Lots to chat about on the podcast this month, and not just COVID! There's been blog posts about clots, troponin and even telly, as well as the Journal Club series.

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... 

Welcome to our seventh webinar and journal club reviewing recent research and featuring COVID-19 updates, hosted by the University of Manchester, Manchester Royal Infirmary and Royal College of Emergency Medicine in collaboration with St Emlyn's.

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

Welcome to our sixth COVID-19 Journal Club Podcast.

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

Welcome to our fifth webinar and journal club reviewing recent research and featuring COVID-19 updates, hosted by the University of Manchester, Manchester Royal Infirmary and Royal College of Emergency Medicine in collaboration with St Emlyn’s.

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

The COVID-19 Journal Club Panel

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.

Over the last few years many of us in the UK have started to incorporate high-sensitivity troponin into the assessment of patients presenting with chest pain.

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 Shownotes

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

Welcome to our fourth webinar and journal club reviewing recent research and featuring COVID-19 updates, hosted by the University of Manchester, Manchester Royal Infirmary and Royal College of Emergency Medicine in collaboration with St Emlyn's.

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

Welcome to our third webinar and journal club reviewing recent research and featuring COVID-19 updates, hosted by the University of Manchester, Manchester Royal Infirmary and Royal College of Emergency Medicine in collaboration with St Emlyn’s.

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

References

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

In this podcast, Dan and Iain talk about the clinical journey of a COVID-19 patient, beyond the ED, with insights from the critical care unit. There are some concepts here that we don’t have time to do full justice to in the podcast, so there is a comprehensive set of "show notes" and all the references at www.stemlynsblog.org/covid-19-and-critical-care

Professor Rick Body is joined by Prof Paul Klapper (Professor of Clinical Virology), Dr Charlie Reynolds (NIHR Clinical Research Fellow), Prof Pam Vallely (Professor of Medical Virology), Dr Anisa Jafar (Academic Clinical Lecturer) and Prof Simon Carley (you know him...) to discuss six papers about COVID-19 infection. 

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

Iain and Simon discuss Covid19 and more in this review of the best of the blog from March 2020.

Simon interviews Dr John Rogers and Dr Nathan Lewis on respiratory infection prevention.

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

The world is consumed by the Coronavirus pandemic, but how do we look after ourselves? Liz and Iain discuss some strategies to stay well over the coming weeks and months. Recorded on 25th March 2020.

Simon chats to Sarah Thornton, consultant anaesthetist, intensivist and head of the NW school of anaesthesia on preparing to work in a critical care unit during the Covid-19 pandemic.

Iain and Simon chat about the current Corona pandemic and the blog in Feb 2020.

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

Dr Roberto Cosentini is an old friend of St Emlyn's who works in Bergamo, in Northern Italy. He is right at the heart of the recent Covid19 outbreak. He kindly found an hour to record a podcast with us on his experiences.

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

 

 

How you can support St Emlyn's

• Join us for #stemlynsLIVE conference May 12th 2020
• Subscribe to the blog (look top right for the link)
• Subscribe to our PODCAST on iTunes
• Follow us on twitter @stemlyns
• PLEASE Like us on Facebook
• Find out more about the St.Emlyn’s team
• Find out more about the MMU MSc in Emergency Medicine here.
• Download one of our FREE e-books here

Shortcode

 

 

 

 

 

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

Our regular round up of the best of the blog from December 2019. Published a little late, largely because of Coronavirus issues and general business.

The latest from the St Emlyn's blog

Simon and Zaf talk about the practicalities of REBOA and discuss whether it's ready for prime time in the UK.

Introduction

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.

Understanding REBOA

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.

Indications and Contraindications

Indications:

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.

Contraindications:

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.

The Procedure

Preparation

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.

Insertion and Inflation

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.

Monitoring and Maintenance

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.

Benefits and Challenges

Benefits

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.

Challenges

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.

Conclusion

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.

Further reading

A Month in Review: Key Takeaways from St Emlyn's September 2019 Content

Welcome to a detailed overview of the latest content from St Emlyn's, focusing on the valuable insights and educational resources we shared throughout September 2019. This month’s offerings span a wide range of topics, from the evolving concept of the "resuscitationist" to the increasing challenges posed by decompensated liver disease, and the ongoing development of emergency medicine education. Here’s a look at the most important takeaways.

The Resuscitationist: More Than Just a Title

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.

Decompensated Liver Disease: A Growing Concern in the ED

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.

Expanding Education: The MSc in Emergency Medicine

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.

Supporting St Emlyn’s: Keep Our Content Free and Accessible

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.

Introducing Coda: The Next Evolution After SMACC

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 Game-Changer in Resuscitation

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.

Looking Ahead: What’s Next for St Emlyn’s?

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: Revolutionizing Head Injury Management with Tranexamic Acid

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.

Overview of the CRASH-3 Trial

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.

Patient Population and Inclusion Criteria

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.

Key Findings of the CRASH-3 Trial

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.

Number Needed to Treat (NNT)

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.

Timing of Administration

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.

Implications for Clinical Practice

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.

Cost-Effectiveness and Accessibility

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.

Considerations for Special Populations

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.

Future Directions: Intramuscular TXA and Beyond

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.

Conclusion: Implementing CRASH-3 Findings in Practice

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.

A vox pop round up of the best of the ERC19 conference in Slovenia.

Our latest podcast from the #stemlynsLIVE conference last year. Dan Horner talks on the concept and potential role of the UK Resuscitationist.

Prof. Rick Body is an internationally recognised expert in diagnostic testing. In this podcast he takes us through diagnostics today and also the near future which may change almost everything. 

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

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

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

vb

S

This is Chris's talk from #stemlynsLIVE on GI emergencies. Remember to check out the blog for the background, references and more.

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

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

Workplace Safety: A Pressing Concern

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

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

Leadership in Education: Simon Carley’s New Role

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

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

Pediatric Status Epilepticus: Evaluating Second-Line Agents

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

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

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

Understanding Clinical Trials: The Importance of Statistical Literacy

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

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

Prolonged Field Care in the ED: Learning from Military Medicine

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

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

Atrial Fibrillation: Reassessing Cardioversion Strategies

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

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

Traumatic Cardiac Arrest: Reevaluating Chest Compressions

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

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

Virtual Reality in Pain Management: An Emerging Tool

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

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

The Power of Peer Review: Enhancing Clinical Practice

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

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

Conclusion

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

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

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

Traumatic Cardiac Arrest: Insights from Military Experience

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

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

From the Battlefield to the Emergency Room: Evolving TCA Management

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

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

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

Challenging Old Assumptions: New Data on TCA Survival

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

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

The Controversy Around Chest Compressions in TCA

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

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

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

Key Findings: Prioritizing Blood Over Compressions

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

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

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

Translating Research into Practice

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

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

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

Conclusion: A New Paradigm for Traumatic Cardiac Arrest

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

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

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

Alan Grayson takes us through his thoughts on ATLS. Is it really as terrible the #FOAMed world makes out?

Navigating a Mental Health Crisis in Healthcare: A Guide to Recovery

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.

Understanding the Crisis Point

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.

Preparing for a Crisis Before It Happens

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.

What to Do 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.

The Path to Recovery

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.

Dealing with Shame and Guilt

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.

Moving Forward

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.

Conclusion

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.

St. Emlyn's April 2019 Podcast Highlights

Hello and welcome to the St. Emlyn's blog. I'm Simon Carley, and today I'll be sharing the exciting developments from April 2019 on our St. Emlyn's blog. This month has been packed with insightful posts and groundbreaking research, so let's dive in.

Andromeda Shock Trial: A New Perspective

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.

Enhancing Learning with Minimal Effort

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.

Aortic Emergencies: Key Insights from George Willis

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.

Ambulatory Care for PEs: Dan Horner's Expert Insights

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.

Coping with Clinical Tragedies: Liz Crowe's Personal Journey

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.

Final Thoughts

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.

Highlights from March 2019: Key Insights and Updates

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

Management of Adult Congenital Heart Disease

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

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

Common Issues in ACHD Patients

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

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

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

Key Takeaways for Emergency Physicians

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

A Deeper Dive into Fontan Circulation

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

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

Top Trauma Papers from the Trauma UK Conference

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

The PAMPer Trial

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

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

Bougie Use in the ED

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

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

Late Presenting Head Injury Patients

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

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

The Zero Point Survey

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

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

Responsible Volunteering Overseas

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

The Ethics of Volunteering

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

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

Volunteering Responsibly

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

Case Study: Volunteering in South Africa

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

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

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

The Future of SMACC: CODA

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

CODA: A New Beginning

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

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

Looking Ahead

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

What to Expect from CODA

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

Additional Highlights from March

Critical Appraisal Nuggets (CANS) on P-values

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

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

Dual Coding in Medical Education

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

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

The Impact of Reboa in Trauma Care

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

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

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

The Role of Evidence-Based Practice

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

Final Thoughts

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

Stay Connected

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

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

Back in late 2018 we gathered in Manchester for the inaugural #stemlynsLIVE conference. Our friend Dr George Wills gave a great talk on Aortic Emergencies.

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.

vb

S

Also check out these excellent #FOAMed resources.

• Subscribe to the blog (look top right for the link)
• Subscribe to our PODCAST on iTunes
• Follow us on twitter @stemlyns
• PLEASE Like us on Facebook
• Find out more about the St.Emlyn’s team

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

Understanding P Values: A Comprehensive Guide for Clinicians

Welcome to St Emlyn's blog, where we delve into the complex world of P values—a crucial element in medical research. For emergency medicine clinicians, understanding P values is essential for interpreting study results and applying them effectively in clinical practice. This post aims to demystify P values and enhance your critical appraisal skills.

What Are P Values?

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.

The Null Hypothesis and Significance Testing

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 Magic of 0.05

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.

Clinical vs. Statistical 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

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.

Moving Beyond 0.05

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.

Multiple Testing and Bonferroni Adjustment

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 in Clinical Trials

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.

Effect Size and Confidence Intervals

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.

Practical Tips for Interpreting P Values

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.

Conclusion

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!

St. Emlyn's January Roundup: Key Insights and Innovations

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!

Reflecting on 2018: Transformational Reads and Achievements

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.

Goals for 2019: Innovations and Personal Aspirations

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.

New Year’s Resolutions: Insights from Liz Crowe

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.

Tetanus Guidelines: New Insights and Practical Applications

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.

Excellence in Emergency Medicine: Claire Richmond’s Contributions

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.

Prognosticating Cardiac Arrest Outcomes: Dan Horner’s Research

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.

Celebrating Evidence-Based Medicine: Critical Appraisal E-Book

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.

Pre-Medication for Ketamine Sedation: Exploring New Research

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.

HEMS and Traumatic Cardiac Arrest: Evaluating Outcomes

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.

Looking Ahead: Plans for the Future

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.

Support St. Emlyn’s: Keeping Education Free and Accessible

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!

In this episode of the St. Emlyn's podcast, Rick Body and Charlie Reynard discuss an influential research project conducted by Dr. Reynard during his academic foundation program. The paper, titled 'Optimizing Antiplatelet Utilization in the Acute Care Setting,' explores decision-making under clinical uncertainty, specifically in emergency medicine for suspected acute coronary syndromes (ACS). Through systematic reviews and decision tree modeling, the research evaluates the benefits and risks of various antiplatelet therapies, such as Ticagrelor and aspirin versus Clopidogrel and aspirin. The findings reveal that Ticagrelor and aspirin are often more beneficial for patients with a greater than 8% probability of ACS, while Clopidogrel holds little to no place in current practice. The discussion opened up new questions about dynamic risk prediction and the importance of modeling to inform clinical decisions.

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

This podcast and presentation was recorded at the St Emlyn's LIVE conference in Manchester 2018. In this presentation Clare takes us through the rationale, principles, training and practice that we need in order to continually develop as prehospital and resuscitation practitioners.

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. 

This podcast was recorded at the Intensive Care Society State of the Art meeting in London 2018. Simon Carley interviews Prof Peter Brindley on the interface of technology, humans and humanity in critical care. The audio was recorded live and at the venue so there is a fair bit of background noise, but we hope that this does not distract from a wide ranging and fascinating podcast.

Five strategies to improve your resuscitations.

1. Zero point survey

2. Peer review

3. 10 in 10

4. Hot debriefs

5. Fly the patient

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

Salim Rezaie from the REBEL EM podcast takes us through the optimal management of cardiac arrest and also explores some of the controversies and difficulties that make the difference to our patients. 

You can read a lot more about the background to this talk, see the evidence and watch the video on the St Emlyn's site. Just follow this link. https://www.stemlynsblog.org/beyond-acls-salim-rezaie-at-stemlynslive/