The St.Emlyn’s Podcast

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September 5, 2015  

Ep 55 - Communicating (not Breaking) Bad News with Liz Crowe

Liz Crowe joins Iain Beardsell to discuss really difficult conversations in the ED. How do we communicate terrible news in the ED and critical care.

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St.Emlyn's

July 26, 2015  

Ep 54 - Intro to EM: Analgesia in the ED.

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.

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July 16, 2015  

Ep 54 - A tribute to John Hinds

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.

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July 12, 2015  

Ep 53 - Day 2 and 3 Round Up (SMACCUS)

Day 2 and 3 at #smaccUS. Iain and Simon round up the highlights and look forward to #smaccDUB.

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July 7, 2015  

Ep 52 - Managing grief in the ED with Liz Crowe

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.

RIP John Hinds
Crack the Chest talk at SMACCUS

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St.Emlyn's

June 25, 2015  

Ep 51 - Day One Round Up (SMACCUS)

The first day of #smacc15 was amazing. An incredible introduction and an amazing program.

Have a listen to what the St.Emlyn's team got up to on day one.
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June 24, 2015  

Ep 50 - All in a day’s work (SMACC 2015)

Iain and Simon discuss Iain's SMACC talk and how we deal with difficult cases in the ED.

June 24, 2015  

Ep 49 - SMACC Workshops Review and Pearls

Recorded in Chicago at the SMACC US Conference, Nat, Rick, Simon and Iain discuss the day of workshops and look forward to the main conference.

June 4, 2015  

Ep 48 - Intro to EM: The patient with back pain.

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.

Back pain is a multi system disorder....., until you can prove otherwise.

Don't forget to listen to Iain's talk on chronic pain link here.  https://vimeo.com/97811644

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Red flag symptoms and analgesia advice below.

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May 22, 2015  

Ep 47 - Barbra Backus on Risk scores in Acute Coronary syndromes

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.

 
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May 6, 2015  

Ep 46 - Intro to EM: The patient with asthma

Iain and Simon discuss the initial management of severe and life threatening asthma in the resus room.

Another podcast in the induction series aimed at new starters in Emergency Medicine.

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April 27, 2015  

Ep 45 - Top 10 trauma papers 2014-2015.

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

This talk was presented at the Trauma Care Conference in Telford 2015. It's a great conference and I'd encourage you to attend.
If you want to know more visit www.stemlynsblog.org for more discussion and links to all the papers discussed.
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April 18, 2015  

Ep 44 - Tim Draycott on Obstetric Trauma (LTC 2014)

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!

March 26, 2015  

Ep 43 - APLS 2015 updates for the management of the serious injured child

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

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

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March 22, 2015  

Ep 42 - Paediatric Major Trauma with Ross Fisher (LTC 2014)

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I recently met Ross in the flesh. What a super chap. A great clinician who really wants to improve care for injured children in the UK and around the world.
In this podcast he gives us a paediatric perspective on how we should approach the seriously injured child.

Great stuff, controversial in places, challenging to adult dogma and always excellent.

S

PS. If you ever get to hear him speak.... then do, he's awesome. Check this out.

March 15, 2015  

Ep 41 - Is trauma an elite sport? with Tom Evens (LTC 2014)

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Tom Evens is a doctor, rowing coach, prehospitalist and awesome resuscitationist. In this podcast he talks about aspiring to be excellent and whether we can draw parallels with sport.
Great stuff.
Check out the marginal gains post which is referenced in the podcast here http://stemlynsblog.org/ed-need-matt-parker-st-emlyns/
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February 27, 2015  

Ep 40 - Opiate overdose in the ED

stemlyns31400.jpgSimon and Iain debate how the management of opiate OD has changed in the ED.

Surely you're not still giving massive doses of naloxone IV and IM are you? Really? Maybe this will make you think again.

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February 22, 2015  

Ep 39 - Prof. Tim Harris on Shock Assessment (LTC 2014)

Do you think you're awesome at assessing shock?

Think again!

The stupendous Prof Tim Harris (who St.Emlyn's loves) tells us that all is not quite as it seems.....

Listen, learn, be awesome.

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February 10, 2015  

Ep 38 - New (or are they really new) Oral Anticoagulants and the Emergency Physician PART 2

Rick and Kirstin delve deeper into the world of Novel Oral Anti Coagulants.

February 2, 2015  

Ep 37 - Karim Brohi at LTC (LTC 2014)

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.

Tricky!

Check out the blog post that accompanies this podcast here.

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January 24, 2015  

Ep 36 - The GoodSAM app with Mark Wilson (LTC 2014)

Live from the London Trauma Conference 2014. Iain Beardsell interviews Mark Wilson on the need for rapid response, digital technology and the GoodSAM app.

January 18, 2015  

Ep 35 - New (or are they really new) Oral Anticoagulants and the Emergency Physician PART 1

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
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R

January 14, 2015  

Ep 34 - Intro to EM: Problems in Early Pregnancy

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 :-)

January 6, 2015  

Ep 33 - Impact Brain Apnoea with Gareth Davies from London HEMS (LTC 2014)

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.

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St.Emlyn's

December 23, 2014  

Ep 32 - The Christmas review podcast 2014

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.

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December 11, 2014  

Ep 31 - London Trauma Conference: Day three round up.

It's prehospital and helicopter day at #LTC2014! Iain and guest podcaster Caroline Leech chat through the key points of the day.

Download the GoodSAM app! https://www.goodsamapp.org
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Nat
December 10, 2014  

Ep 30 - London Trauma Conference: Day two round up.

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.

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December 9, 2014  

Ep 29 - London Trauma Conference: Day one round up.

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.

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December 3, 2014  

Ep 28 - Iain and Nat preview the amazing London Trauma Conference.

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.

http://www.londontraumaconference.com/

Have fun :-)

S

November 29, 2014  

Ep 27 - Intro to EM: The patient with chest pain

Iain and Simon discuss the dilemmas of dealing with the patient presenting with chest pain to the ED.

Blog post link here

November 24, 2014  

Ep 26 - Intro to EM: The ED approach to the child with shortness of breath

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.

November 12, 2014  

Ep 24 - Getting started in Emergency Medicine Research

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

October 31, 2014  

Ep 23 - Smacc Chicago update

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

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DOI - Both Iain and myself are being funded to attend. 
October 31, 2014  

Ep 22 - Button Battery ingestion in children

Simon and Nat with a linked podcast to the blog post on the ingestion of button batteries by children.
http://stemlynsblog.org/button-batteries/

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October 28, 2014  

Ep 21 - Code for Cash and Credibility

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/

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October 23, 2014  

Ep 20 - Understanding Troponin Part 3: The NICE guidance.

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

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September 30, 2014  

Ep19 - In Situ and Guerrilla Sim in the ED

1400simman.jpgIain 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.

Much of the work in this podcast should be attributed to John Gatward from Sydney Australia who inspired us to start and to Kirten Walthall our new Sim Fellow who introduced records and departmental learning processes to our systems. 
There are a couple of errors on the podcast. Firstly it's roughly 18 months that we have been doing in situ sim, time must fly so much that I said 9 months! Secondly, on reflection we average 2-4 sim sessions per week, but that includes some sessions that are not in situ, held in a separate area when training other groups of docs in the hospital. The ED in situ frequency is 2-3 sessions per week.
As ever we stand on the shoulders of these giants who support what we all hope to achieve.
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September 23, 2014  

Ep 18 - Victoria Brazil on great presentations with St.Emlyn’s

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.

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September 12, 2014  

Ep 17 - Diffuse Axonal Injury with John Hell

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.

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Iain Beardsell

August 22, 2014  

Ep 16 - Intro to EM: The patient with syncope (transient loss of consiousness)

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.

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August 7, 2014  

Ep 15 - Understanding Troponin Part 2

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

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

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


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

Rick

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

August 6, 2014  

Ep 14 - Exeter CEM conference with Adam Reuben

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

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

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

You can see the program here

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August 3, 2014  

Ep 13 - Intro to EM: The patient with shortness of breath

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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:

  • Pneumonia
  • Asthma/COPD
  • Pulmonary Embolism
  • Acute left ventricular failure
  • Pneumothorax

 

Breathless Patients Podcast

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.

http://vimeo.com/35310564

 

Take Home Points

  • Oxygen should be used in the patient with shortness of breath and the patient monitored closely. Hypoxia kills
  • Always rule out life threatening causes first
  • These patients are sick - do not be afraid to ask advice from a senior colleague early
  • Look for clues - you don't have to wait until the penultimate page of the story to solve the mystery.


What have you learned about breathless patients?

 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?

  • A chest x-ray is often useful in patients who are short of breath; your ED seniors might be able to use bedside ultrasound to further ascertain the underlying pathology, so get help early!
  • ECGs are often useful in these patients
  • Blood gases can also provide lots of useful information - think carefully about whether you need arterial gases and if so, please use local anaesthetic.
  • If nothing makes sense - get a blood sugar, remembering that metabolic disease may cause an acidosis, presenting with an increased respiratory rate (although not often true dyspnoea).
  • And GET SENIOR HELP (including getting your seniors to assess you for those all-important workplace-based assessments; definitely start those early)


Other resources

Chest Radiographs

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).

Chest X-Ray Anatomy  -  Chest X-Ray Abnormalities  -  Chest X-Ray Systematic Approach

Blood Gases

Think! Do you really need an ABG? If the answer is yes, please use local anaesthetic! Your patients will thank you...

Further Reading on Shortness of Breath

The Flipped EM Classroom - Shortness of Breath (with further links).


Natalie May

 

August 1, 2014  

Ep 12 - Intro to EM: The patient with headache

HORIZONS.jpgWe'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:

  • Subarachnoid Haemorrhage
  • Meningitis
  • Tumours and Space Occupying Lesions
  • Temporal Arteritis

Listen to Simon and Iain discuss how to approach these patients here

Further Resources

Headaches at Life in the Fast Lane - a great summary from the LiTFL crew

NICE Guidelines (NCG150) - diagnosis and management of headaches; there's a flowchart and some red flags although you could read the St Emlyn's summary here!

Headache from the Flipped EM Classroom

July 27, 2014  

Ep - 11 Understanding Troponin Part 1

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

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

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

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

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

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

Rick

July 21, 2014  

Ep 10 - Intro to EM: Staying safe in your first job

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

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

Ep 9 - What can we do about targets in the ED?

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

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

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

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

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

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

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July 8, 2014  

Ep 8 - Trauma Team Leadership

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

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

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

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

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June 29, 2014  

Ep 7 - Delving into the Number Needed To Treat, RRR and ARR. Why we love natural frequencies

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.

S

June 26, 2014  

Ep 6 - SMACC Back-Back on What to believe and when to change.

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

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

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

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

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