NIHR Clinical Research Fellow), Prof Pam Vallely (Professor of Medical Virology), Dr Anisa Jafar (Academic Clinical Lecturer), Dr Casey Parker and Prof Simon Carley (you know him…) to discuss six papers about COVID-19 infection.

The live event took place on Tuesday 21st April 2020

References: 

Paper 1 (00:00) Tang W, Cao Z, Han M, et al. Hydroxychloroquine in patients with COVID-19: an open-label, randomized, controlled trial. April 2020. doi:10.1101/2020.04.10.20060558

03:10 - Paper 1 – Guan et al. Clinical characteristics of Coronavirus disease 2019 in China. NEJM Feb 28 2020

https://www.nejm.org/doi/full/10.1056/NEJMoa2002032

16:54 Paper 2 – Zou et al. Single Cell RNA-SEQ Data Analysis on the receptor ACE2 expression reveals the potential risk of different human organs vulnerable to 2019-NCOV infection. Frontiers of Medicine. Mar 12 2020.

https://link.springer.com/content/pdf/10.1007/s11684-020-0754-0.pdf

21:43 Paper 3 – Gautret et al. Hydroxychloroquine and azithromycin treatment of COVID-19: Results of an open-label non-randomised clinical trial. International Journal of Antimicrobial Agents. 20 Mar 2020

https://www.sciencedirect.com/science/article/pii/S0924857920300996?via%3Dihub

25:25 Paper 4 – Cao et al. A trial of Lopinavir-Ritonavir in adults hospitalized with severe COVID-19. NEJM Mar 18 2020

https://www.nejm.org/doi/pdf/10.1056/NEJMoa2001282

29:35 Paper 5 – Cui et al. Prevalence of venous thromboembolism in patients with severe Coronavirus pneumonia. Journal of Thrombosis and Haemostasis. Apr 9 2020 doi:10.1111/jth.14830

https://onlinelibrary.wiley.com/doi/epdf/10.1111/jth.14830

34:14 Paper 6 – Lynarts et al. Prediction models for diagnosis and prognosis of COVID-19 infection: systematic review and critical appraisal. BMJ. Apr 7 2020 BMJ 2020;369:m1328

https://www.bmj.com/content/bmj/369/bmj.m1328.full.pdf

John a Sports and Exercise Medicine Consultant in Manchester. He is also Chief Medical Officer for British Triathlon and Visiting Professor in Sport & Exercise Medicine at Manchester Metropolitan University.

Nathan is lead performance nutrition scientist at the English Institute of Sport and at ORRECO.

These two academics take us through how sports science might be able to support our wellbeing during the Covid19 pandemic.

References

1. Recommendations to maintain immune health in athletes https://www.tandfonline.com/loi/tejs20
2. Probiotics https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006895.pub3/epdf/full 
3. Vitamin D and Respiratory Tract Infections: A Systematic Review and Meta-Analysis of Randomized Controlled Trials https://pubmed.ncbi.nlm.nih.gov/23840373/
4. Vitamin C for prevention and treatment of pneumonia https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013134/full
5. Vitamin C and common cold https://www.cochrane.org/CD000980/ARI_vitamin-c-for-preventing-and-treating-the-common-cold 
6. Effect of Flavonoids on Upper Respiratory Tract Infections and Immune Function: A Systematic Review and Meta-Analysis https://pubmed.ncbi.nlm.nih.gov/27184276/
7. Vitamin C and Infections https://pubmed.ncbi.nlm.nih.gov/28353648/
8. Zinc lozenges and the common cold: a meta-analysis comparing zinc acetate and zinc gluconate, and the role of zinc dosage https://pubmed.ncbi.nlm.nih.gov/28515951/

Iain remains positive, but Simon thinks the glass is half full. Time will tell who is right (though in truth there is a lot of common ground).

S

There are so many essential lessons in this podcast. Please share with clinical and non-clinical colleagues, as we need to plan NOW. Roberto is quite clear that if we don't train and get plans into place before the wave of cases hit us then both ourselves and our patients will suffer.

In the interest of speed I'm not going to summarise the whole podcast. You have to listen to it all yourself to see what's relevant to you. These are some of my take away messages.

• Divide your department into resp patients and non-resp patients
• Wear PPE and know how to use it
• You will need clinicians who do not usually work in ED. Train and orientate them now (before you need them).
• Most patients are hypoxic and this responds to O2 and CPAP. You're going to need a lot of CPAP and how that happens could be tricky. They found hoods the best (Ed - but how many of those do we have?).
• Although hypoxic, patients have good lung compliance.
• They regularly saw diurnal variation with many patients presenting in the early afternoon.
• It's emotionally exhausting. Prepare yourself and your team psychologically and support them during the pandemic. Roberto's department has an embedded psychologist.
• Health care worker infections were quite low (because they wore PPE for all resp cases).
• Flow through the department and onto wards is absolutely vital.
• Flow out the the main hospitals to other units that can rehabilitate is vital.
• Decisions for ICU level care were similar to normal (in his hospital)

We rarely declare one of our podcasts a 'must listen' but this is an exception. Please listen and share widely. Please think hard about the issues Roberto raises and PLEASE ACT NOW.

vb

S

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October 2019 was a bustling month for the St Emlyn's team, filled with important conferences, groundbreaking research, and engaging discussions in emergency medicine. This round-up covers the highlights, from tactical trauma insights to controversial trial results, providing a comprehensive overview of the month’s most significant developments.

The month started with the Tactical Trauma Conference in Sundsvall, Sweden, where Pete Hume, a colleague from Virchester, presented on the response to the Manchester Arena bombing. This tragic event, involving many pediatric casualties, posed significant challenges in managing a high volume of injured children. Pete’s presentation highlighted the crucial lessons learned during the response, emphasizing the importance of preparedness and efficient resource management.

A standout talk at the conference was given by Geoff Yost, who discussed the 2017 Las Vegas shooting. A key takeaway from his presentation was the importance of utilizing bystanders during mass casualty incidents. Bystanders are often the first to respond, and their actions can significantly influence outcomes. This was exemplified by the recent London Bridge attack, where members of the public intervened using improvised weapons like a narwhal tusk.

Pete also provided insights into leadership in crisis situations, a topic covered by Kate Pryor at the conference. Overall, the Tactical Trauma Conference underscored the need for collaboration with bystanders and the importance of effective leadership during emergencies.

The R.CEM Annual Scientific Conference, held in Gateshead at the end of October, brought together emergency clinicians, nurses, paramedics, and researchers to discuss the latest developments in emergency medicine. Chris Gray, a member of the St Emlyn's team, attended and shared his experiences through a series of blog posts.

One of the most anticipated studies discussed at the conference was the NOPE PAX study on the use of tranexamic acid for treating nosebleeds. Although the results are not yet publicly available, the study is expected to provide valuable insights into this increasingly popular treatment. Another key study was the CAP-IT study, which focuses on the use of antibiotics in pediatric pneumonia—a topic of ongoing debate in the context of antibiotic stewardship.

The conference also featured discussions on the CRASH-3 trial, particularly concerning the use of tranexamic acid in traumatic brain injury. Ian Roberts delivered a compelling presentation on the mechanisms of tranexamic acid and the significant differences in its use across various regions, including the UK, the US, and Australasia.

A major highlight of the R.CEM conference was the presentation of the TIRED study, the first major project from the Trainees Emergency Research Network (TERN). Led by Dan Horner, the study surveyed the levels of fatigue among emergency physicians across the UK, using the Need for Recovery Score to assess recovery time after shifts.

The study revealed concerning results, with emergency clinicians scoring an average of 73 on the Need for Recovery Score, significantly higher than the previous highest score of 55 recorded for Iranian miners. This suggests that emergency clinicians are under immense pressure, leading to high levels of fatigue.

Interestingly, older clinicians had lower scores, indicating either greater resilience or better workload management. However, the study raises the controversial question of whether the job’s demands are causing some clinicians to leave the profession early.

The TERN network is continuing to explore critical questions in emergency medicine, with upcoming studies on subarachnoid hemorrhage and the necessity of lumbar punctures.

The European Resuscitation Council meeting in Slovenia was another key event in October. The chain of survival—early recognition, CPR, defibrillation, and post-resuscitation care—was a major focus of the conference. While much attention is often given to post-resuscitation care, the most significant impact on survival comes from the early stages of the chain.

The GoodSAM app, which allows trained responders to be notified of nearby emergencies, plays a crucial role in this early response. The app has already made a significant difference in several cases, including cardiac arrests.

Another important discussion at the conference was the use of hypothermia in post-cardiac arrest care. Following the TTM1 trial, which suggested that hypothermia might not be as beneficial as once thought, some clinicians have stopped temperature management altogether. However, evidence presented at the ERC meeting indicates that this may have led to an increase in post-arrest mortality. The ongoing TTM2 trial aims to provide more clarity on the role of hypothermia in post-cardiac arrest care.

Dan Horner’s study on thromboprophylaxis in lower limb immobilization is another significant piece of research published this month. The study, a systematic review, highlighted that the incidence of significant deep vein thrombosis (DVT) in patients with lower limb immobilization is around 2%, and anticoagulation almost certainly reduces this risk.

However, the study also pointed out that there is no clear consensus on which risk stratification tool is best for identifying patients at risk of DVT. The GemNet guidelines from R.CEM are a solid option, but more research is needed in this area. The study also discussed the choice of anticoagulant, noting that while low-molecular-weight heparin is the most commonly used, the use of DOACs, such as rivaroxaban, is on the rise.

As an emergency physician, the balance between preventing life-threatening complications like pulmonary embolism and avoiding significant bleeding events remains a critical consideration in patient care.

The R.CEM Annual Scientific Conference also featured a presentation on the top 10 papers from the past year, covering a wide range of topics in emergency medicine.

One key study explored whether early or delayed cardioversion should be performed in recent-onset atrial fibrillation, with the conclusion leaning towards not immediately intervening. Another study examined whether ventilation should continue during RSI (rapid sequence induction), with evidence suggesting that it should.

The debate over cricoid pressure during RSI continues, with recent evidence indicating that it may not be necessary and could even be harmful in some cases. Magnesium in atrial fibrillation was also discussed, with the evidence supporting its use, particularly when combined with other treatments.

The presentation also covered the use of vasopressors in hemorrhagic shock, with early evidence suggesting they might be beneficial, though more research is needed. Finally, the discussion touched on diagnosing pulmonary embolism in pregnancy using the YEARS score, a promising but still developing area of research.

The CRASH-3 trial, focusing on the use of tranexamic acid in traumatic brain injury, has generated significant debate in the emergency medicine community. While the trial’s findings have already started to influence practice in the UK, the way the results were interpreted and publicized has been controversial.

The debate centres around two main camps: one that argues the trial didn’t conclusively prove that tranexamic acid reduces mortality in traumatic brain injury and another that believes the evidence strongly suggests a benefit in certain subgroups. While not the final word on the subject, the CRASH-3 trial provides enough evidence to justify the use of tranexamic acid in specific scenarios.

As October ends and November begins, there’s much to look forward to. The Asian Conference of Emergency Medicine in India promises to be an exciting event, and the Resuscitology Conference in December is already sold out, with plans to run it again in 2020.

Emergency medicine is more intense than ever, with record numbers of patients and some of the toughest days experienced in the field. Despite these challenges, the St Emlyn's team continues to provide exceptional care and remain at the forefront of emergency medicine research and practice.

Thank you for following along with this month’s round-up. Stay tuned for more updates from St Emlyn's as we continue to explore, learn, and share the latest in emergency medicine.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a minimally invasive technique designed to control hemorrhage in patients with life-threatening bleeding and offers a bridge to definitive surgical intervention. Here at St Emlyn’s, we are committed to exploring innovative solutions that enhance patient outcomes in emergency medicine. In this post, we delve into the essentials of REBOA, its clinical application, benefits, and challenges.

REBOA involves the insertion of a balloon catheter into the aorta via the femoral artery. By inflating the balloon, we can occlude the aorta, thus controlling bleeding below the point of occlusion. This procedure is particularly useful in cases of non-compressible torso haemorrhage, where traditional methods of haemorrhage control are inadequate.

1. Hemorrhagic shock from pelvic fractures or abdominal bleeding.
2. Trauma patients with signs of severe hemorrhage unresponsive to fluid resuscitation.
3. As a temporary measure until surgical control of bleeding is achieved.

1. Patients with known aortic pathology (e.g., aortic dissection).
2. Significant injury above the diaphragm.
3. Prolonged transport times where REBOA may not be beneficial.

Before performing REBOA, it is crucial to ensure that the patient is appropriately resuscitated and stabilized as much as possible. This includes securing the airway, ensuring adequate ventilation, and achieving initial hemodynamic stabilization.

1. Vascular Access: Gain access to the common femoral artery using ultrasound guidance to minimize complications.
2. Catheter Insertion: Insert the REBOA catheter through a sheath into the femoral artery. Advance the catheter under fluoroscopic or ultrasound guidance to the desired level in the aorta (Zone I: above the celiac artery for abdominal hemorrhage, Zone III: above the bifurcation of the iliac arteries for pelvic hemorrhage).
3. Balloon Inflation: Inflate the balloon to occlude the aorta. This temporarily controls bleeding and allows time for definitive surgical repair.

Continuous monitoring of vital signs and catheter position is essential. The occlusion time should be minimized to reduce ischemic complications. Ideally, REBOA should serve as a bridge to definitive surgical intervention within 30-60 minutes.

1. Rapid Hemorrhage Control: REBOA can quickly control bleeding, buying crucial time for surgical intervention.
2. Less Invasive: Compared to traditional open thoracotomy with aortic cross-clamping, REBOA is less invasive, reducing associated morbidity.
3. Improved Survival Rates: Emerging evidence suggests that REBOA can improve survival rates in appropriately selected trauma patients.

1. Technical Expertise: REBOA requires specific training and expertise. Improper technique can lead to significant complications.
2. Ischemic Complications: Prolonged aortic occlusion can lead to ischemia of distal organs and tissues, necessitating careful monitoring and timely deflation.
3. Resource Intensive: REBOA demands resources such as fluoroscopy, ultrasound, and trained personnel, which may not be available in all settings.

REBOA represents a promising advancement in trauma care, offering a vital tool in the management of life-threatening haemorrhage, but it's utility in the Emergency Department is uncertain.

The term "resuscitationist" has become a buzzword within the emergency medicine (EM) and critical care communities, especially following its emergence from the SMACC (Social Media and Critical Care) conferences. Dan Horner delved into this concept in a recent presentation, sparking a broader discussion about what it truly means to identify as a resuscitationist.

At its core, being a resuscitationist isn’t just about having an interest in the resuscitation room. It requires a blend of sharp clinical skills, deep knowledge of resuscitation science, and the ability to apply evidence-based practices effectively. But beyond technical expertise, leadership and teamwork are crucial. A resuscitationist must excel in managing high-stakes, chaotic situations where decisions are made with limited information and under intense time pressure.

Moreover, Dan highlights the importance of humility and collaboration. The best resuscitationists are those who recognize their own limitations and are skilled at drawing on the strengths of others, whether from different specialties or professions. This collaborative approach not only enhances patient care but also builds stronger, more effective resuscitation teams.

Liver disease is on the rise, particularly due to lifestyle factors like alcohol consumption and obesity. Gareth Roberts tackled this pressing issue in his blog post on decompensated liver disease, which is becoming increasingly common in emergency departments (EDs) across the UK and beyond.

Gareth outlines a comprehensive care bundle designed to manage patients with decompensated liver disease effectively. This bundle includes seven key points:

1. Thorough Investigation: Quick and accurate investigations are essential, particularly for detecting complications like spontaneous bacterial peritonitis (SBP), which can be life-threatening.

2. Infection Management: Aggressive treatment of infections is critical, with a focus on using appropriate antibiotics and monitoring for SBP.

3. Acute Kidney Injury (AKI) and Hyponatremia: These complications are common in liver disease patients and must be managed carefully. Gareth discusses the potential benefits of human albumin in these cases.

4. GI Bleeding: Gastrointestinal bleeding, especially from varices, poses a significant risk. Gareth directs readers to additional resources on St Emlyn’s, including a presentation by Chris Gray on managing GI bleeding.

5. Hepatic Encephalopathy: This condition can severely alter a patient’s mental status and requires careful management. With the increasing prevalence of liver disease, understanding and managing hepatic encephalopathy is more important than ever.

Gareth’s post is a must-read for anyone dealing with liver disease in the ED, providing both practical advice and links to further resources.

Education is a cornerstone of St Emlyn’s, and we’re excited to announce the expansion of the MSc in Emergency Medicine at Manchester Metropolitan University. This program has been running successfully for several years and is now broadening its scope to include paramedics, making it a truly multi-professional and multi-disciplinary course.

The MSc program offers a variety of modules tailored to the specific needs of different healthcare professionals. Whether you’re looking to deepen your clinical knowledge, enhance your leadership skills, or explore new areas of emergency medicine, this program has something to offer. For more details, visit our website or reach out directly.

St Emlyn’s remains committed to providing free and open-access content to the global emergency medicine community. However, maintaining and expanding our offerings requires resources. If you find value in what we provide, please consider supporting us financially. Even a small contribution can help us continue to deliver high-quality content to healthcare professionals worldwide.

Coda is the latest evolution in the SMACC legacy, aiming to broaden the scope of its predecessor by incorporating a wider range of specialties, including oncology, public health, and surgery. As a member of the Coda executive team, I can attest to the ambitious goals of this new conference series.

Coda retains the clinical excellence that SMACC was known for, but with an added emphasis on advocacy. Each year, Coda will tackle a significant global health issue, with the inaugural theme focusing on climate change and its impact on medical practice.

It’s important to note that while climate change is a key focus, it won’t dominate the entire conference. Only about 25% of the program will be dedicated to this theme, with the remaining 75% featuring the high-quality clinical content you’ve come to expect from SMACC. The first Coda conference is set to take place in Melbourne in 2020, and we encourage you to participate, whether in person or remotely.

The Zero Point Survey, a concept championed by Cliff Reid, is gaining widespread recognition for its transformative impact on resuscitation practices. The idea shifts the focus of the primary survey in resuscitation from when you first encounter the patient to what you do before you even meet them.

This approach emphasizes the importance of preparation—both mental and environmental. By optimizing everything you can control before the patient arrives, you set the stage for delivering high-quality care when it matters most.

Feedback from the EM community has been overwhelmingly positive, with many clinicians reporting that the Zero Point Survey has changed how they manage the resuscitation room. It’s not just a theoretical concept; it’s a practical tool that’s making a real difference in patient outcomes.

If you’re not yet familiar with the Zero Point Survey, I strongly encourage you to explore the resources available on the St Emlyn’s website, including an excellent video by Cliff Reid that outlines the key elements of this approach.

As we wrap up our review of September’s content, it’s clear that the St Emlyn’s team has been hard at work bringing you the latest in emergency medicine education and clinical practice. But there’s much more to come.

In the coming months, we’ll be covering exciting topics at upcoming conferences, including the ArchiEM conference in Gateshead and the Slovenia ERC conference. These events promise to bring fresh insights and new perspectives that we’ll be sharing with you through our blog posts and podcasts.

In the meantime, keep doing the incredible work you do in emergency medicine. It’s a challenging field, but it’s also incredibly rewarding, and you’re making a difference every day. Thank you for being part of the St Emlyn’s community, and I look forward to continuing this journey with you.

Stay tuned for more great content, and as always, keep pushing the boundaries of what’s possible in emergency care.

The CRASH-3 trial, a landmark study in the field of emergency medicine, has brought significant attention to the potential role of tranexamic acid (TXA) in managing traumatic brain injury (TBI). As one of the largest randomized controlled trials ever conducted on head injury patients, its findings could reshape clinical practices globally, particularly in the pre-hospital and emergency department settings.

The CRASH-3 trial was designed to assess the efficacy of TXA in reducing mortality among patients with traumatic brain injury. TXA is an antifibrinolytic agent commonly used to prevent excessive bleeding in various medical scenarios, such as trauma, surgery, and postpartum hemorrhage. The question posed by CRASH-3 was whether TXA could also reduce deaths in patients who had suffered a TBI, a question that had remained unanswered despite the success of the CRASH-2 trial in managing extracranial bleeding.

The trial focused on adults aged 16 years and older who had sustained a traumatic brain injury. To be included, patients needed to have either a Glasgow Coma Scale (GCS) score of 12 or lower or a positive CT scan indicating intracranial bleeding. Notably, patients with significant extracranial bleeding were excluded from the trial to specifically measure the effect of TXA on TBI outcomes.

A critical aspect of the trial was the timing of TXA administration. Initially, the protocol allowed TXA to be administered within eight hours of injury. However, as data from other studies like the WOMAN trial and CRASH-2 became available, suggesting that the benefits of TXA diminish after three hours, the protocol was adjusted. This change meant that the majority of patients received TXA within three hours of injury, a key factor in the study's final analysis.

The CRASH-3 trial enrolled 12,737 patients across 29 countries, making it one of the most extensive studies of its kind. The primary outcome measured was all-cause mortality at 28 days post-injury. The results showed that overall mortality was slightly lower in the TXA group (18.5%) compared to the placebo group (19.8%), although this difference was not statistically significant.

However, a pre-specified subgroup analysis provided more compelling evidence. When patients with a GCS of 3 and bilateral unreactive pupils (indicating very severe brain injury) were excluded, TXA demonstrated a more significant benefit. In this subgroup, the mortality rate was 12.5% in the TXA group versus 14% in the placebo group, a statistically significant reduction with a relative risk of 0.89. This finding suggests that TXA is particularly beneficial for patients with moderate head injuries (GCS 9-15) who are more likely to survive if bleeding is controlled.

One of the critical metrics for evaluating the effectiveness of a treatment is the number needed to treat (NNT). In the CRASH-3 trial, the NNT was 67, meaning that 67 patients would need to be treated with TXA to save one additional life at 28 days post-injury. For comparison, the NNT for aspirin in acute myocardial infarction is about 42, which is widely regarded as highly effective. An NNT of 67 is therefore quite favorable in the context of emergency medicine, particularly for a condition as serious as traumatic brain injury.

The CRASH-3 trial strongly reinforced the importance of administering TXA as early as possible after a head injury. The data indicated a 10% reduction in TXA’s effectiveness for every 20-minute delay in patients with mild to moderate head injury. This underscores the need for TXA to be administered in the pre-hospital setting, ideally by paramedics at the scene or en route to the hospital. Delaying treatment until after arrival at the emergency department or after conducting a CT scan may significantly reduce the drug's benefits.

The results of the CRASH-3 trial suggest that TXA should be considered for all patients with moderate traumatic brain injury, particularly those with a GCS of 9 to 15 and confirmed intracranial bleeding. For patients with severe head injuries (GCS of 8 or less, or with bilateral unreactive pupils), the benefits of TXA are less clear, likely due to the severity of the primary brain injury.

Given the trial’s findings, it is recommended that TXA be integrated into clinical protocols for the management of head injuries. This is especially relevant in pre-hospital care, where early intervention is possible. TXA should be administered as soon as possible after the injury occurs, particularly in cases where a significant delay in getting to the hospital is expected.

Another important aspect of TXA is its cost-effectiveness. In the UK, a 1-gram dose of TXA costs approximately £1, making it an affordable treatment option for healthcare systems worldwide. This low cost makes TXA a viable option not only in high-income countries but also in low- and middle-income countries where healthcare resources are often limited. Given its affordability and the potential to save lives, TXA is an attractive option for widespread use in managing traumatic brain injury globally.

Although the CRASH-3 trial focused on adults, there is a strong rationale for extending its findings to pediatric patients. The physiology of traumatic brain injury in children is similar to that in adults, and there is no evidence to suggest that TXA would act differently in a younger population. As such, it would be reasonable to use TXA in children with TBI, following the same dosing guidelines adjusted for body weight.

While CRASH-3 has provided valuable insights, research into TXA’s potential uses continues. One area of interest is the development of intramuscular (IM) TXA, which could be particularly useful in pre-hospital settings where intravenous (IV) access is challenging. The possibility of an auto-injector for TXA is also being explored, which could simplify administration and further broaden its use, especially in resource-limited settings.

The CRASH-3 trial marks a significant advancement in our approach to treating traumatic brain injury. The evidence strongly supports the use of TXA, particularly in patients with moderate head injuries who receive the drug within three hours of injury. TXA is safe, cost-effective, and easy to administer, making it a valuable tool in both pre-hospital and hospital settings.

The implementation of CRASH-3’s findings into clinical practice could save thousands of lives annually, particularly in settings where early intervention is possible. As the emergency medicine community, we must act swiftly to incorporate these findings into our protocols and training, ensuring that TXA is used effectively to improve outcomes for patients with traumatic brain injury worldwide.

One of the significant topics covered was the management of acute lower gastrointestinal (GI) bleeding, a common but challenging condition in the emergency department (ED). The complexity of managing these cases often lies in determining the correct priority of care, appropriate management strategies, and even the correct speciality for handling these patients.

We reviewed a consensus guideline from the British Society of Gastroenterology and Hepatology, published in Gut, which offers practical recommendations for the diagnosis and management of acute lower GI bleeds. The guideline emphasizes the importance of using stratification tools to distinguish between stable and unstable patients, which can help streamline management in the ED.

For stable patients, the Oakland score is recommended. This scoring system helps identify which patients can be safely managed on an outpatient basis, reducing unnecessary hospital admissions. Conversely, patients with a major bleed should be admitted and scheduled for a colonoscopy at the earliest opportunity. The guideline also highlights the value of CT angiography for hemodynamically unstable patients, a practice increasingly integrated into emergency care.

Transfusion thresholds, set at 70 grams per litre, align with standard practices in other clinical settings, with adjustments for patients with cardiovascular disease. The guideline also recommends having dedicated GI bleed leads within trusts to ensure seamless coordination with emergency services.

Another crucial discussion from August focused on the environmental impact of healthcare, particularly in anaesthesia. In the UK, healthcare is a significant contributor to climate change, driven by factors like travel, disposable materials, and the use of anaesthetic gases such as nitrous oxide and desflurane.

A key paper by Cliff Shelton and colleagues underscores the need to adopt more sustainable practices in anaesthesia. For example, desflurane is approximately 3,000 times more potent as a greenhouse gas than carbon dioxide. The paper advocates for reducing the use of high-polluting gases and considering greener alternatives where possible.

This shift towards sustainability in healthcare is essential, although challenging, given the nature of medical practice. However, small changes, such as reducing nitrous oxide use in departments where alternatives exist, can collectively make a significant difference. The paper serves as a call to action for healthcare professionals to be more mindful of their environmental impact and to seek sustainable solutions in their practices.

The debate over the best laryngoscope for pre-hospital rapid sequence intubation (RSI) is ongoing, and in August, we reviewed a study that contributed valuable data to this discussion. Published in Critical Care Medicine, the study compared the Macintosh and McGrath laryngoscopes in pre-hospital settings, involving 514 adult emergency patients.

The study found that both devices were equally effective for pre-hospital RSI. Notably, it also revealed that switching to a different device after a failed intubation attempt was more successful than repeating the attempt with the same device. This finding aligns with the 30-second RSI drills many practitioners use, which advocate for changing the approach after a failed attempt.

These findings have practical implications for both pre-hospital and in-hospital care. In the ED, switching to a video laryngoscope, such as the McGrath, after a failed intubation attempt could improve patient outcomes. As video laryngoscopes become more accessible in emergency departments, integrating them into RSI protocols could be a beneficial strategy.

Rusty Carroll’s ongoing series on PTSD within the ambulance service continues to be one of the most impactful contributions to the St Emlyn’s blog. The August instalment focused on the aftermath of PTSD, exploring the journey towards understanding what “normal” looks like after such an experience.

Rusty’s candid reflections resonate with many in the emergency services community, highlighting the mental health challenges prevalent in our field. The series has received positive feedback, with many readers finding comfort and validation in Rusty’s experiences.

However, the widespread relatability of this series also underscores a concerning reality: many emergency service professionals are struggling with similar issues. As a community, we need to support one another, promote mental health awareness, and advocate for resources to address the psychological toll of our work. Revisiting Rusty’s previous installments in this series is highly recommended for a deeper understanding of the complex emotions associated with PTSD in emergency services.

Another fascinating topic from August was the metabolic and biochemical characteristics of packed red cell transfusions, which have significant implications for trauma care in the ED. This discussion was sparked by a conversation on Twitter, leading to critical reflections on the assumptions we hold about blood transfusions.

In trauma care, blood is often regarded as a superior alternative to crystalloids. However, the reality of what we’re transfusing—packed red cells—is quite different from whole blood. A study we reviewed highlighted some surprising statistics about the contents of packed red cells, including a pH of 6.79, a potassium level of 20, and a lactate level of 9.4. These figures reveal that packed red cells are far from the idealized image of whole blood.

The metabolic implications of these characteristics are significant, particularly in the context of massive transfusions. For instance, packed red cells have low levels of 2,3-DPG, which affects their ability to release oxygen to tissues. This raises important questions about how we use blood in trauma resuscitation and whether our current practices are truly optimal.

There’s also an ongoing pre-hospital trial in the UK, known as the RePHILL trial, which is examining the outcomes of patients randomized to receive either blood or no blood in pre-hospital settings. The results of this trial are eagerly anticipated and could challenge the assumption that blood is always better. This could lead to more nuanced transfusion practices in the future.

Finally, we explored the future of diagnostics with insights from Rick Body. His presentation, originally given at the St Emlyn’s Live conference, offers a compelling vision of where diagnostics in the ED is heading. With the rise of machine learning, artificial intelligence (AI), and personalized diagnostics, the landscape of emergency medicine is rapidly evolving.

These technologies are already being integrated into diagnostic processes, but they bring new challenges. The data generated by AI and machine learning can be complex, requiring a shift in how we interpret diagnostic results. We must move away from binary thinking and embrace a more nuanced understanding that includes probabilities, uncertainties, and complexities.

As emergency medicine professionals, we need to prepare for this shift by engaging with these new technologies and incorporating them into our clinical practice. The future of diagnostics is exciting, but it will require ongoing education and adaptation to fully harness its potential.

August 2019 was a month rich with insightful discussions and important research that continue to influence our practice in emergency medicine. From managing lower GI bleeding and the environmental impact of anaesthesia to the complexities of blood transfusions and the future of diagnostics, these topics highlight the diverse challenges and opportunities we face in the ED.

The St Emlyn’s blog and podcast aim to keep you informed and engaged with the latest developments in our field. This review has provided valuable insights that can be applied in your practice, helping you stay ahead in the ever-evolving landscape of emergency medicine. Stay tuned for more updates, and as always, feel free to share your thoughts and experiences with us. Until next time, take care and continue to push the boundaries of what’s possible in emergency medicine.

Welcome back to St Emlyn’s, where we continue to share the latest insights, discussions, and advancements in emergency medicine. July 2019 was particularly rich in content, covering a wide range of topics from practical clinical advice to deeper reflections on the ethics and philosophy of emergency medicine. Here, we summarize the key points from the month’s posts, optimized for clarity and relevance.

Before diving into the content highlights, there are two important announcements:

On December 14th, 2019, the Resuscitology course will be held in Manchester. This course, led by Cliff Reid, offers an in-depth exploration of why certain resuscitation techniques work and how they can be improved in high-stakes scenarios. This is a must-attend for anyone involved in emergency or critical care. Registration details are available on our blog.

Recruitment is now open for the 2019-2020 cohort of the MSc in Emergency Medicine. This three-year online program, available to both doctors and nurses, offers an advanced curriculum in emergency medicine. Alumni like Janus Bae, Alan Grace, and Natalie May have found it immensely beneficial. By 2020, we hope to extend the program to paramedics as well, broadening its reach and impact.

This month’s content ranged from clinical insights and research updates to philosophical discussions about the practice of emergency medicine.

Zaf Kasim, now practicing in the United States, and Rashid Akhil from Pakistan collaborated on a blog post discussing the management of natural disasters, terrorist attacks, and major incidents in Pakistan. Zaf, who trained with us in Verchester, has become an authority in endovascular resuscitation, REBOA, and ECMO.

This post sheds light on the expertise developed by medical professionals in Pakistan, particularly in response to large-scale disasters like the 2005 Kashmir earthquake. It’s a crucial read for anyone interested in global health or disaster medicine, as it demonstrates how effective disaster response systems can be developed even in resource-limited settings.

Chris Gray revisited a talk he gave at the St Emlyn’s Live Conference, focusing on the challenges of managing major gastrointestinal (GI) hemorrhage. Patients presenting with significant upper or lower GI bleeds pose unique challenges, particularly regarding airway management.

Chris offers practical advice, emphasizing the importance of resuscitating before intubation and considering video laryngoscopy in difficult cases. The post also highlights the SALAD (Suction Assisted Laryngoscopy and Airway Decontamination) technique, which is particularly useful in managing patients with large amounts of gastric contents.

Additionally, Chris touches on the use of PPIs, tranexamic acid (TXA), and terlipressin, although he advises caution until more evidence is available. The ongoing HALT-IT trial in the UK, investigating TXA in GI bleeds, is something to watch closely.

Listeriosis, though uncommon, can have severe consequences, particularly for vulnerable populations like the elderly, pregnant women, newborns, and the immunocompromised. This blog post was prompted by a recent outbreak in the UK linked to contaminated hospital food.

The post emphasizes the importance of considering listeriosis in differential diagnoses, particularly for patients presenting with unexplained gastrointestinal symptoms. Blood cultures are essential for diagnosis, making it important to include them in the workup for high-risk patients. Early diagnosis is key to improving outcomes in these cases.

“The Great Day Paradox” delves into the ethical and emotional challenges of emergency medicine. Inspired by a talk at the Don’t Forget the Bubbles conference, this post explores the contrast between the excitement clinicians feel during life-saving procedures and the often devastating impact these events have on patients.

The post encourages clinicians to reflect on their motivations and maintain a patient-centered approach. Drawing on the teachings of John Hinds, it emphasizes that every procedure should be justified by both clinical need and appropriateness for the patient. This blog is a reminder of the importance of balancing clinical enthusiasm with compassion and ethical care.

Rich Carden reviewed the use of inferior vena cava (IVC) filters in major trauma patients, a topic that has been debated for years. IVC filters are intended to prevent pulmonary embolism (PE) in high-risk patients, such as those with significant lower limb or pelvic fractures.

Rich discusses a recent randomized controlled trial published in the New England Journal of Medicine, which found that early prophylactic use of IVC filters did not reduce the incidence of symptomatic pulmonary embolism or death at 90 days. This finding suggests that IVC filters should not be used routinely in major trauma patients, though there may be specific cases where they are warranted.

Ashley Leibig’s presentation at St Emlyn’s Live focused on psychological performance in the resus room, drawing on her experience with StarFlight in Texas. Her blog post explores key concepts such as human factors, crew resource management, and self-awareness in high-pressure situations.

Ashley’s practical advice on managing oneself, the team, and the environment in emergency medicine is invaluable. This post is essential reading for anyone looking to improve their performance under pressure, whether in emergency medicine or other high-stress fields.

The concept of the resuscitative care unit (RCU) or ED-based critical care units was the focus of our final post of the month. Inspired by a paper published in the Emergency Medicine Journal (EMJ), this blog discusses the idea of creating RCUs to serve as a bridge between the emergency department and intensive care.

RCUs are proposed as a solution for managing critically ill patients who require short-term intensive care but may not need full ICU admission. The post also references a JAMA study showing that ED-based ICUs can improve survival rates for critically ill patients. As emergency departments continue to evolve, integrating critical care capabilities is becoming increasingly important.

July 2019 was a month filled with rich, varied content at St Emlyn’s, offering practical advice, research updates, and philosophical reflections on emergency medicine. Whether you’re interested in disaster management, GI haemorrhage, or the ethical challenges of our profession, this month’s highlights provide valuable insights.

We encourage you to engage with our content, share your thoughts, and continue learning. Don’t forget to check out our upcoming events, including the Resuscitology course and the MSc in Emergency Medicine. If you find our content valuable, please consider supporting us through a small donation to help keep St Emlyn’s free and accessible to all.

Thank you for being part of the St Emlyn’s community. We look forward to bringing you more valuable content in the coming months.

You can read more and see the slides/video at http://www.stemlynsblog.com

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

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The DFTB conference, held in London this year, has quickly become an essential event for those involved in pediatric emergency medicine. With a focus on both pediatric and adolescent healthcare, the conference offers invaluable insights and practical advice that can benefit even those who primarily work in adult emergency medicine.

One of the standout topics from the conference was the Paradox of a Good Day in Emergency Medicine. This paradox arises from the nature of emergency medicine, where a "good day" for a clinician—filled with successful procedures and exciting cases—often coincides with what is likely the worst day of a patient’s life. This duality highlights the emotional and ethical complexities that emergency physicians must navigate. As practitioners advance in their careers, they often shift from focusing on the technical aspects of their work to becoming more aware of the profound impact these situations have on patients and their families.

The emotional burden of emergency medicine was another significant theme at the DFTB conference, especially in sessions led by Kim Holt and Neil Spenceley. Holt, who has been involved in whistleblowing in the high-profile Baby P case, shared her experiences of dealing with criticism and professional challenges. Her story serves as a reminder of the resilience required to navigate the ethical and emotional complexities of healthcare.

Spenceley’s session on doctors in distress emphasized the importance of creating supportive systems within healthcare departments. He argued that instead of focusing on making individuals more resilient, we should design systems that inherently support healthcare professionals. This shift in perspective is crucial in addressing the high levels of burnout and stress among emergency medicine practitioners.

Laura Howard’s research on the psychological well-being of emergency physicians further explored this issue. Her qualitative study, which involved interviews with senior emergency physicians, revealed that the emotional impact of the job affects everyone, regardless of their experience level. Events like traumatic deaths, particularly those involving children or body disruptions, were identified as particularly distressing and had lasting effects on the practitioners involved. Howard’s work underscores the need for robust support systems to help clinicians manage the cumulative toll of their work.

The DFTB conference also shed light on the often-overlooked area of adolescent healthcare. As healthcare providers, we tend to categorize patients as either adults or children, but adolescents require a tailored approach that addresses their unique needs. Russell Viner, a leader in pediatric healthcare, discussed how the concept of adolescence has evolved over time. In previous generations, adolescence was a brief period between puberty and adulthood, often marked by early milestones like starting a family. Today, however, adolescence is prolonged, with young people delaying traditional markers of adulthood due to social, educational, and economic factors.

This shift has significant implications for how we approach healthcare for adolescents. In our practice, we must ensure that we are not only addressing the physical health of teenagers but also their mental and emotional well-being. This includes creating healthcare environments that are welcoming and appropriate for adolescents and offering resources that cater to their specific health concerns.

The importance of continuous learning and staying current with the latest research and best practices was another key message from June. Alan Grayson’s talk on going beyond ATLS (Advanced Trauma Life Support) was particularly impactful. While ATLS has been a cornerstone of trauma care globally, Grayson challenged us to think critically about its limitations, especially in high-income countries where multi-disciplinary teams are the norm.

Grayson emphasized the need to focus on the basics—such as administering tranexamic acid, providing adequate analgesia, and ensuring timely administration of antibiotics—before diving into more advanced interventions like REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta). This back-to-basics approach serves as a crucial reminder that even in a high-tech medical environment, the fundamentals of care are what ultimately save lives.

Jason Smith’s session on traumatic cardiac arrest offered new insights into how we approach this challenging situation. Traditional management has focused on chest compressions, adrenaline, and fluid resuscitation, but emerging evidence suggests that in cases of traumatic cardiac arrest, these interventions may not be as beneficial as once thought. Instead, giving blood and stopping the bleeding were identified as more critical interventions. However, Smith cautioned that this approach should be reserved for hypovolemic cardiac arrest, highlighting the importance of understanding the underlying cause of the arrest before determining the treatment course.

A more technical but equally important topic discussed in June was the use of intraosseous (IO) blood sampling. For years, many clinicians have been taught that IO access can provide reliable blood samples for analysis. However, recent evidence suggests otherwise. A systematic review revealed that while it might be possible to obtain certain values like hemoglobin and sodium, the reliability of these results is questionable. Moreover, using IO samples for blood gas analysis or putting marrow through automatic analyzers can lead to equipment malfunction, a concern that has understandably caused anxiety among laboratory staff.

Given this evidence, it’s clear that we need to rethink our approach to IO blood sampling. While it might still have a place in certain situations, particularly for microbiological cultures, relying on IO samples for comprehensive blood analysis is not advisable. This is another example of how continuous learning and critical evaluation of existing practices are essential for improving patient care and ensuring the best possible outcomes.

As we reflect on the lessons from June, it’s evident that emergency medicine is a constantly evolving field that demands both continuous learning and emotional resilience. Whether through attending conferences like Don’t Forget the Bubbles, staying updated on the latest research, or addressing the psychological impact of our work, it’s clear that adaptation and mutual support are key to thriving in this challenging yet rewarding profession.

At St Emlyn's, we are committed to fostering a culture of lifelong learning, open discussion, and mutual support. As we move into the second half of the year, let’s carry forward the insights we’ve gained, keep pushing the boundaries of our knowledge, and continue to support each other in the demanding yet rewarding field of emergency medicine. Take care, and keep up the incredible work you do.

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.

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.

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.

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.

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.

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 (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.

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 (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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Healthcare professionals, particularly those working in critical care and emergency medicine, often face intense situations that test their emotional and mental resilience. While most of the time, we manage to cope with the challenges, there are rare moments that catch us completely off guard, leaving us feeling utterly broken. This guide explores what to do when work breaks you—a situation that is seldom discussed but is profoundly important.

It's crucial to distinguish between the routine stressors of healthcare work and a true mental health crisis. The latter is not just a rough day or a series of challenging weeks. Instead, it's a once-in-a-career event that completely shakes your confidence and leaves you questioning your ability to continue in your role. These moments can be triggered by traumatic patient cases, critical errors, or cumulative stress that finally overwhelms you.

When such a crisis occurs, it’s important to recognize that what you're experiencing goes beyond normal stress—it’s a mental health crisis. Symptoms may include tremors, uncontrollable crying, sleeplessness, and a sense of detachment. These are signs that your mental health is under severe strain, and they should be taken seriously.

One of the most valuable steps you can take is to prepare for the possibility of a mental health crisis before it happens. Just as we plan for emergencies in our professional roles, we should also have a plan in place for our mental well-being.

1. Build a Support Network: Identify a few trusted individuals—whether colleagues, friends, or family—who can be your go-to support in times of crisis. Share with them the kinds of situations that might overwhelm you and how they can help if the time comes.

2. Establish a Routine: Develop a daily routine that includes exercise, healthy eating, and regular sleep. Routine can serve as a stabilizing force during a crisis, providing a sense of normalcy when everything else feels chaotic.

3. Seek Professional Help: It’s wise to establish a relationship with a therapist or counsellor before a crisis hits so you have someone to turn to when you need it. If therapy isn’t an option, know how to access support through your GP or other services.

4. Practice Self-Care: Identify activities that help you relax and de-stress. Whether it’s meditation, reading, or spending time with loved ones, incorporate these into your routine. These activities can become particularly crucial during a crisis.

When you find yourself in the midst of a mental health crisis, your judgment may be impaired, making it difficult to make decisions or know what to do next. Here’s how to navigate those critical moments:

1. Reach Out for Support: Even though your instinct may be to withdraw, it’s essential to reach out to someone in your support network. Connection is key to navigating a crisis. Tell them what’s happened and how you’re feeling, even if it feels incredibly difficult to do so.

2. Stick to Your Routine: Maintain your daily routine as much as possible, even if it feels challenging. Simple actions like getting up at the same time, eating regular meals, and exercising can help you regain a sense of control.

3. Avoid Self-Medication: The temptation to numb your feelings with alcohol, drugs, or other substances can be strong during a crisis. However, these can exacerbate the situation. If you feel the need for medication, consult with a healthcare professional instead of self-medicating.

4. Seek Professional Help: If you’re struggling to cope, don’t hesitate to seek professional assistance. Talking to a professional, whether through your GP, a therapist, or a crisis hotline, can provide the validation and support you need.

Once the immediate crisis has passed, the journey to recovery begins. This process is often slow and requires patience, self-compassion, and continued support.

1. Allow Yourself Time: Recovery from a work-related mental health crisis takes time, often longer than expected. Be patient with yourself and understand that healing is a gradual process that may take months or even years.

2. Maintain Your Routine: Continue the routine that helped you during the crisis. Regular exercise, healthy eating, and sufficient sleep are the foundations of good mental health and will support your recovery.

3. Reconnect with Your Purpose: Reflect on why you chose your profession and what you love about your job. Reconnecting with these motivations can help you find meaning and purpose again, even after a traumatic experience.

4. Set Small Goals: During your recovery, set small, achievable goals rather than overwhelming yourself with big plans. Celebrate small victories, whether it’s getting through a day at work, completing a project, or simply feeling a bit better.

5. Practice Self-Compassion: Treat yourself with the same compassion you would offer a friend or colleague going through a similar situation. Acknowledge your progress, and don’t be too hard on yourself if recovery takes longer than expected.

One of the most challenging aspects of recovery is dealing with feelings of shame and guilt, which can be powerful and difficult to overcome.

1. Acknowledge Your Feelings: It’s normal to feel shame and guilt after a traumatic event, but also understand that these feelings are often irrational and not based on reality.

2. Challenge Negative Thoughts: When feelings of shame or guilt arise, challenge them by asking yourself if they are truly justified. Often, these feelings are rooted in distorted thinking patterns that can be corrected.

3. Talk About It: Sharing your feelings with someone you trust can help alleviate the burden of shame and guilt. Expressing these emotions can reduce their power over you and facilitate healing.

4. Focus on the Positive: Remind yourself of all the good you’ve done in your career. Think about the lives you’ve touched and the positive impact you’ve had. Your career is more than just one event; it’s a series of contributions that define your professional journey.

At St. Emlyn’s, we believe that your narrative as a healthcare professional is not defined by a single event. You are more than the challenges you’ve faced, and you have the strength to overcome even the most difficult moments. Remember that you are part of a community that understands what you’re going through and is here to support you.

1. Stay Connected: Don’t let the crisis isolate you. Stay connected with your colleagues, friends, and family, who can provide support, perspective, and encouragement as you move forward.

2. Keep Learning: Use your experience as an opportunity for growth. Reflect on what you can learn from the crisis and how it can make you a better healthcare professional.

3. Be Compassionate: Always remember to be compassionate towards yourself. Healing from a work-related mental health crisis is not easy, but with time, support, and self-care, you can emerge stronger and more resilient.

If you’ve experienced or are currently going through a mental health crisis due to work, know that you are not alone. The feelings of being broken, the shame, the guilt, and the fear are all part of the process—but they do not define you. By preparing in advance, seeking support, and practising self-compassion, you can navigate even the darkest moments.

At St. Emlyn’s, we’re here to remind you that your worth is not measured by your worst days. Your career is a journey, and while it may have its challenges, it is also filled with moments of profound impact, healing, and growth. Take the time to care for yourself, to heal, and to reconnect with your purpose. You are important, and your work is valued.

We begin with a thought-provoking journal club post by Dan Horner, an intensivist and emergency physician, who explores the Andromeda Shock trial. This study, conducted in Argentina, compared two resuscitation strategies for patients with septic shock: targeting lactate levels versus peripheral perfusion as measured by capillary refill time.

The Andromeda Shock trial is fascinating because it challenges our reliance on measurable indicators like lactate levels. Many experts argue that lactate doesn't provide the information we think it does about sepsis. Rich Carden's excellent blog on lactate delves into this topic, explaining why the common assumption that lactate indicates anaerobic metabolism is incorrect. Insights from leading intensivists like John Mayberg and Simon Finfer prompt a reevaluation of how we interpret lactate levels.

In the trial, patients managed using peripheral perfusion monitoring showed better outcomes than those managed by lactate levels. Although the trial is underpowered to show definitive differences, the findings suggest that both methods are likely similar in effectiveness. This study highlights the need to reconsider our approach to monitoring septic shock patients and suggests that capillary refill time could be a valuable, low-cost alternative to lactate measurement.

Next, we turn to an intriguing blog by Nick Smith, who shares a lazy yet effective way to enhance learning. Inspired by Matthew Walker's book "Why We Sleep," Nick discusses the critical role of rest in learning and retention. The key takeaway is simple: if you're not well-rested before and after learning, you won't retain information effectively.

Nick emphasizes understanding individual learning rhythms. Some people, like early risers, learn best in the morning, while night owls perform better later in the day. This insight is crucial for medical educators and learners alike. For instance, teenagers naturally have later sleep cycles, making early morning learning sessions less effective.

Walker’s book provides compelling evidence on how sleep affects cognitive function and memory consolidation. During sleep, particularly REM sleep, the brain processes and organizes information learned throughout the day. Lack of sleep disrupts this process, leading to poorer retention and understanding.

Nick integrates these scientific insights with practical advice, making his blog an invaluable resource for optimizing learning strategies. He offers tips on improving sleep hygiene, such as maintaining a consistent sleep schedule, creating a restful environment, and avoiding stimulants before bedtime.

Nick also highlights the impact of disrupted sleep patterns, especially when attending international conferences. Jet lag and lack of sleep can severely hamper your ability to absorb new information. Moreover, alcohol consumption negatively affects learning, which is worth considering during conference social events.

Nick's post is packed with practical tips and impressive infographics that make the information easily digestible. It's a must-read for anyone involved in medical education or looking to optimize their learning strategies.

George Willis, a renowned speaker and former professional American football player, presented on aortic emergencies at the St. Emlyn's Live Conference. His talk is a goldmine of information for emergency medicine practitioners. Aortic emergencies, such as ruptured aortic aneurysms and dissections, are critical conditions that require swift diagnosis and management.

George emphasizes using clinical history and tools like ultrasound to diagnose aortic emergencies. For example, ultrasound can identify abdominal aortic aneurysms and dissections via transthoracic echo. He also discusses managing these patients, particularly those with dissections, who present unique challenges due to their unstable blood pressure.

One notable case George describes involves managing pericardial effusion and tamponade resulting from aortic dissection. Techniques like pericardiocentesis can be life-saving, buying valuable time for definitive treatment. George's practical tips and real-world examples make his presentation an invaluable resource for anyone dealing with aortic emergencies.

Managing aortic emergencies requires a nuanced approach, particularly when dealing with unstable patients. George discusses using medications like labetalol for beta-blockade and alpha-blockade to manage blood pressure in dissection patients. These medications help reduce the strain on the aorta without compromising patient safety.

George also covers using imaging techniques, such as CT angiography, to confirm diagnoses and plan interventions. The ability to quickly and accurately diagnose these conditions is crucial for timely surgical intervention, which can significantly improve patient outcomes.

Dan Horner returns with another insightful blog, this time on the ambulatory management of pulmonary embolisms (PEs). At the Arkham conference in Belfast, Dan discussed the benefits and challenges of treating PEs as outpatients. His post is a comprehensive guide to identifying which patients can be safely managed at home and which require hospital admission.

Dan explores various prognostic factors and scoring systems, such as PESI and sPESI, used to predict complications in PE patients. While these scores are better than Gestalt, they are not without limitations. Dan also touches on biomarkers and their role in predicting PE outcomes, though current data is not definitive.

Identifying patients who can be safely managed on an outpatient basis is crucial for optimizing resource use and improving patient comfort. Dan discusses the criteria for outpatient management, including the absence of hemodynamic instability, low bleeding risk, and adequate home support. These criteria help ensure that only patients with a low risk of complications are selected for ambulatory care.

Treatment options for PEs are evolving, with a shift from traditional anticoagulants like Warfarin to NOACs/DOACs. While these newer agents offer convenience, the evidence base is still developing. Dan also addresses the complexities of managing PEs in special populations, such as pregnant patients, highlighting the need for individualized care and informed discussions with patients.

Implementing ambulatory care for PEs requires careful planning and coordination. Dan provides practical advice on setting up ambulatory care pathways, including patient education, follow-up protocols, and the use of telemedicine to monitor patients remotely. He also discusses the importance of multidisciplinary collaboration in managing these patients.

Dan's blog is a treasure trove of resources, including guidelines for outpatient management, risk scores, and follow-up strategies. It's an essential read for anyone involved in the care of PE patients, offering the latest evidence and practical advice.

To conclude our April roundup, we have two deeply moving blogs by Liz Crowe, where she shares her experiences of dealing with clinical tragedies. Liz's candid account of a recent tragic event in her professional life resonates with many healthcare professionals who have faced similar situations. Her blogs not only describe the emotional impact of these events but also offer strategies for coping and recovery.

Liz's first blog delves into the profound emotional toll that clinical tragedies can take on healthcare providers. She describes the initial shock, feelings of guilt and helplessness, and the long-lasting impact on mental health. These experiences are not uncommon in the medical field, where the stakes are high, and the outcomes can sometimes be devastating.

Liz emphasizes the importance of acknowledging and processing these experiences, rather than burying the emotions. She provides practical advice on how to support yourself, your colleagues, and your loved ones during such challenging times. Liz's insights are invaluable for anyone in the healthcare field, offering guidance on how to navigate the emotional aftermath of clinical tragedies.

In her second blog, Liz focuses on strategies for coping with and recovering from clinical tragedies. She highlights the importance of seeking professional help when needed, whether through counseling, peer support groups, or other mental health resources. Liz also emphasizes the value of self-care practices, such as exercise, mindfulness, and maintaining a healthy work-life balance.

Liz shares her personal journey of recovery, including the support she received from colleagues and the strategies that helped her regain her confidence and resilience. Her story is a powerful reminder that, while clinical tragedies are deeply challenging, it is possible to heal and continue to provide compassionate care to patients.

Liz's blogs also underscore the importance of building a supportive community within the healthcare profession. She advocates for open conversations about mental health and the emotional challenges of medical practice, fostering an environment where healthcare providers feel safe to share their experiences and seek help.

Liz's blogs are a must-read for anyone who has experienced or is supporting someone through a clinical tragedy. They offer hope and practical strategies for healing and moving forward.

April 2019 has been an incredibly insightful month on the St. Emlyn's blog. From groundbreaking research and practical medical education tips to deeply personal reflections on clinical tragedies, we've covered a wide range of topics. Each post offers valuable insights and practical advice for healthcare professionals.

As we continue to face the challenges of a busy emergency department, it's crucial to stay informed and up-to-date with the latest evidence and best practices. Whether you're managing septic shock, improving your learning strategies, diagnosing aortic emergencies, treating PEs, or coping with clinical tragedies, the St. Emlyn's blog has you covered.

The diversity of topics covered this month highlights the importance of continuous learning and adaptation in emergency medicine. By staying abreast of the latest research and best practices, we can ensure that we are providing the highest quality care to our patients.

Thank you for joining us on this journey through April 2019. We hope you find these posts as enlightening and helpful as we do. Stay tuned for more exciting updates and insights from the St. Emlyn's team. Enjoy your emergency medicine practice, and we'll speak to you again soon.

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.

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.

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.

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.

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 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.

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.

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, 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.

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.

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.

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.

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.

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 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.

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.

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.

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.

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.

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.

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.

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.

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!

Hello and welcome to the St Emlyn's Podcast! I’m Simon Carly, and today, albeit a little later than planned, I'll be diving into the fascinating February papers and blogs that have graced the St Emlyn's Podcast. If you missed out in February, fear not—you can always revisit the archives on our blog. It’s all there, waiting for you to explore. Let’s take a deep dive into what made February such an exciting month in emergency medicine.

A Journey to Jeddah: Bridging Borders in Emergency Medicine

In February, I had the distinct honour of travelling to Jeddah, Saudi Arabia, to join the Saudi Arabian Society of Emergency Medicine. Jeddah is a city brimming with activity and change. Despite Saudi Arabia being vastly different from the UK, I found common ground with the emergency physicians there. Many of them have trained abroad in Canada, the US, and the UK, making them kindred spirits with shared values and ideas in treating emergency patients.

During my visit, I was invited to present the top ten trauma papers, a task I thoroughly enjoy. These papers, detailed on our website, included highlights like the PAMPER trial and airway management papers around cardiac arrest. We also delved into studies beyond trauma, such as the Airways 2 study on superox in critically ill patients and intubation with ED use of bougies, which we advocate at St. Emlyn’s. Additionally, the conservative management of pneumothoraces, a topic we've discussed before, is becoming increasingly recognized as safe, especially for traumatic pneumothoraces visible only on CT scans.

PTSD and the Road to Recovery: Insights from Rusty Carroll

Our friend and colleague, Rusty Carroll, has shared another compelling post on PTSD. Rusty’s previous blogs detailed his recovery journey from PTSD, stemming from his work in the ambulance service. His latest update brings us into his post-therapy life as he navigates a new, rewarding, and successful path. For anyone experiencing PTSD or knowing someone who is, Rusty's series is invaluable. His journey may differ from yours, but understanding that there is a path to recovery is incredibly encouraging.

PTSD is a serious issue that affects many healthcare professionals, and Rusty’s openness about his struggles and recovery provides a beacon of hope for others. His posts cover various aspects of his journey, from the initial recognition of symptoms to the therapeutic interventions that helped him reclaim his life. Rusty emphasizes the importance of seeking help, breaking the stigma associated with mental health issues, and supporting colleagues who may be going through similar experiences.

Understanding Trauma Mortality: A Shift in Focus

In our journal club, we explored why bleeding trauma patients die. This editorial by Karen Broe and John Holcomb in Critical Care Medicine challenges our preconceptions about trauma mortality. The implementation of pre-hospital systems, emergency management, and damage control surgery has significantly reduced pre-hospital deaths. However, this has shifted mortality to the emergency department's early hours and even later, 24 hours down the line.

We are now seeing deaths caused by late systematic immunosuppression, persistent inflammation, and catabolism syndromes. Despite successful initial management, patients are still succumbing later on. This shift indicates that our trauma story is far from complete. More research is needed to understand and address these late-phase deaths, suggesting that critical care phases hold the key to future advancements.

This new understanding prompts us to reconsider our approaches in trauma care. While we have made significant strides in reducing early mortality, the challenge now lies in managing these complex late-phase issues. This involves multidisciplinary collaboration, innovative research, and a commitment to continuous improvement in trauma care protocols.

Reevaluating PE in Syncope: A Fresh Perspective

Natalie May published a follow-up paper related to the PESIT study, which had previously suggested a high incidence of pulmonary embolism (PE) as a cause of syncope. This controversial study, conducted in Italy, sparked debates across various platforms, including EM Nerd, EMCrit, Emlyns Note, and Rebel EM.

However, new research from the North American Syncope Consortium reveals a much lower prevalence of PE among emergency department patients with syncope. This is a significant finding, as it challenges the alarming figures from the PESIT study. It allows us to return to our previous practices of using well-established tools like Wells' scoring and PERC scoring without the heightened fear of PE being the primary cause of syncope.

Natalie’s analysis provides a balanced perspective, highlighting the importance of context in interpreting study results. The discrepancy between the PESIT study and the North American Syncope Consortium's findings underscores the need for ongoing research and validation of clinical guidelines. As emergency physicians, staying informed about such developments ensures that we provide the best care based on the latest evidence.

Philosophy of Emergency Medicine: Workplace Relationships Matter

Stefan Brzezins contributes a thought-provoking post on the importance of workplace relationships. Stefan, a colleague who has worked in South Africa and now the UK, highlights how our interactions with colleagues significantly impact our behaviour, happiness, and departmental efficiency. Dysfunctional departments often correlate with poor personal relationships among consultants and senior nurses, ultimately affecting patient care.

Stefan's advice includes not taking unnecessary offence, showing gratitude, celebrating the good news, and fostering teamwork. While these may seem obvious, their implementation can transform workplace dynamics. Reflecting on Stefan's insights has prompted me to reevaluate my practices and strive for better interpersonal relationships at work.

Good workplace relationships are foundational to creating a supportive and effective healthcare environment. When colleagues communicate openly, show appreciation for each other’s efforts, and work collaboratively, they experience higher job satisfaction, reduced stress, and, ultimately, better patient outcomes. Stefan’s post serves as a reminder that the human element of healthcare is just as important as the clinical skills we bring to our practice.

Ventilation During RSI: Revisiting Established Practices

Another significant post examines whether we should continue ventilation during rapid sequence intubation (RSI). Traditional teaching discouraged ventilation during the apnea period due to safety concerns. However, for critically ill patients with low oxygen saturation, not ventilating can lead to severe hypoxia.

A randomized control trial in the ED assessed the safety of ventilation during this period. The study found that patients who were ventilated during the apnea period had less oxygen desaturation without significant adverse effects. While the study's sample size is small, it supports our evolving practices and aligns with our experiences. However, it is crucial to critically assess the study's methodology and incorporate this knowledge cautiously into clinical practice.

This trial’s findings challenge the long-standing dogma of no ventilation during RSI, pushing us to rethink and potentially update our protocols. As emergency medicine evolves, we must remain flexible and willing to adapt our practices based on emerging evidence. Ensuring that our approaches are both safe and effective is paramount to improving patient outcomes.

The Role of Scribes in the ED: Efficiency and Quality Improvement

Chris Gray's post on the use of scribes in the ED follows a previous discussion on this topic. Scribes can save time and improve documentation quality, which is vital in a high-pressure environment. A randomized control trial demonstrated that scribes do save time, though the effect size was modest. The potential for better documentation quality is equally important, making scribes a valuable addition to emergency departments. We are keen to hear from anyone using scribes in the UK, as this practice is more common in the US.

The use of scribes can enhance the efficiency of emergency departments by allowing physicians to focus more on patient care rather than administrative tasks. Improved documentation can also lead to better patient tracking, follow-up, and overall care quality. As our healthcare systems become increasingly strained, innovations like scribes offer practical solutions to maintain high standards of care.

Reflecting on February: A Busy Month in Emergency Medicine

February was packed with insights and developments in emergency medicine. From international collaborations and trauma management advancements to revisiting PTSD recovery stories and philosophical reflections on workplace relationships, the month offered a wealth of knowledge. As we move into March, we look forward to sharing more exciting updates, including coverage of the SMACC conference.

The diversity of topics covered in February highlights the multifaceted nature of emergency medicine. Each paper and blog post contributes to a broader understanding of how we can improve patient care, support our colleagues, and adapt to new challenges. This continuous learning process is what makes emergency medicine such a dynamic and rewarding field.

Supporting the St Emlyn's Podcast: Your Contribution Matters

Since 2012, we've funded the blog and podcast out of our own pockets. As our audience grows, so do our expenses. If you find our content valuable and wish to support us, please consider making a small donation or subscribing regularly. Your contributions help us keep St Emlyn's a free, open-access medical education resource for all.

By supporting the St Emlyn's Podcast, you enable us to continue delivering high-quality, evidence-based content to the emergency medicine community. Your donations help cover the costs of hosting, producing, and distributing our materials, ensuring that we can reach a global audience of healthcare professionals.

Conclusion

The February edition of the St Emlyn's Podcast provided a rich tapestry of insights and developments in emergency medicine. From my journey to Jeddah and the fascinating trauma studies to the personal stories of PTSD recovery and the philosophical reflections on workplace relationships, there was something for everyone.

Our exploration of new research, such as the reevaluation of PE in syncope and the safety of ventilation during RSI, underscores the importance of staying informed and adaptable in our practice. Meanwhile, discussions on the role of scribes and the significance of workplace dynamics highlight the multifaceted challenges we face in emergency medicine.

As we look forward to March and beyond, we remain committed to bringing you the latest in emergency medicine and fostering a community of continuous learning and improvement. Thank you for joining us on this journey, and we appreciate your support in keeping St Emlyn's a vital resource for all.

Stay tuned for more insights, updates, and discussions. Until then, keep pushing the boundaries of emergency medicine, supporting your colleagues, and striving for excellence in patient care. Have a great time, and we’ll be back with you shortly.

Exploring the Latest in Emergency Medicine: February 2024 Edition

Hello and welcome to the St Emlyn's Podcast! I’m Simon Carly, and today, albeit a little later than planned, I'll be diving into the fascinating February papers and blogs that have graced the St Emlyn's Podcast. If you missed out in February, fear not—you can always revisit the archives on our blog. It’s all there, waiting for you to explore. Let’s take a deep dive into what made February such an exciting month in emergency medicine.

A Journey to Jeddah: Bridging Borders in Emergency Medicine

In February, I had the distinct honour of travelling to Jeddah, Saudi Arabia, to join the Saudi Arabian Society of Emergency Medicine. Jeddah is a city brimming with activity and change. Despite Saudi Arabia being vastly different from the UK, I found common ground with the emergency physicians there. Many of them have trained abroad in Canada, the US, and the UK, making them kindred spirits with shared values and ideas in treating emergency patients.

During my visit, I was invited to present the top ten trauma papers, a task I thoroughly enjoy. These papers, detailed on our website, included highlights like the PAMPER trial and airway management papers around cardiac arrest. We also delved into studies beyond trauma, such as the Airways 2 study on superox in critically ill patients and intubation with ED use of bougies, which we advocate at St. Emlyn’s. Additionally, the conservative management of pneumothoraces, a topic we've discussed before, is becoming increasingly recognized as safe, especially for traumatic pneumothoraces visible only on CT scans.

PTSD and the Road to Recovery: Insights from Rusty Carroll

Our friend and colleague, Rusty Carroll, has shared another compelling post on PTSD. Rusty’s previous blogs detailed his recovery journey from PTSD, stemming from his work in the ambulance service. His latest update brings us into his post-therapy life as he navigates a new, rewarding, and successful path. For anyone experiencing PTSD or knowing someone who is, Rusty's series is invaluable. His journey may differ from yours, but understanding that there is a path to recovery is incredibly encouraging.

PTSD is a serious issue that affects many healthcare professionals, and Rusty’s openness about his struggles and recovery provides a beacon of hope for others. His posts cover various aspects of his journey, from the initial recognition of symptoms to the therapeutic interventions that helped him reclaim his life. Rusty emphasizes the importance of seeking help, breaking the stigma associated with mental health issues, and supporting colleagues who may be going through similar experiences.

Understanding Trauma Mortality: A Shift in Focus

In our journal club, we explored why bleeding trauma patients die. This editorial by Karen Broe and John Holcomb in Critical Care Medicine challenges our preconceptions about trauma mortality. The implementation of pre-hospital systems, emergency management, and damage control surgery has significantly reduced pre-hospital deaths. However, this has shifted mortality to the emergency department's early hours and even later, 24 hours down the line.

We are now seeing deaths caused by late systematic immunosuppression, persistent inflammation, and catabolism syndromes. Despite successful initial management, patients are still succumbing later on. This shift indicates that our trauma story is far from complete. More research is needed to understand and address these late-phase deaths, suggesting that critical care phases hold the key to future advancements.

This new understanding prompts us to reconsider our approaches in trauma care. While we have made significant strides in reducing early mortality, the challenge now lies in managing these complex late-phase issues. This involves multidisciplinary collaboration, innovative research, and a commitment to continuous improvement in trauma care protocols.

Reevaluating PE in Syncope: A Fresh Perspective

Natalie May published a follow-up paper related to the PESIT study, which had previously suggested a high incidence of pulmonary embolism (PE) as a cause of syncope. This controversial study, conducted in Italy, sparked debates across various platforms, including EM Nerd, EMCrit, Emlyns Note, and Rebel EM.

However, new research from the North American Syncope Consortium reveals a much lower prevalence of PE among emergency department patients with syncope. This is a significant finding, as it challenges the alarming figures from the PESIT study. It allows us to return to our previous practices of using well-established tools like Wells' scoring and PERC scoring without the heightened fear of PE being the primary cause of syncope.

Natalie’s analysis provides a balanced perspective, highlighting the importance of context in interpreting study results. The discrepancy between the PESIT study and the North American Syncope Consortium's findings underscores the need for ongoing research and validation of clinical guidelines. As emergency physicians, staying informed about such developments ensures that we provide the best care based on the latest evidence.

Philosophy of Emergency Medicine: Workplace Relationships Matter

Stefan Brzezins contributes a thought-provoking post on the importance of workplace relationships. Stefan, a colleague who has worked in South Africa and now the UK, highlights how our interactions with colleagues significantly impact our behaviour, happiness, and departmental efficiency. Dysfunctional departments often correlate with poor personal relationships among consultants and senior nurses, ultimately affecting patient care.

Stefan's advice includes not taking unnecessary offence, showing gratitude, celebrating the good news, and fostering teamwork. While these may seem obvious, their implementation can transform workplace dynamics. Reflecting on Stefan's insights has prompted me to reevaluate my practices and strive for better interpersonal relationships at work.

Good workplace relationships are foundational to creating a supportive and effective healthcare environment. When colleagues communicate openly, show appreciation for each other’s efforts, and work collaboratively, it leads to higher job satisfaction, reduced stress, and ultimately better patient outcomes. Stefan’s post serves as a reminder that the human element of healthcare is just as important as the clinical skills we bring to our practice.

Ventilation During RSI: Revisiting Established Practices

Another significant post examines whether we should continue ventilation during rapid sequence intubation (RSI). Traditional teaching discouraged ventilation during the apnea period due to safety concerns. However, for critically ill patients with low oxygen saturation, not ventilating can lead to severe hypoxia.

A randomized control trial in the ED assessed the safety of ventilation during this period. The study found that patients who were ventilated during the apnea period had less oxygen desaturation without significant adverse effects. While the study's sample size is small, it supports our evolving practices and aligns with our experiences. However, it is crucial to critically assess the study's methodology and incorporate this knowledge cautiously into clinical practice.

This trial’s findings challenge the long-standing dogma of no ventilation during RSI, pushing us to rethink and potentially update our protocols. As emergency medicine evolves, we must remain flexible and willing to adapt our practices based on emerging evidence. Ensuring that our approaches are both safe and effective is paramount to improving patient outcomes.

The Role of Scribes in the ED: Efficiency and Quality Improvement

Chris Gray's post on the use of scribes in the ED follows a previous discussion on this topic. Scribes can save time and improve documentation quality, which is vital in a high-pressure environment. A randomized control trial demonstrated that scribes do save time, though the effect size was modest. The potential for better documentation quality is equally important, making scribes a valuable addition to emergency departments. We are keen to hear from anyone using scribes in the UK, as this practice is more common in the US.

The use of scribes can enhance the efficiency of emergency departments by allowing physicians to focus more on patient care rather than administrative tasks. Improved documentation can also lead to better patient tracking, follow-up, and overall care quality. As our healthcare systems become increasingly strained, innovations like scribes offer practical solutions to maintain high standards of care.

Reflecting on February: A Busy Month in Emergency Medicine

February was packed with insights and developments in emergency medicine. From international collaborations and trauma management advancements to revisiting PTSD recovery stories and philosophical reflections on workplace relationships, the month offered a wealth of knowledge. As we move into March, we look forward to sharing more exciting updates, including coverage of the SMACC conference.

The diversity of topics covered in February highlights the multifaceted nature of emergency medicine. Each paper and blog post contributes to a broader understanding of how we can improve patient care, support our colleagues, and adapt to new challenges. This continuous learning process is what makes emergency medicine such a dynamic and rewarding field.

Supporting the St Emlyn's Podcast: Your Contribution Matters

Since 2012, we've funded the blog and podcast out of our own pockets. As our audience grows, so do our expenses. If you find our content valuable and wish to support us, please consider making a small donation or subscribing regularly. Your contributions help us keep St Emlyn's a free, open-access medical education resource for all.

By supporting the St Emlyn's Podcast, you enable us to continue delivering high-quality, evidence-based content to the emergency medicine community. Your donations help cover the costs of hosting, producing, and distributing our materials, ensuring that we can reach a global audience of healthcare professionals.

Conclusion

The February edition of the St Emlyn's Podcast provided a rich tapestry of insights and developments in emergency medicine. From my journey to Jeddah and the fascinating trauma studies to the personal stories of PTSD recovery and the philosophical reflections on workplace relationships, there was something for everyone.

Our exploration of new research, such as the reevaluation of PE in syncope and the safety of ventilation during RSI, underscores the importance of staying informed and adaptable in our practice. Meanwhile, discussions on the role of scribes and the significance of workplace dynamics highlight the multifaceted challenges we face in emergency medicine.

As we look forward to March and beyond, we remain committed to bringing you the latest in emergency medicine and fostering a community of continuous learning and improvement. Thank you for joining us on this journey, and we appreciate your support in keeping St Emlyn's a vital resource for all.

Stay tuned for more insights, updates, and discussions. Until then, keep pushing the boundaries of emergency medicine, supporting your colleagues, and striving for excellence in patient care. Have a great time, and we’ll be back with you shortly.

All emergency physicians know that it's all to easy to miss an aortic catastrophe. Listen to George's wisdom on common pitfalls and top tips to make you a better emergency clinician.

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P values are a measure of the probability that an observed difference could have occurred just by chance if the null hypothesis were true. The null hypothesis generally states that there is no difference between two treatments or interventions. Thus, a P value helps us determine whether the observed data is consistent with this hypothesis.

To grasp P values fully, we start with the null hypothesis. In any trial, we begin with the premise that there is no difference between the treatments being tested. Our goal is to test this null hypothesis and ideally disprove it, a process known as significance testing.

When we calculate a P value, we express the probability of obtaining a result as extreme as the one observed, assuming the null hypothesis is true. For instance, a P value of 0.05 suggests a 5% chance that the observed difference is due to random variation alone.

The threshold of 0.05 has become a benchmark in research. A P value below this threshold is often considered statistically significant, while one above is not. However, this binary approach oversimplifies statistical analysis. The figure 0.05 is arbitrary and does not imply that results just above or below this threshold are vastly different in terms of practical significance.

Distinguishing between statistical significance and clinical significance is crucial. A statistically significant result with a very small P value may not always translate into clinical importance. For example, a large study might find that a new treatment reduces blood pressure by 0.5 millimetres of mercury with a P value of 0.001. While statistically significant, such a small reduction may not be clinically relevant.

Conversely, a clinically significant finding might not reach the strict threshold of statistical significance, particularly in smaller studies. Therefore, it's essential to consider both the magnitude of the effect and its practical implications in clinical practice.

The fragility index is an alternative measure that addresses some limitations of P values. It calculates the number of events that would need to change to alter the study's results from statistically significant to non-significant. This index provides insight into the robustness of the findings. Surprisingly, even large trials can have a low fragility index, indicating that their results hinge on a small number of events.

Recognizing the limitations of the 0.05 threshold, some researchers advocate for more stringent criteria, such as a P value of 0.02, particularly in large randomized controlled trials (RCTs). This approach aims to reduce the likelihood of false-positive results and improve the reliability of findings. However, it also raises the bar for demonstrating the efficacy of new treatments, which can be a double-edged sword.

A significant challenge in research is multiple testing. Conducting numerous statistical tests increases the probability of finding at least one significant result purely by chance. This issue is particularly relevant in exploratory studies where multiple outcomes are assessed.

One method to address this problem is the Bonferroni adjustment, which adjusts the significance threshold based on the number of tests performed. While this approach helps control the risk of false positives, it can be overly conservative and reduce the power to detect true effects. Therefore, it should be used judiciously.

Interim analysis is a crucial aspect of clinical trials, allowing researchers to assess the effectiveness or harm of an intervention before the study's completion. However, performing multiple interim analyses can increase the risk of false-positive findings. To mitigate this risk, researchers use techniques like P value spending functions, which adjust the significance threshold for each interim analysis.

Additionally, the number of interim analyses should be limited and pre-specified in the study protocol. This ensures that decisions to stop a trial early are based on robust evidence and not on arbitrary or opportunistic analyses.

P values alone do not provide a complete picture of the study results. It's equally important to consider the effect size, which measures the magnitude of the difference between treatments. A small P value might indicate statistical significance, but without a substantial effect size, the clinical relevance of the finding remains questionable.

Confidence intervals (CIs) complement P values by providing a range within which the true effect size is likely to lie. A 95% CI means that if the study were repeated multiple times, 95% of the calculated intervals would contain the true effect size. CIs offer valuable context for interpreting P values and understanding the precision of the estimated effect.

1. Understand the Null Hypothesis: Always start with a clear understanding of the null hypothesis and what the study aims to test.
2. Look Beyond the P Value: Consider the effect size, confidence intervals, and clinical significance of the findings.
3. Be Cautious with Multiple Testing: Recognize the increased risk of false positives with multiple comparisons and apply appropriate adjustments.
4. Assess the Fragility Index: Use the fragility index to gauge the robustness of the study's findings.
5. Consider Interim Analysis: Ensure that interim analyses are pre-planned and interpreted with caution to avoid bias.
6. Question the Threshold: Remember that the 0.05 threshold is not a magic number. Interpret P values in the context of the study design, sample size, and practical implications.

P values are a fundamental aspect of medical research, but their interpretation requires a nuanced understanding. By considering the null hypothesis, clinical significance, effect size, and confidence intervals, we can make more informed decisions based on the data. As emergency medicine clinicians, our goal is to apply research findings judiciously to improve patient care.

We hope this deep dive into P values has clarified their role and limitations in research. Remember, the journey to mastering statistical concepts is ongoing, and continuous learning is key. If you have any questions or thoughts, please share them in the comments below. Happy appraising, and stay curious!

Hello and welcome to the St. Emlyn’s Podcast. I’m Simon Carley, joined by Rick Body. Today, we’re bringing you our January roundup, sharing the most intriguing and impactful content we've covered this month. From reflecting on 2018 to exploring new guidelines and innovations in emergency medicine, we have a lot to discuss. Let’s dive in!

As we started January, we reflected on 2018, a year filled with significant achievements and insights. One standout discussion was our review of key books that left a lasting impact. A personal favorite of mine is "Why We Sleep" by Matthew Walker. This book has been transformational for me, influencing how I live and advise others on health, well-being, and performance. The insights on sleep’s importance in education, creativity, and overall health are profound.

Rick, did anything from our 2018 review resonate with you?

Rick Body: Absolutely, Simon. The variety of books we discussed was impressive. It was enlightening to hear about others' achievements in 2018 and their goals for 2019. This exercise really focused my mind on what I hope to achieve this year.

As we moved from reflections to aspirations, we set our sights on exciting projects for 2019. One major highlight is the AI incubator for emergency care. This initiative aims to support academic careers and foster partnerships between data and industry to enhance medical technologies. It’s an exhilarating time for advancements in emergency care.

Rick is incredibly busy with groundbreaking work, particularly in diagnostics in Manchester. His research and speaking engagements are making waves in the medical community. For more details on these projects, check out the blog where all the information is comprehensively covered.

We explored New Year’s resolutions with Liz Crowe, who offered a fresh perspective on well-being and resolutions. Instead of focusing on all-or-nothing goals, Liz suggests starting small and seeking rewards rather than punishments. This approach makes significant lifestyle changes more manageable and sustainable. Committing to resolutions publicly or with a friend can enhance accountability and success.

Rick, do you have any New Year’s resolutions?

Rick Body: It’s challenging to pinpoint one or two, but Liz’s advice on avoiding binary thinking is crucial. Recognizing progress rather than dwelling on setbacks can make a big difference.

In January, we delved into updated tetanus guidelines, highlighting significant changes. Previously, a single booster in your early 20s was deemed sufficient, but the new guidelines recommend a 10-year booster. This change stems from the recognition that immunity wanes over time. Interestingly, point-of-care testing is now available to detect active tetanus immunization, allowing for more tailored booster decisions.

These updates are crucial for emergency physicians to ensure compliance with current standards and provide optimal patient care. The blog post simplifies these guidelines, making them accessible and easy to understand.

We featured Claire Richmond, a hero in the emergency medicine community. Claire, who works with Sydney HEMS, delivered an inspiring keynote at the St. Emlyn’s live conference. Her talk focused on excellence, performance, training, and development in retrieval medicine. She emphasized the importance of honesty, feedback, and continuous improvement.

For those aspiring to achieve self-actualization in emergency medicine, Claire’s insights are invaluable. We’ve shared the video and podcast of her talk, and we highly recommend checking them out.

Another highlight of January was Professor Dan Horner’s discussion on serum neurofilament light chains, a promising tool for prognosticating cardiac arrest outcomes. This research, stemming from the TTM trial, suggests that these biomarkers can provide early predictions about patient outcomes. Early identification of patients likely to have poor neurological outcomes can significantly impact family discussions, treatment decisions, and overall management.

This research is groundbreaking and holds potential for future clinical applications, although it’s not yet ready for immediate practice.

We’re incredibly proud of our journal club series at St. Emlyn’s, which advocates for evidence-based medicine. This series highlights the latest research, making it accessible and understandable. To celebrate the contributions over the past year, we’ve compiled an e-book available for free download. This resource is a testament to our commitment to advancing medical knowledge and practice.

One of the intriguing studies we covered this month examined pre-medication with midazolam or haloperidol for ketamine sedation. The randomized control trial suggested that pre-medication could reduce complications like abnormal behaviors and emergence phenomena. However, it also increased recovery time, requiring more resources and nursing time.

While the findings are interesting, they haven’t convinced us to change our current practice. However, it’s essential to stay informed about such research to make informed decisions in clinical practice.

We also discussed the role of HEMS in improving outcomes for traumatic cardiac arrest. The study from the UK highlighted the high-level interventions provided by HEMS teams. However, it raised questions about the overall impact on patient survival. Of the 263 patients attended, only seven survived, and all had achieved ROSC before HEMS arrival. This data suggests that while HEMS interventions are critical, their direct impact on survival needs further evaluation.

This topic is sure to spark debate, and we appreciate the transparency of HEMS services in sharing their data and encouraging open discussions.

As we wrap up January, we’re excited about the plans for the coming months. Simon is heading to Jeddah for a significant event, and we’re considering hosting another St. Emlyn’s live conference and teaching course. We’re exploring innovative formats for medical conferences and welcome your ideas on how we can make these events even more impactful.

Since 2012, we’ve funded the blog and podcast out of our own pockets, but as our audience has grown, so have the costs. If you find our content valuable, please consider making a small donation or subscribing for regular contributions. Your support helps us keep St. Emlyn’s free and accessible to all.

Thank you for your time and continued support. Stay tuned for more updates, and as always, enjoy your emergency medicine practice and take care!

00:00 Introduction to the Podcast

00:26 Charlie's Research Background

00:52 Overview of the Research Paper

01:17 Decision Making Under Uncertainty

03:05 Systematic Reviews and Data Collection

03:46 Building the Decision Tree Model

04:48 Results and Key Findings

08:07 Implications for Clinical Practice

09:19 Future Directions and Conclusion

You can read more from the event at http://www.stemlynsblog.org 

This is a great presentation for anyone interested in continually developing their own and their colleagues practice, delivered by someone who really knows what they are talking about and who works for one of the best developed resuscitation services in the world.

Clare is an Emergency Physician and specialist in Pre-Hospital Care and Retrieval medicine based in Sydney, with Royal Prince Alfred Hospital and Sydney HEMS. She has completed a fellowship in simulation based education, and enjoys training with “real” people - patients, bystanders and the other clinicians we come across as we treat our patients every day. She is a lecturer with the University of Sydney, and is involved in education for the NSW Institute for Trauma Injury Management. When Clare is not working on helicopters or training teams, she is studying yoga or hanging out with her puppy, Archie. 

First up, we have an insightful contribution from Ross Fischer, a key member of the St. Emlyn’s team and a Pediatric Surgeon based in Sheffield. Ross has delved into the topic of tribalism in healthcare, a subject we've explored previously but which remains ever relevant.

Tribalism refers to the formation of groups or 'tribes' based on common beliefs and cultures, which significantly influences our behaviour and treatment approaches in healthcare. Ross's blog revisits a remarkable presentation by Vic Brazil at SMACC Gold in 2014, highlighting how tribalism drives our interactions and behaviours within the medical field.

In healthcare, tribes often form around specialities – emergency physicians, surgeons, anaesthetists, etc. While having a strong group identity can be positive, it can also lead to unhealthy competition and misunderstandings. For example, emergency physicians might unfairly label surgeons as uncooperative, which is not only untrue but also counterproductive.

Ross's extensive experience across various medical cultures has given him a unique perspective on this issue. His blog emphasizes the importance of recognizing and mitigating tribalism to foster better cooperation and ultimately improve patient care. Some strategies he suggests include using personal names during referrals, face-to-face communication, being supportive rather than critical when things go wrong, organizing social events across specialities, and calling out tribalism in casual conversations.

Next, I’ve put together a blog on the conservative management of chest trauma, inspired by several presentations I've done this year on torso trauma. The increasing body of evidence suggests that not all chest injuries, such as hemothoraces and small pneumothoraces, require invasive intervention.

Reflecting on my early days in emergency medicine, we operated under the strict guideline that any pneumothorax or hemothorax warranted a chest drain. However, advances in imaging technology, like whole-body CT scans, have revealed that many small pneumothoraces and hemothoraces were previously undetected and thus untreated without significant complications.

Recent studies, including a substantial observational study by Walker, support the safety of conservative management for many of these cases. This shift in practice aligns with our experiences here in Virchester, where we often opt to observe rather than immediately intervene with chest drains, even in ventilated patients. The evidence is still evolving, but it’s encouraging to see data supporting less invasive approaches.

Dan Horner, Professor of Emergency Medicine at Virchester West, has shared three exceptional posts from our time at the Intensive Care Society conference in London. The interface between emergency medicine and ICU is a critical area, and Dan’s insights are invaluable for anyone interested in this field.

One standout topic from the conference was Tom Evans' presentation on exercise physiology. Though I missed it, the demonstration with Olympic rowers on stage, showcasing their lactate levels, was reportedly phenomenal. This type of hands-on demonstration highlights the extraordinary resilience and adaptability of human physiology, insights that are crucial for both emergency and intensive care practitioners.

In addition to exercise physiology, Dan and I covered the continuum of patient care from the roadside to critical care, emphasizing the importance of effective handovers and collaborative work with paramedics. Our discussions included the zero point survey, ATMIST handovers, and the significance of follow-ups to ensure paramedics receive feedback on their patients' outcomes, all crucial elements for improving patient care and professional practice.

Natalie May wrapped up our review of the FemInEM conference, emphasizing the multifaceted nature of medicine. The themes of passion, role models, organization, consistency, persistence, mentorship, and leadership were central to the conference discussions. FIX19, the upcoming FemInEM event, promises to continue this tradition of exploring how medical professionals can impact not just clinical outcomes but also their own lives, colleagues, and the broader community.

Gareth Roberts, a recent addition to our consultant team in Manchester, provided a comprehensive review of HIV management from an emergency physician’s perspective. His blog focuses on post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), critical areas for emergency physicians to master.

With the ongoing changes in HIV treatment and prevention, understanding the nuances of PEP and PrEP is vital. Gareth also touches on the rise of chemsex and its implications for emergency medicine, emphasizing the need for awareness and appropriate management strategies for patients involved in these practices.

Rich Cardens explored the intriguing findings from his PhD research on trauma laparotomy. Despite significant advancements in trauma care over the past decade, the mortality rate for trauma laparotomy has remained unchanged. This surprising discovery prompts a deeper investigation into the factors influencing these outcomes.

Rich's research compares data from the JTTR military registry and the Royal London Hospital, highlighting the need for a comprehensive trauma emergency laparotomy audit. Understanding why mortality rates haven't improved could lead to better strategies and practices in trauma care.

For a lighter, yet still educational note, Janos Byan Beethar found an entertaining yet insightful study in the Injury Prevention Journal. This study analyzed the mortality of characters in Game of Thrones, a bit of fun that doubles as a critical appraisal exercise. With over half of the 330 characters meeting untimely deaths through injury, burns, or poisoning, the study offers a unique way to engage with epidemiological concepts and cause-effect associations.

Interestingly, the study also suggests that characters who change allegiances have a higher survival rate – perhaps a subtle hint at the importance of adaptability in both fictional and real-world scenarios.

As we close out December, it’s clear that 2018 has been a year of growth, learning, and exciting developments here at St. Emlyn’s. From addressing tribalism in healthcare to exploring conservative management strategies for chest trauma, and from the latest insights in intensive care to the evolving field of HIV management, our blogs have covered a wide range of critical topics.

We look forward to continuing this journey in 2019, bringing you the latest research, discussions, and insights in emergency medicine. Whether through our blogs, podcasts, or live events, we aim to foster a community of continuous learning and professional growth.

Stay connected with us on Twitter, Facebook, the blog, and the podcast. We’re here to support you in your practice and to ensure you stay at the forefront of emergency medicine. Here’s to another great year with St. Emlyn’s!

We begin our review in New York, where Natalie May attended the FIX (FeminEM) Conference. In her second post about this event, Natalie explores profound themes, particularly around leadership and motivation in the medical field.

Jennifer Walthall's talk emphasized the importance of acting within the system to drive change. When joining an organization that may not align with your values, you can either work within the system to improve it or fight from the outside. Walthall advocates for influencing change from within, suggesting that once embedded, you can effectively drive improvements.

Lara Goldstein's session on leadership identified four critical attributes of a good leader:

1. Listening: Truly understanding your team.
2. Recognizing the Impact of Small Actions: Little things add up.
3. Conflict Management: Not everyone will like you, and that's okay.
4. Gratitude, Kindness, and Decency: Core values that should guide every leader.

Natalie's detailed reflections on the FIX Conference are a must-read for those interested in these themes. Attending FIX in 2019 should be on your list if possible!

Dan Horner analyzed the POLAR trial in one of our journal club posts. The POLAR trial is a significant randomized control trial investigating the effects of hypothermia in the early stages after a brain injury. This study follows the Eurotherm trial, which explored hypothermia's role in patients with severe brain injuries in the ICU.

The POLAR trial involved 511 patients with severe brain injuries, randomized to either hypothermia (cooling to 33-35°C) or maintaining normothermia for 72 hours. Despite strong pathophysiological evidence supporting hypothermia, the trial found no significant difference in outcomes after six months. Initial results suggest that routine hypothermia for early-stage brain injury might not be beneficial, but long-term data follow-up is crucial. This trial, published in JAMA, is essential reading for anyone involved in emergency medicine or critical care.

Zaf Qasim, a former Manchester trainee now making waves in the US, contributed an enlightening post on the use of whole blood in trauma resuscitation. This approach, which makes intuitive sense—replacing lost whole blood with whole blood—contrasts with the UK practice of separating blood into components for transfusion.

Zaf argues that whole blood could simplify and improve trauma care, reducing the time and complexity of reconstituting blood components in the body. Although not yet standard in the UK, this method is gaining traction in places like London HEMS and various European centers. As data continues to emerge, this could revolutionize trauma care, harkening back to practices from the Second World War and Vietnam.

Natalie May returns with a provocative post challenging the use of the term "sexy" in clinical medicine, especially in resuscitation-related specialties. Often used to describe procedures or equipment, this term can inadvertently perpetuate gender biases and undermine professionalism.

Natalie, supported by her husband Oli May's humorous yet insightful critique, urges us to reconsider such language. The term "sexy" in a medical context is not a compliment and can contribute to a culture that sexualizes women in the workplace. This reflection is especially relevant for departments striving to maintain professionalism and inclusivity.

In the realm of medical education, Nick Smith's debut blog post introduces us to cognitive load theory. As a clinical educator in Manchester, Nick explores how intrinsic, extrinsic, and germane cognitive loads affect learning and teaching.

Nick's post is a valuable resource for educators aiming to optimize their teaching strategies. By understanding and managing cognitive load, we can create more effective and supportive learning environments for our trainees. This post is part of a broader series on educational theories that are crucial for medical educators.

Medical student Claire Bromley shares her transformative elective experience at Mitchell's Plain with the BAD EM team. Working with leaders like Katya Evans and Craig Wylie, Claire's reflections offer deep insights into the challenges and rewards of emergency medicine in South Africa.

Claire highlights the stark differences between UK and South African healthcare systems, particularly the intense workload and resource constraints in the public sector. Her experience underscores the importance of preparation, respect, and adaptability for anyone considering working in a different health economy.

Natalie May's final post for November reflects on promoting diversity and inclusivity in the emergency department. She emphasizes that the ED is unique in its diversity, seeing patients from all walks of life.

Natalie advocates for a broader understanding of diversity beyond ethnicity, including gender, disability, and sexual orientation. Her insights are essential for ED professionals committed to providing equitable care and fostering an inclusive environment.

I had the pleasure of discussing "Learning in the Social Age" at the Emerge 10 conference in Scotland. This presentation, supported by a blog post, explores how the internet and social media are transforming medical education.

We are now competing on a global scale as educators, with learners accessing information from various sources worldwide. This shift necessitates embracing new methods of engagement, ensuring our teaching remains relevant and impactful.

We wrapped up November with a highlight from St Emlyn's Live, featuring Salim Rezaie from the RebelEM blog and podcast. Salim's presentation on "Beyond ALS" challenges us to rethink cardiac arrest management, focusing on advanced techniques and evidence-based practices.

Salim's talk covers crucial aspects such as minimizing shock pauses, effective adrenaline administration, and optimizing IV/IO access. For anyone serious about improving their ALS skills, this blog, podcast, and accompanying videos are indispensable resources.

November was a whirlwind of activity and learning at St Emlyn's, and we have plenty more in store for December. As we approach the holiday season, we hope you find time to explore these posts and integrate their lessons into your practice. Thank you for being part of the St Emlyn's community, and we look forward to continuing this journey of learning and improvement together.

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/