Iain and Simon discuss the core skills that all EM clinicians need to manage pain in the ED.
These are the basics, but don't be put off. The basics are more important than the fancy stuff that we will discuss in a later podcast.
A podcast mini to round up and look forward to the next few months on the podcast.
We also have a special recording of Danny Boy from the Irish Youth Choir and conducted by Greg Beardsell. This performance was dedicated to Dr John Hinds in Dublin following his untimely death in a motorcycle accident.
Please listen and take a moment to remember him and all that he has done to inspire everyone involved in the care of the injured.
Liz Crowe has delivered some great talks at SMACC, and her talents do not stop there. In her real job she is a social worker on PICUs in Australia. She has a wealth of experience at helping people through difficult times and she shares that with us here on the podcast.
In truth this is something we planned to do when we were all in Chicago but the podcast has added poignancy following the tragic death of John Hinds. Although planned as a stand alone subject we cannot help but contextualise the topic in light of recent tragic events.
We hope it helps now and in the future.
Another induction podcast on a common condition in the ED. Back pain in the ED - it's not all musculoskeletal and there are some really risky diagnoses out there that you need to think about.
Don't forget to listen to Iain's talk on chronic pain link here. https://vimeo.com/97811644
Red flag symptoms and analgesia advice below.
Barbra Backus joins Rick Body to discuss the origin, development and future of risk scores for ED patients with possible acute coronary syndromes. Two researchers at the top of their game, and authors of the HEART and MACS scores.
A first podcast with Simon Laing from the RCEMFOAMed team. We look back at influential trauma related papers from 2014-2015.
Iain interviews the wonderful Tim Draycott on the management of the Obstetric patient with trauma.Tim is a consultant Obstetrician from Bristol and is a great speaker on this rather terrifying topic!
A short podcast updating the UK Advanced Paediatric Life Support (APLS) course guidelines for the management of trauma in children.
Don't forget to read the blog post here. APLS Updates: New kids on the block,
Great stuff, controversial in places, challenging to adult dogma and always excellent.
PS. If you ever get to hear him speak.... then do, he's awesome. Check this out.
Do you think you're awesome at assessing shock?
The stupendous Prof Tim Harris (who St.Emlyn's loves) tells us that all is not quite as it seems.....
Listen, learn, be awesome.
Rick and Kirstin delve deeper into the world of Novel Oral Anti Coagulants.
Karim Brohi joins the St.Emlyn's team at the London Trauma Conference to talk on vascular injury and arterial dissection. A whole range of diagnoses that you should not miss, but which is easy to miss.
Live from the London Trauma Conference 2014. Iain Beardsell interviews Mark Wilson on the need for rapid response, digital technology and the GoodSAM app.
Rick Body and Kerstin de Wit discuss the role of NOACs in clinical management. Part 1 addresses the basics, stuff you should know if you are prescribing these drugs.
Part 1 tells us the good stuff, don't forget to listen to 2 and 3 in the next few weeks as not everything is perfect ;-)
Check out the BLOG POST HERE
The number of patients seen in each ED with problems relating to early pregnancy in the UK is very variable - some hospitals have rapid referral pathways for patients who know they are pregnant. It's still worth thinking about early pregnancy problems though as all EDs see young women and many of these may not yet know that they are pregnant.
Our induction podcast covers our approach to women presenting to the ED
Nat and Iain :-)
First of our podcasts from the London Trauma Conference.
A fantastic episode with Iain talking to Gareth Davies (from London HEMS) talking about Impact Brain Apnoea.
A Christmas review of the world of EM, CC and resuscitation #FOAMed.
This review is no way exclusive and focuses on sites that people may not be familiar with. Take it as read that EMCRIT, LITFL, PHARM, ICN, SGEM, EMLitofNote, ALiEM, Resus.me, KI docs, etc. are already known to be awesome. Check them out and follow the many excellent #FOAMed sites around the world.
Check out the big hitters here http://www.aliem.com/social-media-index/
There are also so many other sites that we have not mentioned, but which we regularly visit and listen to.
It's prehospital and helicopter day at #LTC2014! Iain and guest podcaster Caroline Leech chat through the key points of the day.
Old, young, pregnant, social, airways, cricoid and dogmalysis. There is loads to catch up on from #LTC2014.
Iain and Nat take you through the day.
Whilst I remain in Virchester healing the sick and injured, Nat and Iain are sharing the #FOAMed love at the London Trauma Conference. This is the first round up from day 1 with many highlights and a few tasters for some more podcasts to come.
Next week Iain and Nat will be in London for the best trauma conference in the world. Join them in person, online, on the podcast and on twitter.
Check out the program here, it's amazing.
Have fun :-)
Iain Beardsell and Natalie May talk you through a wise and safe approach to the child with moderate shortness of breath. Listen and learn from the St.Emlyn's team.
The Challenge and Value of Research in Emergency Medicine: at DGINA 2014
Rick Body's talk from DGINA on the need for research in EM.
Check out the associated blog post at http://stemlynsblog.org
Iain and Simon talk about the upcoming SMACC conference in Chicago and do their very best to persuade you to come to the best conference in the world
Simon and Iain discuss what might appear to be a rather dull subject, but it's not. Coding is a key to developing your department and also to secure the functions of UK emergency departments.
A great primer for everyone coming up to FCEM and to anyone interested in how Emergency Departments are funded in the UK.
Follow this link to the associated blog post http://stemlynsblog.org/show-money/
Rick and Iain explore how the latest guidance about the use of high sensitivity troponin was developed and how far we can be assured that it is evidence based.
The NICE guidance is available here. http://www.nice.org.uk/guidance/dg15
Iain and Simon talk through the practicalities of in situ sim in the ED. How do we make it happen in a way that works and helps individuals, teams and departments learn together.
Vic Brazil of #FOAMed and #SMACC fame came to talk to the St.Emlyn's team in Virchester.
Listen in for top tips on looking great and sounding super.
John Hell is a Neurointensivist at University Hospital Southampton and very kindly gave up an afternoon to record his thoughts and share his considerable wisdom about Diffuse Axonal Injury.
I also managed to get him to discuss some other topics including the choice of induction agents and intravenous fluids in patients with head injury.
Please listen, enjoy and comment. We'd love to hear from you, and don't forget to visit the blog site for additional information, slides and content.
This podcast is part of our induction series for new docs starting in UK emergency departments.
You can check out the full post and supporting materials over at the main St.Emlyn's website.
Recently we published part one of our series on cardiac troponins. If you haven't checked it out yet, you can find it here. In the second part, we're going to take a look at high sensitivity troponins and some of the more advanced areas around understanding cardiac troponin and its use in practice. We'll give you a quick run down on the troponin lingo - the language you need to be able to speak in order to fully understand how to use high sensitivity troponin in your practice, including terms like the limit of blank, limit of detection, co-efficient of variation and 99th percentile.
We'll also ask whether Joe Lex had a point when he stirred up controversy around these assays with this legendary tweet:
What if we called it "low specificity troponin" instead of "high sensitivity troponin?" Would that knock some sense into people?
— Joe Lex (@JoeLex5) October 9, 2012
So, check out the associated BLOG POST here and listen to the podcast. There is more on diagnostics and troponin to come very soon.
Hope you enjoy! Please keep the feedback, questions and comments coming. As always, we'd love to hear from you.
DOI: Much of my research work involves HsT. To help with this I have received reagents from companies who make HsT assays, but I not received any other financial benefit or gifts in kind as part of my work and have no financial ties to any companies.
Breathless patients are a challenge in the ED. Shortness of breath can be a frightening presenting complaint for both patients and doctors. As always, think about the possible life threatening causes and actively rule them out. For breathless patients think especially about:
In this podcast Iain and Simon discuss their approach to breathless patients in the ED which we hope will provide you with a good starting point.
For those of you who are more visual learners here is the video recorded a few years ago for SEMEP featuring our very own Iain Beardsell.
Oxygen - or no oxygen??
Oxygen administration is rarely a problem in the immediate and acute setting - and can save lives. So yes, when you first approach a patient who is short of breath, get that oxygen on while you make your assessment then think about the finer points of respiratory failure afterwards.
Where do I begin?
A focused history, including asking the patient about previous conditions and whether they know what's going on!
And then - initial assessment and examination including vital signs (especially respiratory rate), looking for clues as to the underlying cause of their breathlessness, remembering the five common causes.
What treatments might be useful?
A small fluid bolus might help and carries relatively little risk; think about the need for nebulised bronchodilators for patients with asthma or COPD, and remember that antibiotics given early to patients with sepsis save lives.
If the patient has pain we should definitely treat that too.
Which investigations might help me find out more?
One of the key investigations in patients with shortness of breath is the humble chest radiograph. There are some phenomenal FOAM resources for interpretation of CXRs (along with other XRs) at Radiology Masterclass. Well worth bookmarking for your ED shifts (but do ask a senior if you're unsure).
Think! Do you really need an ABG? If the answer is yes, please use local anaesthetic! Your patients will thank you...
The Flipped EM Classroom - Shortness of Breath (with further links).
We've all had headaches, but not often severe enough to prompt us to seek help in an Emergency Department.
In our practice 10% of patients who do present to the ED with a primary presentation of headache will have serious pathology and our job as Emergency Physicians is to work out who these are. Key to this is actively ruling out the life-threatening and life-changing diagnoses:
Listen to Simon and Iain discuss how to approach these patients here
Headaches at Life in the Fast Lane - a great summary from the LiTFL crew
Headache from the Flipped EM Classroom
Do you remember when it took three days to 'rule in' or 'rule out' an acute myocardial infarction (AMI)? When I was a medical student doing my first clinical attachments, I remember doing ward rounds on the CCU seeing patients with suspected AMI. The way they were managed is a million miles from what we do now. Back then, patients would have serial ECGs and then be admitted for cardiac enzyme evaluation over the course of the next 3 days. We'd measure CK, AST and LDH. 'CK' was the so-called 'early marker', which would rise early after the start of an AMI. Today we use CK as a marker of skeletal muscle damage (e.g. rhabdomyolysis). AST and LDH (today we think of these as liver function tests, I know) were the 'late markers' - and by late I really mean late - we might see a rise on days 2 and 3.
Could you imagine for a second, in today's world, ruling out AMI because their CK and LFTs were normal? It's completely unthinkable. That's how much cardiac troponin has changed our practice. We rely on it so completely to diagnose AMI. And yet, it's one of the most misunderstood tests in medicine. Given how much we use it, I guess we feel that we all should know lots about this test. But doctors still have so many questions. Here are just a few:
This is just a brief list. With the research I do in this area and my experience developing protocols/guidelines, people get in touch to ask questions like this quite a lot. There are loads of questions that people ask - but there are lots of themes in common. We thought it was about time we produced a handy run down in the true spirit of #FOAMed.
Take a listen to Part 1 of our troponin podcast. While Simon and Iain have been prolifically churning out spectacular stuff for some time now, this is my debut on the St. Emlyn's podcast. I really enjoyed talking about troponin with Iain - and I hope we covered some useful stuff.
We'll cover more in part 2, when we'll move on to discussing high sensitivity troponins, what they are, how to use them and how to speak the troponin lingo. Please get in touch if there's anything we haven't covered that you'd like us to, or if there's anything you'd like us to elaborate on some more!
If you're starting out in EM then it can be a scary time. Iain and Simon talk through some of the initial anxieties and ask what you need to know to be safe, sensible and super.
It is a little known fact that to be successful as an emergency physician in the UK it is vital to take a three month rotation in Archery. Archery is a key skill for us all dating back to Medieval times when we introduced the longbow into warfare. This devastating tool could cause panic in opposing forces, scattering them into many wide and ineffective directions. In short they were an effective tool to cause and disruption inthe opposition ranks whilst the noble English armies of old strode forward with their visions of the future. Soldiers trained using targets to hone their skills and to focus on the aim - meeting the target.
Of course these days we do not have real bows and arrows in the emergency department, but archery remains alive and well. In the modern NHS we still train our troops in archery, or at least in the principle aim of archery - to meet the target.
With our long history of target setting and target hitting it is therefore no suprise that we are world leaders in standards/targets/indicators....., whichever term you prefer in fact and it has to be said that a target culture in the NHS has been criticised widely, even being blamed for the exodus of trainees to Southern climes, but there is arguably more to it than that.
In last weeks episode we touched on new targets around trauma care in the UK and that raised many questions and opened a debate on twitter. This week we want to take those thoughts further and ask what we, as the archiest of arch archers across the entire NHS can do with these externally set targets.
What we forgot to say in the podcast is the absolute need to work alongside a short stay admissions unit under the ED umbrella. Without that you would really struggle to deliver safe and efficient care. We both work in units with short stay admission units that allow us to deliver safe diagnostic and therapeutic interventions to our patients.
So, with some trepidation Iain and I ask whether all targets are a bad thing....
Iain and Simon discuss the challenges of getting our trauma patients to the CT scanner within 30 minutes of arrival.
The 30 minute target is a UK standard, and we did not set it! All UK trauma centres are judged against the target and (rightly or wrongly) it has become a real issue for many centres.
We would be really be interested in what our International colleagues think about the target and the resultant strategies outlined by the team. There's more on this at the St.Emlyn's website.
As always, we'd love to hear your comments.
Iain and Simon chat about how we can start to translate research findings in to natural frequency summaries that help clinicians and patients alike understand the value of therapeutic interventions.
The NNT site we mention is just fantastic. Visit them here
Great revision page here by the amazing LITFL crew
The NNT for tranexamic acid is 67 not 50.
Hopefully you will have already seen and listened to my SMACC talk on 'What to believe and when to change'. If not then please whizz over to the site now and have a listen. I really enjoyed exploring the uncertainties that exist around when we decide to adopt or abandon therapies.
My belief is that it's really difficult to define the perfect moment and that it's only in retrospect that we can define it.
Since appearing on the ICN network and St.Emlyn's, Scott Weingart, one of the best and most innovative clinicians I know has come back and argued for early adoption. You can check out his rationale on his site and see what you think.
I actually agree with many of the things he tells us, although he has confined himself to one side of the argument. In terms of a defence of early adoption he makes a good case, but like all debates there needs to be another side to the story, so sit back and listen to why we must reflect hard on the decisions we make in deciding what we do, why we do it, and most importantly when.