Summary of the St Emlyn's Teaching Course: Key Takeaways and Innovations in Medical Education

The recent St Emlyn's Teaching Course in Copenhagen marked an exciting event, bringing together educators and clinicians to explore new methods and insights in medical education. This event, held for the first time in Europe, was characterized by a diverse international audience and a focus on integrating traditional teaching methods with modern innovations, particularly in the realm of social media and technology-enhanced learning.

Day 1: Engaging Icebreakers and Personal Branding

The course began with an unconventional icebreaker where participants created business cards featuring a logo or symbol representing themselves, along with their name, email, and an informal skill unrelated to work. This exercise was designed to foster meaningful connections and discussions, helping participants to introduce themselves through a personal and creative lens. This approach emphasized the importance of recognizing the multidimensional nature of clinicians, highlighting their interests and skills beyond the professional sphere.

Holistic Approach to Clinician Well-being

A central theme of the course was the holistic approach to medical education, focusing on the well-being of healthcare professionals. George Willis, an emergency physician with a background in professional football, shared his insights on maintaining mental health in stressful environments. He introduced the concept of resilience as a muscle that can be trained and strengthened, but also cautioned against overworking it to avoid burnout. This metaphor emphasized the importance of prehabilitation, setting boundaries, and ensuring adequate recovery time, crucial for sustaining a long and healthy career in medicine.

Power of Personal Narratives

The value of personal stories in medical education was underscored by Robert Lloyd, who shared his experiences working in South Africa's Khayelitsha Hospital. His honest account of the challenges faced in resource-limited settings, combined with his discussion on purposeful practice and cognitive reframing, offered valuable lessons on learning from failures and continuously improving. Robert's narrative highlighted the emotional and ethical complexities of medical practice, emphasizing the need for empathy and compassion, even under challenging circumstances.

Reflective Exercises on Identity and Values

Natalie May led an introspective exercise called "touchstone," where participants identified their core values and priorities. This exercise was based on the idea of carrying a symbolic stone inscribed with what matters most to them, often unrelated to work. The goal was to encourage reflection on how professional decisions align with personal values, prompting attendees to consider potential trade-offs when taking on new responsibilities. This exercise was a powerful tool for fostering self-awareness and prioritization, reinforcing the course's emphasis on meta-learning and personal development.

The Social Age of Learning

The afternoon sessions shifted focus to the role of social media in medical education. Led by Celine, Julie, and Sandra, the discussion centered on Julian Stodd's concept of the "social age of learning," where social connections and collaborative learning are paramount. The faculty explored various social media platforms, debating the relevance of platforms like Twitter versus newer options like Instagram. Participants engaged in a hands-on exercise to develop a new brand for a social media presence, focusing on content strategy, target audiences, and engagement tactics. This session highlighted the potential of social media as a tool for professional development and education while also addressing ethical considerations, such as patient confidentiality and the balance between personal and professional personas.

Building Personal Learning Networks

Julie Stodd's session on personal learning networks (PLNs) emphasized their importance in ongoing professional growth. PLNs consist of a network of peers, mentors, and resources that support continuous learning. The diverse backgrounds of the course's faculty and participants exemplified the power of these networks, facilitated by online connections and shared professional interests. Julie discussed strategies for building and maintaining PLNs, including engaging in online forums, attending conferences, and seeking mentorship. The session also underscored the value of diversity within PLNs, encouraging connections across different specialties and cultures to broaden perspectives.

Reflective Practice and Looking Ahead

The course concluded with reflections on the discussions and exercises, reiterating the importance of a holistic and reflective approach to medical education. The emphasis on personal well-being, the integration of personal narratives into teaching, and the strategic use of social media are all critical components of modern medical education. The upcoming sessions on simulation and feedback promised to build on these foundations, providing practical tools and techniques for teaching and clinical practice.

The St Emlyn's Teaching Course in Copenhagen was a rich learning experience, providing valuable insights and fostering a global community of educators and clinicians. The course's focus on personal growth, ethical considerations, and the effective use of technology in education highlighted the evolving nature of medical education in the social age. As the participants continue their professional journeys, the lessons learned from this course will undoubtedly influence their teaching methods and personal development, contributing to a more connected and resilient medical community.

A critical appraisal nuggest on simple ways to understand the true effect of an intervention. Also see this more in depth podcast done with Iain Beardsell

http://ebem.podbean.com/2011/11/03/statistics-2/

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In this episode of the St Emlyn's podcast, Ian Beardsell and Simon Carley review the top 10 trauma papers of the year, highlighting key findings and their implications for trauma care. The selection includes significant studies published in high-profile journals such as The Lancet and the New England Journal of Medicine, offering valuable insights for healthcare professionals in emergency and trauma medicine.

1. Whole Body CT Scanning: REACT-2 Study

The REACT-2 study explored the impact of whole-body CT (WBCT) scanning on trauma patients, particularly its effect on mortality rates. The study involved 1400 patients and found no significant difference in mortality between those who received WBCT and those who underwent more selective CT scanning. The difference in radiation exposure was minimal, suggesting that WBCT's comprehensive imaging might be more beneficial than harmful, especially in elderly patients where missed injuries can complicate outcomes. This study reassures trauma team leaders that current scanning practices are appropriate and highlights the importance of a patient-centred approach based on clinical presentation.

2. Impact Brain Apnea (IBA)

Impact brain apnea, characterized by apnea and a catecholamine surge following a severe head blow, has been increasingly recognized in trauma care. The paper, co-authored by John Hines and Mark Wilson, provides a detailed explanation of IBA's pathophysiological mechanisms. This condition can lead to cardiac arrest if not promptly addressed, emphasizing the need for immediate intervention in cases of traumatic brain injury (TBI). Understanding IBA helps emergency care providers identify and treat potentially life-threatening conditions that may not be immediately apparent.

3. Decompressive Craniectomy for Raised ICP: RESCUE-ICP Trial

The RESCUE-ICP trial examined the outcomes of decompressive craniectomy in patients with refractory intracranial pressure (ICP) due to severe TBI. The study found that while the procedure increased survival rates, many survivors experienced significant disability. This raises ethical considerations about the quality of life post-intervention. The trial underscores the importance of informed consent and discussions about potential outcomes with patients' families, aligning treatment with patient values.

4. STITCH Trial: Surgery Timing for Intracranial Bleeds

The STITCH trial focused on the timing of surgical intervention in patients with traumatic intracranial bleeds. Although the trial faced recruitment challenges and was terminated early, results suggested better outcomes with early surgery. This finding, while not statistically conclusive, supports the notion that timely intervention can reduce mortality and improve recovery. Emergency physicians and neurosurgeons should consider these findings when deciding on surgical timing in TBI cases.

5. Traumatic Cardiac Arrest: Epidemiology and Outcomes

Using data from the Trauma Audit and Research Network (TARN), this study examined traumatic cardiac arrest (TCA) cases, revealing a 30-day survival rate of 7.5%. This rate, similar to medical cardiac arrests, challenges the perception that TCA is almost always fatal. The study highlights the importance of aggressive resuscitation efforts and underscores the need for ongoing training to retain skills in managing these rare but critical events.

6. Open vs. Closed Chest Compressions in TCA

The effectiveness of open chest (thoracotomy) versus closed chest compressions in TCA was explored, with findings indicating similar outcomes in terms of end-tidal CO2 levels, a marker for effective CPR. This challenges the notion that thoracotomy should always be performed in TCA cases. The study suggests that standard advanced life support (ALS) protocols may suffice in certain scenarios, especially where thoracotomy is not practical.

7. Rocuronium vs. Succinylcholine for RSI in Severe Brain Injury

The choice between rocuronium and succinylcholine for rapid sequence intubation (RSI) in severe brain injury remains debated. An observational study found no significant overall difference in mortality between the two drugs, though succinylcholine was associated with higher mortality in severe head injury cases. This suggests a possible preference for rocuronium in such scenarios, though the evidence is not strong enough to mandate a change in practice.

8. Intraosseous Needle Length in Obese Patients

As obesity becomes more prevalent, appropriate intraosseous (IO) needle length is crucial for effective vascular access. The study recommended using longer yellow IO needles for patients with a BMI over 43, as standard blue needles may not reach the marrow. This is particularly important in emergency situations where IV access is difficult, ensuring proper drug administration and preventing complications like compartment syndrome.

9. Optimal Site for Needle Decompression in Tension Pneumothorax

A systematic review recommended the anterior axillary line as the preferred site for needle decompression in tension pneumothorax, aligning with standard chest drain placement. The review also noted significant complication rates associated with needle decompression, suggesting that alternative methods like thoracostomy may be necessary in certain cases. This finding emphasizes the need for precise technique and careful consideration in managing tension pneumothorax.

10. Weekend Effect in Major Trauma Care

The study examined the "weekend effect" in major trauma care, finding no significant difference in mortality between weekend and weekday admissions. This suggests that well-resourced, consultant-led trauma care can provide consistent outcomes regardless of the day. The findings advocate for the 24/7 availability of senior emergency physicians and trauma teams, ensuring high-quality care at all times.

Conclusion

This year's top trauma papers provide valuable insights into current practices and emerging trends in trauma care. While there may not have been groundbreaking changes, the studies reinforce the importance of evidence-based decision-making, ongoing training, and ethical considerations in patient management. As the field evolves, staying informed about the latest research is crucial for improving patient outcomes and delivering high-quality trauma care. For further details and access to the studies, visit the Sentemlin site and related FOAMed resources.

In a new podcast format Simon (@EMManchester) and Iain (@docib) discuss the month's offerings from the St Emlyn's blog and podcast (www.stemlynsblog.org).

It's been a month full of interesting posts on subjects as diverse as Thrombolysis in Stroke (Alan Grayson), The Future of Emergency Medicine in the Social Age (Simon), Cardiac Arrest Centres (Simon), Love in Critical Care (Liz Crowe), Transfers (Nat and Simon), Thrombolysis in PE (a guest post from FOAMed legend Anand Swarminathan) and Benzos in Back Pain (Janos). Head to the website for the articles themselves and all the references and links you need.

We're aiminig to make this a regular monthly podcast - let us know if it's useful and enjoyable and how we could make it even more educational.

Nat and Simon discuss the complexities of transferring a patient from the resus room to CT and back again. Look out for the blog post soon on stemlynsblog.org

Setting up a really great journal club.

Title: Mastering Chest Drains: Essential Tips and Techniques for Emergency Medicine

In this comprehensive guide, Simon Carley and Rick Bodey from St Emlyns explore the essential aspects of chest drains, also known as intercostal drains or chest tubes, focusing on their importance, optimal techniques, and common pitfalls in emergency medicine.

Importance of Chest Drains

Chest drains are critical for managing conditions like pneumothorax, hemothorax, and pleural effusion by removing air, blood, or fluid from the pleural cavity. Despite not being a daily procedure in the UK, proficiency in chest drain insertion is crucial due to the potential for severe complications, including organ damage and infection. Proper training and careful execution are necessary, especially as new technologies and medical practices evolve.

Choosing the Right Size

Traditionally, large-bore drains (32-36 French) were used for pneumothoraces to prevent blockage by clots. However, recent evidence supports the use of smaller drains (28-32 French), even for trauma patients. Smaller drains are less invasive, cause less discomfort, and are equally effective. The move towards smaller drains aligns with a trend in medicine favoring minimally invasive procedures, which reduce patient risk and enhance comfort.

Management of Occult Pneumothoraces

Advances in imaging, like CT scans and ultrasound, have increased the detection of occult pneumothoraces, which are often asymptomatic and not visible on chest x-rays. Traditional guidelines recommended chest drains for all traumatic pneumothoraces, but recent research suggests conservative management may be appropriate in many cases. A systematic review found no significant difference in outcomes between patients with occult pneumothoraces managed conservatively and those who received chest drains. This highlights the importance of assessing each patient's condition, monitoring closely, and only intervening when necessary, particularly in stable, asymptomatic patients.

Optimizing Analgesia

Pain management during chest drain insertion is vital. Traditional local anesthesia methods are often insufficient, especially in trauma settings. Ketamine has emerged as an effective option, providing both analgesia and sedation without significant respiratory depression. Administered in small, incremental doses, ketamine helps manage pain and anxiety, making the procedure more tolerable. Additional analgesics, like fentanyl and midazolam, can complement ketamine, offering a multimodal approach to pain management.

Intra-Pleural Analgesia

Injecting local anesthetics, such as bupivacaine, into the pleural cavity can further enhance patient comfort, particularly as the lung re-expands and contacts the parietal pleura. This method is supported by randomized controlled trials and can significantly reduce pain in the first few hours post-insertion, aiding in better respiratory function and reducing the risk of complications like pneumonia.

Securing the Drain

Properly securing the chest drain is crucial to prevent accidental dislodgement, especially during patient transport or imaging. Techniques like Neil Bandari's "Jo'burg knot" offer reliable methods for securing drains, though simpler techniques may suffice for less frequent practitioners. Transparent dressings are recommended to allow monitoring of the insertion site and ensure the drain remains securely anchored.

The Role of Ultrasound

Ultrasound is an invaluable tool for accurately placing chest drains, particularly in cases of pleural effusion or complex pleural anatomy. It aids in identifying the best insertion site, reducing the risk of complications, and confirming the resolution of pneumothorax. Ultrasound is especially useful in patients with obesity or chronic lung conditions, where traditional landmarks may not be reliable.

Aspiration of Pneumothoraces

For primary spontaneous pneumothoraces, aspiration may be a viable alternative to chest drain insertion, particularly when specific criteria are met. This less invasive approach can be performed with a standard IV cannula or a small Seldinger technique, which also provides a pathway for chest drain insertion if necessary. This method is beneficial in outpatient settings, allowing for quick resolution without hospitalization.

Conclusion

The management of chest drains is a dynamic field, continually evolving with new research and technology. Emergency medicine practitioners must stay informed and adapt to evidence-based practices, including the use of smaller chest drains, conservative management of occult pneumothoraces, optimized analgesia, and the application of ultrasound. The goal is to provide safe, effective, and patient-centered care, minimizing unnecessary interventions.

At St Emlyns, we strive to share knowledge and best practices to enhance patient care. We invite our readers to contribute their insights and experiences, fostering a collaborative approach to improving clinical skills and outcomes in emergency medicine.

Understanding Intention to Treat in Clinical Trials: A Key Concept for Critical Appraisal

Welcome to the St Emlyns podcast! In this episode, Simon Carley and Rick Bodey delve into an essential topic for anyone interested in critical appraisal and clinical trials—Intention to Treat (ITT). This principle is a cornerstone in the analysis of randomized controlled trials (RCTs), crucial for ensuring the validity and applicability of study findings.

What is Intention to Treat (ITT)?

ITT is a methodological principle used in the analysis of data from RCTs. It requires that participants be analyzed in the groups to which they were originally randomized, regardless of whether they adhered to the treatment protocol. This approach helps maintain the benefits of randomization, such as comparability between groups, and provides a more conservative and realistic estimate of a treatment's effectiveness.

The ITT principle is essential because it preserves the randomization process's integrity, ensuring that the groups remain comparable. This comparability helps minimize bias, allowing researchers to attribute differences in outcomes to the interventions rather than to other confounding factors.

Importance of ITT in Clinical Trials

The ITT principle plays a critical role in RCTs by ensuring that the analysis reflects real-world scenarios where patients may not perfectly adhere to treatment regimens. For example, in a trial comparing a new anticoagulant, Carleyoxaban, to warfarin, ITT analysis would include all participants, even those who did not complete the treatment due to side effects. This comprehensive approach provides a more accurate reflection of the treatment's potential benefits and risks in everyday clinical practice.

By including all participants as originally allocated, ITT analysis helps prevent bias introduced by excluding participants who experience adverse effects or switch treatments. This is vital for obtaining a realistic estimate of the treatment's effect, considering real-world complexities such as patient non-compliance.

Challenges and Considerations

While ITT is the gold standard for RCT analysis, it does come with challenges. One significant challenge is that it can obscure the reasons why participants dropped out or switched treatments. These reasons can provide valuable insights into the treatment's tolerability and feasibility. For instance, in the hypothetical trial with Carleyoxaban, understanding why 50% of participants dropped out could highlight serious side effects that might not be evident from an ITT analysis alone.

In some cases, a per-protocol analysis, which includes only those participants who fully adhered to the treatment protocol, can offer additional insights. This type of analysis can help distinguish between a treatment's efficacy (its effect under ideal conditions) and effectiveness (its effect in a typical clinical setting). However, per-protocol analysis can introduce bias by including only those who were more likely to tolerate and benefit from the treatment.

ITT vs. Per-Protocol Analysis

Per-protocol analysis is particularly valuable in certain situations, such as non-inferiority trials. These trials aim to show that a new treatment is not worse than an existing one. In such cases, per-protocol analysis can provide a more conservative estimate, ensuring that observed differences are not due to adherence variations between groups.

For example, in a trial evaluating a new protocol for early discharge of patients with suspected pulmonary embolism, ITT might show no difference in outcomes if many participants did not follow the new protocol. However, a per-protocol analysis could reveal whether the protocol, when followed, led to improved outcomes or safety concerns.

Similarly, in trials assessing new medications, ITT can provide a realistic estimate by accounting for dropouts due to side effects. This is crucial for understanding the medication's overall safety and effectiveness in the general population.

Practical Implications for Clinicians

For clinicians, understanding ITT is essential for interpreting the results of clinical trials. ITT analysis offers a pragmatic view of a treatment's potential benefits and risks, reflecting the complexities of real-world clinical practice. When deciding whether to use a new treatment, clinicians must consider factors like patient adherence and potential side effects, both of which are accounted for in ITT analyses.

Moreover, clinicians should be critical when appraising studies, checking whether ITT principles were followed. This includes examining flow diagrams that show participant allocation and follow-up, ensuring that the number of participants analyzed matches those initially randomized. Such diligence helps ensure that study findings are robust and applicable to clinical practice.

Conclusion and Key Takeaways

1. ITT is Essential: It preserves the benefits of randomization and provides a realistic estimate of treatment effects by including all participants as initially allocated.

2. Per-Protocol Analysis: While useful in certain contexts, such as non-inferiority trials, it should be interpreted cautiously due to potential biases.

3. Real-World Relevance: ITT helps clinicians understand the applicability of trial results in everyday practice, considering issues like non-compliance and side effects.

4. Critical Appraisal: Clinicians should always verify if ITT analysis was performed when appraising studies, as it ensures a comprehensive understanding of the treatment's effectiveness.

As we continue to explore critical appraisal and clinical trials, we encourage you to stay tuned to the St Emlyns podcast. Future episodes will delve deeper into various aspects of clinical research, providing valuable insights to enhance your practice. Understanding concepts like ITT not only improves your ability to interpret research but also equips you with the tools to make informed, evidence-based decisions in patient care.

Thank you for joining us in this discussion. The ITT principle is a key component of high-quality RCTs and an essential concept for anyone involved in clinical research or patient care. By mastering this and other critical appraisal tools, you can significantly improve your understanding of medical literature and contribute to better patient outcomes. Stay curious, keep learning, and we'll see you in the next episode of the St Emlyns podcast!

Insights from the New York Teaching Course: Enhancing Medical Education

Welcome to the St. Emlyn's blog! I'm Iain Beardsell, sharing insights from the recent New York Teaching Course, an event organized by Rob Rogers and Saline Rissai. This course brought together educators from diverse backgrounds, including pediatric surgeons, flight nurses, PhD students, and even a veterinarian, all united by the goal of becoming better educators. Notable attendees included Ross Fischer, Ashley Leibig, Sandra Viggers, and Camilla Sauronson, who shared their experiences and key takeaways.

Diverse Expertise and Shared Learning

The New York Teaching Course offered a unique opportunity to learn from a broad spectrum of expertise. Ross Fischer, a Pediatric Surgeon and presentation expert, found it humbling to be sought after for his advice on presentation skills. He highlighted the importance of continual improvement, noting the evolution of presentations over the years. His blog, ffoliet.com, offers valuable tips for enhancing presentation skills, a crucial aspect of effective teaching.

Ashley Leibig, known for her contributions to St. Emlyn's and her work at SMAC, emphasized the value of open communication. She appreciated the honesty in feedback sessions, where participants openly shared their past errors and positive feedback practices. This openness is essential for professional growth and creating a safe learning environment.

Sandra Viggers, a research fellow at the Copenhagen Academy for Medical Education and Simulation, focused on the power of vulnerability in simulation and debriefing. She found the social events particularly impactful, highlighting a moment where a participant shared a personal story, moving many to tears. This reinforced the importance of sharing and building a supportive community in educational settings.

Camilla Sauronson, a medical student from Denmark and PhD candidate in Tourette Syndrome, valued the inspiring environment of the course. She was particularly interested in innovative teaching methods like the flipped classroom, which involves engaging learners with materials before group discussions. This method fosters active learning and deeper understanding, a shift from traditional lecture-based teaching.

Key Takeaways and Learning Points

The course provided numerous valuable insights and practical lessons:

1. Flipped Classroom: Camilla Sauronson emphasized the effectiveness of the flipped classroom approach, which encourages students to engage with educational content before attending group discussions. This method promotes active learning and enriches classroom interactions.

2. Constructive Feedback: The feedback session led by George Willis was a highlight, demonstrating the importance of giving constructive feedback. Ashley Leibig noted the challenges in providing good feedback but appreciated the practical pointers provided during the session. Effective feedback is critical for personal and professional development.

3. Presentation Skills: Ross Fischer underscored the continuous need to refine presentation skills. His insights into slide design and delivery were invaluable, reminding educators of the importance of clear and engaging communication in teaching.

4. Resilience and Wellbeing: Sandra Viggers reflected on Chris Doty's talk on resilience. Doty discussed recognizing signs of burnout and the importance of self-care. Sandra emphasized the need for educators to be mindful of their own and their learners' wellbeing, highlighting the role of supportive relationships in preventing burnout.

5. Engaging Lectures: Ken Mills' interactive workshop on evidence-based medicine showcased that lectures can be both educational and entertaining. Using historical figures to illustrate concepts made the session memorable and engaging, demonstrating that education can and should be enjoyable.

Building a Supportive Educational Community

A particularly poignant moment during the course was a participant sharing a deeply personal story during a social event. Sandra Viggers emphasized the significance of vulnerability and the supportive community fostered at the course. This sense of community is vital in emergency medicine and education, where the pressures of the job can be intense. Building strong, supportive networks helps individuals navigate challenges and grow both personally and professionally.

Practical Applications and Future Directions

As the course concluded, participants were encouraged to apply what they had learned in their own teaching practices. Key practical steps include:

• Implementing the Flipped Classroom: Start by incorporating pre-session materials like podcasts or articles, fostering richer discussions during group sessions.
• Developing Effective Feedback Techniques: Create a structured approach to giving feedback, focusing on being constructive and empathetic.
• Enhancing Presentation Skills: Regularly review and improve presentation materials, seeking feedback from peers.
• Prioritizing Wellbeing: Integrate wellbeing discussions into educational curricula and encourage self-care practices among staff and students.
• Fostering a Supportive Community: Create opportunities for personal sharing and team-building, strengthening trust and collaboration.

Looking Forward

The New York Teaching Course was an enriching experience, and similar events are planned for the future, including one in Copenhagen before the next SMAC conference. These courses provide more than just educational content; they are opportunities to connect with a global community of educators dedicated to improving their craft.

For more detailed reflections and session summaries, the Scan FOAM website offers comprehensive coverage. Their posts provide a virtual experience of the course, nearly as immersive as attending in person.

Conclusion: A Commitment to Continuous Improvement

The New York Teaching Course reinforced that teaching is not merely about imparting knowledge but about connecting with students, being vulnerable, and continuously improving. Whether you're an experienced educator or just starting, there's always room for growth. Let's carry forward the lessons learned, strive to be better educators, and support our students and colleagues. Thank you for joining us on this journey, and stay tuned for more insights and stories from St. Emlyn's. Keep learning, keep teaching, and be the best educator you can be.

Here's the podcast on BRUE and ALTE's in the emergency department. 

Simon and Iain chat about the first few days at EuSEM in Vienna. Some of the clinical and social highlights. We also have a bonus podcast at the end recorded with a volunteer at Iain's "Podcasting for Beginners'" talk. For more from EuSEM (The European Society for Emergency Medicine) congress follow the #eusem16 hashtag on Twitter.

Comprehensive Overview of Upper GI Bleeds in Emergency Medicine

Upper gastrointestinal (GI) bleeding is a common and potentially life-threatening condition encountered in emergency medicine. It encompasses a broad spectrum of clinical presentations, ranging from mild cases with minimal blood loss to severe, life-threatening hemorrhages. Understanding the various causes, accurate risk stratification, and appropriate management strategies are crucial for optimizing patient outcomes.

Causes and Mimics of Upper GI Bleeding

Upper GI bleeding originates from the upper part of the gastrointestinal tract, including the esophagus, stomach, and the duodenum. Common causes include:

1. Mallory-Weiss Tears: These are tears at the gastroesophageal junction caused by forceful vomiting or retching.
2. Gastritis and Peptic Ulcer Disease: These conditions involve inflammation or ulceration in the stomach or duodenum and are frequent causes of bleeding.
3. Esophageal Varices: Dilated veins in the esophagus, often due to liver disease and portal hypertension, can rupture and cause severe bleeding.
4. Gastroesophageal Reflux Disease (GERD): Chronic acid reflux can lead to esophagitis and bleeding.

It is also important to distinguish true upper GI bleeding from conditions that mimic it. For example, blood from a nosebleed (epistaxis) may be swallowed and later vomited, simulating GI bleeding. Additionally, differentiating between hemoptysis (coughing up blood) and hematemesis (vomiting blood) is essential for accurate diagnosis.

Risk Stratification Using the Glasgow-Blatchford Score (GBS)

Effective management of upper GI bleeding begins with risk stratification to determine the severity of the condition and the need for urgent intervention. The Glasgow-Blatchford Score (GBS) is a widely utilized tool that helps predict the need for medical treatment and the risk of adverse outcomes. It considers several clinical parameters, including:

• Blood Urea Nitrogen (BUN): Elevated levels suggest significant bleeding.
• Hemoglobin Levels: Low levels indicate blood loss.
• Systolic Blood Pressure: Hypotension is a sign of significant hemorrhage.
• Pulse Rate: Tachycardia can indicate a compensatory response to blood loss.
• Clinical Signs: The presence of melena, syncope, or liver disease increases the risk score.

Patients with a GBS of zero are considered low risk and may be suitable for outpatient management with appropriate follow-up. Those with higher scores require hospitalization for further evaluation and treatment, including possible endoscopy.

Initial Management and Resuscitation

The immediate management of patients with upper GI bleeding involves stabilizing the patient and preventing further complications. Key steps include:

1. Airway Management: Ensuring a clear and secure airway is critical, particularly in patients with altered consciousness or ongoing vomiting.
2. Fluid Resuscitation: Intravenous fluids are administered to maintain hemodynamic stability.
3. Blood Product Transfusion: In cases of significant bleeding, transfusions of packed red blood cells, fresh frozen plasma, and platelets may be necessary to manage blood loss and correct coagulopathies.

Role of Endoscopy

Endoscopy is a crucial diagnostic and therapeutic tool in managing upper GI bleeding. It should ideally be performed within 24 hours of presentation to determine the source of bleeding and provide treatment. Urgent endoscopy is particularly indicated for patients with hemodynamic instability or signs of significant bleeding.

Special Considerations for Variceal Bleeding

Variceal bleeding, often seen in patients with chronic liver disease, requires specific management strategies due to its severity and associated complications. Key considerations include:

• Terlipressin: A vasoconstrictor that helps reduce portal pressure and control bleeding in variceal cases.
• Antibiotic Prophylaxis: Administered to prevent infections, which are common in patients with liver disease and variceal bleeding.
• Balloon Tamponade: In situations where endoscopy is not immediately available, a Sengstaken-Blakemore tube can be used as a temporary measure to control bleeding. This procedure should be performed with caution and preferably under the supervision of an experienced specialist.

Multidisciplinary Approach

The management of upper GI bleeding, particularly severe cases, requires a coordinated approach involving multiple specialties. The emergency physician plays a central role in initial stabilization and diagnosis, but collaboration with gastroenterologists, anesthetists, hematologists, and critical care teams is essential. This multidisciplinary team ensures comprehensive care, from initial resuscitation and endoscopic intervention to ongoing monitoring and treatment in critical care settings.

Disposition and Follow-Up

The decision to admit or discharge a patient with upper GI bleeding depends on the severity of the bleeding, patient stability, and the results of risk stratification. Low-risk patients (GBS of zero) may be discharged with a plan for outpatient follow-up and endoscopy. In contrast, patients with higher risk scores or ongoing symptoms should be admitted for further evaluation and treatment.

Conclusion

Upper GI bleeding is a critical condition that demands prompt recognition, accurate assessment, and effective management. By utilizing risk stratification tools like the Glasgow-Blatchford Score and employing a multidisciplinary approach, healthcare providers can significantly improve patient outcomes. Proper diagnosis and timely intervention, including endoscopy and appropriate supportive care, are vital components of successful management.

As always, we encourage healthcare professionals to share their experiences and best practices in managing upper GI bleeds. Engage with us on social media or leave a comment on this blog post to contribute to the ongoing discussion on improving emergency medicine care.

Understanding Blinding in Clinical Trials: A Comprehensive Guide

Blinding, also referred to as masking, is a crucial methodological approach used in clinical trials to eliminate bias and ensure the validity of study outcomes. This practice involves keeping study participants, clinicians, and researchers unaware of the treatment assignments. The goal is to prevent the knowledge of treatment allocation from influencing behaviors, perceptions, or evaluations, thus maintaining the integrity of the research.

Types of Blinding in Clinical Trials

Single Blinding: In this approach, only the participants are unaware of the treatment they receive. For example, in a drug trial comparing an anticoagulant to a placebo, participants do not know which they are receiving. This method helps prevent the placebo effect or other biases arising from participants' expectations. Ensuring effective single blinding requires that the placebo and active treatment appear identical in all sensory aspects, including appearance, taste, and even side effects.

Double Blinding: This method extends the concealment to both participants and the clinicians or researchers administering the treatment. It is crucial because knowledge of the treatment can influence the clinical management of the patient or the interpretation of symptoms. For example, if a doctor knows a patient is receiving a placebo, they might provide less attentive care. Double blinding helps ensure that all patients receive consistent care, and it prevents clinicians from unintentionally influencing the outcomes based on their expectations.

Triple Blinding: The most comprehensive form of blinding, triple blinding, includes blinding the data analysts as well. This method prevents bias during the interpretation of study results, as analysts are unaware of which group received the treatment. This approach is particularly important when the data analysis involves subjective judgments or when the analysis plan is not strictly predefined. Triple blinding helps ensure that data is handled objectively, leading to more reliable conclusions.

Importance of Blinding in Clinical Trials

Blinding is essential to minimize various forms of bias that can compromise the validity of clinical trials. These biases include:

1. Participant Bias: When participants know the treatment they are receiving, it can influence their reporting of symptoms and outcomes, skewing the study results.

2. Observer Bias: Clinicians and researchers may consciously or unconsciously alter their assessments based on their knowledge of the treatment allocation. This can affect how symptoms are recorded or how interventions are implemented, potentially leading to biased outcomes.

3. Analyst Bias: Data analysts may be influenced by their expectations or hypotheses if they know which treatment group participants belong to. This can affect the objectivity of the data analysis, making the results less reliable.

Practical Challenges in Blinding

Despite its importance, blinding is not always feasible or ethical in all types of studies. For example, in trials comparing physical interventions like a wrist splint versus a plaster cast, it is impossible to blind participants or clinicians due to the visible nature of the treatments. In such cases, researchers must adopt a pragmatic approach, using rigorous randomization and transparent reporting to mitigate potential biases.

A notable case highlighting the challenges of blinding is a study conducted by Dan Horner and colleagues on the treatment of calf deep vein thrombosis (DVT). The study compared the use of warfarin with no anticoagulation. Ideally, the study would have included a placebo group, but ethical and practical concerns made this impossible. Patients on warfarin require regular monitoring and dose adjustments, which could not ethically be simulated for a placebo group. As a result, the study was conducted without blinding but still provided valuable insights into the treatment's potential benefits.

Sham Interventions in Blinding

In some studies, particularly those involving surgical procedures, sham interventions are used to maintain blinding. This involves performing procedures on the control group that mimic the intervention without providing therapeutic benefits. For instance, in trials assessing surgical techniques, control group participants might undergo anesthesia and incision without actual surgery. This method is ethically sensitive but can be crucial in preventing bias from influencing the study's outcomes.

Blinding in Diagnostic Studies

Blinding is also vital in diagnostic studies, where it ensures that the assessment of diagnostic tests is not influenced by pre-existing knowledge about the patients. For instance, in evaluating a new diagnostic test like a D-dimer test for pulmonary embolism, blinding the interpreters of test results is essential. It prevents bias in the interpretation of test outcomes, ensuring that results are evaluated based on the test's performance rather than expectations or assumptions.

Conclusion

Blinding is a fundamental component of clinical trial design, crucial for minimizing bias and ensuring the validity of study findings. Whether it is single, double, or triple blinding, the technique helps maintain objectivity in clinical research, making the results more reliable and trustworthy. While blinding is not always possible, especially in trials involving visible interventions, researchers must strive to minimize bias through careful study design and transparent reporting.

As readers and critical appraisers of clinical research, it is essential to look for evidence of blinding and consider its impact on the validity of study results. Understanding the importance and challenges of blinding can help us better interpret clinical trial outcomes and make informed decisions in healthcare.

Thank you for joining us at St. Emlyn's. Stay curious, critically appraise the evidence, and continue exploring the fascinating world of clinical trials. Until next time, stay informed and engaged in advancing medical knowledge.

Understanding Randomization in Clinical Trials: A Guide for Critical Appraisal

Welcome to the St. Emlyn's blog, your go-to resource for insights into emergency medicine and critical care. Today, we're diving into a crucial aspect of clinical research: randomization. Whether you're preparing for exams like the FR-KEM or just want to deepen your understanding of clinical trials, understanding randomization is key to critical appraisal. This blog post will walk you through the essentials, common pitfalls, and best practices for ensuring robust study design.

What is Randomization?

Randomization is a foundational process in clinical trials, particularly those evaluating interventions. It refers to the random allocation of participants into different treatment groups. This process aims to eliminate selection bias and ensure that differences in outcomes can be attributed to the intervention itself rather than other factors.

Why is Randomization Important?
Randomization is crucial because it helps establish causality. Without it, studies might only reveal associations rather than true cause-and-effect relationships. For example, if we observe patients receiving different treatments in a non-randomized manner, systematic differences between the groups—such as varying standards of care—could confound the results. Randomization seeks to balance these factors, allowing for a clearer interpretation of the intervention's effectiveness.

Key Components of Randomization

1. Random Allocation: This is the process of assigning participants to treatment groups purely by chance. It can be done using random number tables, computer-generated sequences, or other methods that ensure allocation is not influenced by investigators or participants.

2. Allocation Concealment: This involves hiding the allocation sequence from those involved in enrolling participants. It's vital to prevent selection bias, where researchers might consciously or unconsciously influence the assignment of participants to specific groups.

3. Blinding: While not a part of randomization per se, blinding is closely related. It refers to keeping participants, healthcare providers, and researchers unaware of which treatment group participants are in. This prevents performance and detection biases.

Common Pitfalls in Randomization

Despite its importance, randomization can be implemented poorly, leading to biased results. Here are some common pitfalls:

• Inadequate Randomization Methods: Methods like assigning treatments based on birth dates or day of the week might seem random but can introduce systematic biases. For instance, there could be differences in care based on the day or time, making these methods unreliable.

• Failure to Conceal Allocation: In the past, brown envelope methods were used, where the treatment assignment was sealed in an envelope. However, this method is vulnerable to tampering. For instance, researchers might be tempted to "peek" at the assignment and selectively enroll participants, compromising the study's integrity.

• Small Sample Sizes: Small trials are particularly vulnerable to imbalance in baseline characteristics between groups purely by chance. This can lead to skewed results that do not accurately reflect the intervention's efficacy.

Best Practices in Randomization

To ensure robust and reliable results, certain best practices should be followed:

1. Use of Reliable Randomization Methods: In modern trials, computer-generated random numbers are the gold standard. They provide true randomness and can be tailored to the specific needs of the study.

2. Allocation Concealment Techniques: More sophisticated methods like centralized randomization, where a third party manages the allocation process, can help maintain concealment. In some studies, web-based or voice-based systems are used, which provide real-time allocation while preventing researchers from manipulating the process.

3. Stratification and Block Randomization: To address the issue of unequal distribution of participants' characteristics, stratification and block randomization are employed. Stratification involves grouping participants based on certain characteristics (e.g., disease severity) and ensuring even distribution across treatment groups. Block randomization, on the other hand, ensures that each treatment group has an equal number of participants within defined blocks, maintaining balance throughout the study.

The Role of Randomization in Analyzing Results

When analyzing the results of a randomized controlled trial (RCT), the first step is to examine the baseline characteristics of the treatment groups. This is often presented in Table 1 of a study. The purpose is to ensure that randomization has successfully created comparable groups. If significant differences exist, they could confound the results, making it harder to attribute outcomes to the intervention alone.

Another critical aspect is to consider the size of the trial. Larger studies are generally better at balancing characteristics between groups, reducing the likelihood of chance imbalances. However, even in well-randomized studies, it's possible for imbalances to occur, especially in smaller trials. Researchers must acknowledge these potential imbalances and adjust their analyses accordingly.

Practical Considerations in Emergency Medicine

In emergency medicine, the need for rapid, reliable randomization methods is particularly pressing. Web-based randomization systems offer a convenient solution, providing quick, secure, and tamper-proof allocation. Similarly, voice-based systems, where a computer assigns treatment groups via a phone call, are another practical option.

For those conducting smaller trials, there are accessible tools available, such as Sealed Envelope (sealedenvelope.com), which offers randomization services tailored to smaller studies. These tools help maintain the integrity of the randomization process, even in resource-limited settings.

Special Considerations: Trials with Diverse Populations

In clinical trials, particularly in emergency settings, researchers often encounter a wide range of patient severities. For instance, in head injury studies, patients can vary significantly in their Glasgow Coma Scale (GCS) scores. In such cases, simple randomization may inadvertently group all severe cases into one treatment arm, skewing the results.

To mitigate this, researchers use stratification, ensuring that key subgroups (e.g., GCS < 8) are evenly represented across treatment groups. This not only improves the internal validity of the study but also enhances the power of the statistical analyses, providing more reliable results.

Advanced Randomization Techniques

As trials become more complex, so do the randomization techniques. Block randomization is one such method that ensures each treatment group receives participants throughout the study, rather than in uneven waves. For example, rather than having all participants receive treatment A first, followed by treatment B, block randomization allocates treatments in smaller blocks (e.g., groups of 20), maintaining balance throughout.

This method is particularly valuable in trials with interim analyses or those that may stop early due to significant findings. It ensures that at any given point, the distribution of participants is roughly equal, allowing for fair and accurate assessment of the treatment effects.

Conclusion: The Importance of Rigorous Randomization

Randomization is the cornerstone of robust clinical trial design. It minimizes biases, balances baseline characteristics, and supports the validity of causal inferences. However, the process must be meticulously planned and executed. From choosing the right method to ensuring allocation concealment, every step is crucial in maintaining the integrity of the study.

For clinicians and researchers, understanding the nuances of randomization helps in critically appraising literature and designing their own studies. Whether you're preparing for an exam or conducting a trial, appreciating the intricacies of randomization will enhance your ability to interpret and apply clinical research findings effectively.

At St. Emlyn's, we emphasize the importance of thorough critical appraisal skills. By mastering these concepts, you'll be better equipped to discern high-quality evidence and make informed decisions in your clinical practice. Stay tuned for more insights and practical tips on navigating the world of clinical research.

Enhancing Pre-Hospital to Hospital Handover: Insights from SMACC Dublin

The SMACC Dublin conference provided a valuable platform for discussing the crucial handover process from pre-hospital teams to hospital staff. This transition is essential for patient safety and continuity of care, as it involves conveying critical information from emergency responders to hospital-based healthcare professionals. The discussion at the conference highlighted several key issues, best practices, and strategies to improve this critical interface.

The Emotional Landscape and Communication Challenges

Dr. Natalie May, reflecting on her shift from hospital to pre-hospital care, emphasized the emotional challenges and the need for empathy and understanding between both teams. Pre-hospital providers often face a tense environment upon hospital arrival, with varying degrees of reception from the hospital team. This tension can arise from perceived disrespect or a lack of understanding of the pre-hospital team's challenges, which can complicate the handover process.

A significant issue in handover is the lack of structured communication. The fast-paced environment of the emergency department (ED) can pressure pre-hospital providers to quickly pass on patients and information, sometimes resulting in incomplete or rushed handovers. To address this, the use of structured communication tools like the AD MISSED acronym (Age, Date/Time, Mechanism of Injury, Injuries, Signs/Symptoms, Treatments, and Decisions) was recommended. This structure helps ensure that all essential information is conveyed systematically, minimizing the risk of information loss.

Best Practices for Handover

One highlighted best practice is the implementation of a clear and consistent protocol. For instance, a Texas hospital has adopted a "hands-off" period during handover, where the receiving team does not intervene until the pre-hospital team has completed their report. This approach helps maintain focus on the verbal communication of critical details without distractions, ensuring a comprehensive transfer of information.

The role of the trauma team leader is also critical. They act as the primary point of contact, receiving the handover and ensuring that all relevant team members understand the conveyed information. The trauma team leader is responsible for verifying the accuracy of the information, clarifying any uncertainties, and coordinating subsequent actions. This leadership role is crucial in maintaining a smooth and efficient handover process.

Overcoming Communication Barriers

Differences in communication styles and preferences between hospitals can pose challenges. The discussion emphasized the need for pre-hospital teams to be adaptable, potentially rehearsing handovers and using aids like whiteboards. Regular joint training sessions between pre-hospital and hospital teams were recommended to align expectations and familiarize each side with the other's protocols. The use of digital tools, such as secure messaging apps, can also facilitate better communication and continuity of care.

The physical environment during handover significantly impacts its effectiveness. A calm, organized setting with minimal interruptions is ideal for ensuring a thorough transfer of information. Designating a specific area for handovers and equipping it with necessary tools, such as a whiteboard and a scribe, can improve the clarity and accuracy of the communication.

The Importance of Feedback

Immediate feedback after handover is crucial for continuous improvement. It allows pre-hospital providers to understand the outcomes of their interventions and the patient's progression. This real-time feedback can highlight areas for protocol refinement and training. Additionally, formal long-term feedback mechanisms, such as follow-up meetings or debriefings, are vital for providing a complete picture of the patient's journey, helping both pre-hospital and hospital teams improve their practices.

Building a Culture of Respect and Understanding

A successful handover process is built on mutual respect and understanding between pre-hospital and hospital teams. Acknowledging the expertise and challenges faced by each group fosters a more cooperative and supportive environment. This respect is essential for enhancing patient care and ensuring a smooth transition from one care setting to another.

To build this culture of respect, regular interdisciplinary workshops and social events can help break down barriers and build rapport among healthcare professionals. Recognizing the unique pressures and responsibilities of each team member contributes to a more harmonious and effective handover process.

Conclusion: Towards a Seamless Continuum of Care

The discussions at SMACC Dublin underscored the importance of an effective handover in emergency medicine. By adopting structured communication protocols, ensuring clear leadership, and fostering a culture of continuous feedback and mutual respect, the gap between pre-hospital and hospital care can be bridged. The ultimate goal is to create a seamless continuum of care, where the transition between healthcare teams is smooth, efficient, and centered on the patient's best interests.

This integrated approach not only improves patient outcomes but also enhances job satisfaction among healthcare providers by reducing miscommunications and misunderstandings. The handover process is a critical component of patient care that requires ongoing attention and improvement.

In conclusion, effective handover practices are essential for ensuring patient safety and continuity of care. The insights from SMACC Dublin provide valuable guidance on refining these practices. By fostering a culture of learning, respect, and collaboration, healthcare providers can ensure that every patient transition is handled with the utmost professionalism and care.

Prioritizing Personal Well-being in Healthcare: A Guide for Medical Professionals

Introduction
In the healthcare profession, we often prioritize patient care over our own well-being. However, maintaining personal health is crucial for providing high-quality care. This blog post explores the importance of well-being for healthcare professionals and offers practical strategies to enhance it. Given the high risks of burnout and compassion fatigue in our field, understanding and improving our well-being is essential.

The Multi-faceted Nature of Well-being
Well-being encompasses physical health, mental and emotional stability, and social connections. These aspects are vital for maintaining overall health but are often neglected due to the demanding nature of healthcare work. Common practices like relying on caffeine, sugar, and alcohol provide temporary relief but are unsustainable in the long run.

1. Diet and Nutrition
   A balanced diet is fundamental to well-being. Many healthcare professionals struggle with poor dietary habits due to busy schedules, often resorting to fast food or skipping meals. This can lead to energy crashes and dependency on unhealthy snacks. Incorporating a balanced diet rich in proteins, fruits, and vegetables can provide sustained energy and support overall health. Simple changes, such as meal prepping and choosing healthy snacks, can significantly improve dietary habits.

2. Physical Activity
   Regular exercise is essential for physical and mental well-being. Despite busy schedules, finding time for physical activity is crucial. Exercise reduces stress and anxiety, improves mood, and boosts overall health. Simple activities like walking, home workouts, or gym visits can be easily integrated into daily routines, even in small amounts.

3. Mental and Emotional Health
   The mental and emotional demands of healthcare work are substantial, often leading to stress and burnout. It is essential to prioritize mental health through practices like mindfulness, therapy, or engaging in hobbies. These activities can provide a mental break and improve emotional resilience, helping professionals cope with the pressures of their work environment.

Practical Strategies for Enhancing Well-being

1. Optimizing Diet
   Start by reassessing your eating habits. Prepare nutritious meals that are easy to take to work, like sandwiches with whole grains, lean proteins, and vegetables. Keep healthy snacks available, such as fruits and nuts, to avoid reaching for unhealthy options. Hydration is also key; drink plenty of water throughout the day to maintain energy levels and reduce cravings.

2. Reducing Caffeine and Sugar
   While caffeine and sugar can provide quick energy, they often lead to dependency and health issues. Gradually reduce caffeine intake by substituting with herbal teas or decaf options. Replace sugary snacks with healthier alternatives, and stay hydrated to help manage cravings and maintain energy levels.

3. Incorporating Exercise
   Integrate physical activity into your routine, starting with realistic goals. Whether it’s a short walk, a quick home workout, or regular gym sessions, exercise is crucial for maintaining health. Even minimal physical activity can have significant benefits, such as improved mood and energy levels.

4. Strengthening Social Connections
   Social interactions are important for emotional support and well-being. Sharing breaks with colleagues, even with healthier beverage options, can maintain the social ritual and foster community. Building strong relationships with colleagues provides a support network for sharing challenges and celebrating successes.

5. Prioritizing Mental Health
   Many organizations offer employee assistance programs, including counseling services. Utilizing these resources can help manage stress and other mental health issues. Practices like mindfulness, journaling, or engaging in creative activities can also aid in managing stress and improving mental clarity.

The Role of Sleep
Sleep is critical for maintaining well-being, especially for those working long hours or night shifts. Developing good sleep hygiene is essential, including consistent sleep patterns and a restful sleep environment. Avoiding stimulants like caffeine before bed can also improve sleep quality, which in turn enhances cognitive function and emotional regulation.

Overcoming Barriers to Well-being

1. Time Constraints
   Lack of time is a common barrier to maintaining well-being. However, small, consistent changes can make a big difference. Meal prepping, scheduling exercise, and setting aside time for mindfulness are all practical strategies that can fit into a busy schedule.

2. Mindset Shifts
   It's important to move away from an all-or-nothing mentality. Focus on gradual, sustainable changes rather than attempting to overhaul your entire lifestyle at once. Start with small, manageable goals and adjust them as you progress.

3. Seeking Support
   A support network is invaluable for maintaining well-being. Whether it’s through friends, family, or professional counselors, sharing your journey can provide motivation and accountability. Colleagues can also offer support and understanding, given the unique challenges of the healthcare profession.

Long-term Benefits
Prioritizing well-being offers numerous benefits, including enhanced capacity for compassionate care, reduced risk of burnout, and a healthier work-life balance. Modeling healthy behaviors can also positively influence colleagues and patients, fostering a culture of well-being within the workplace.

Developing a Personal Well-being Plan
Creating a personal well-being plan involves setting realistic goals and making gradual changes. Assess your current habits and identify areas for improvement. Incorporate elements of physical activity, healthy eating, mental and emotional health, and social connections into your plan. Track your progress, celebrate small victories, and adjust your plan as needed.

Conclusion
As healthcare professionals, taking care of ourselves is crucial to providing the best care for our patients. By prioritizing personal well-being, we can enhance our physical and mental health, improve our capacity for compassionate care, and enjoy a more fulfilling career. Start by making small changes today and share your journey with us at St. Emlyn's. Remember, a healthier you means better care for your patients.

SMACC Dublin 2023: Key Highlights and Reflections

The SMACC (Social Media and Critical Care) conference is a premier event in the field of critical care and emergency medicine. Held in Dublin, this year’s conference brought together healthcare professionals from around the world to share knowledge, foster connections, and inspire each other. The St Emlyn’s team was in attendance, and we are excited to share our reflections on the final day’s events and the broader impact of the conference.

A Night of Celebration: The SMACC Gala Dinner

The SMACC gala dinner is always a highlight of the conference, and this year was no exception. The event spanned six floors, each offering unique entertainment, from folk music to live bands and a DJ. The atmosphere was electric, filled with opportunities for networking and forging new friendships. The gala dinner epitomizes the community spirit of SMACC, where connections are made not just over discussions of clinical topics but also through shared moments of celebration and joy.

Powerful Plenary Sessions: Stories of Resilience and Compassion

Thursday morning’s plenary session featured four outstanding speakers, each offering a unique perspective on critical care. Kath Maiden opened the session with a moving account of her work in Africa, highlighting the challenges and humbling experiences of providing care in resource-limited settings. Her talk set the tone for a morning of deep reflection on the global disparities in healthcare.

Dr. Nikki Blackwell followed with an impactful presentation on her experiences in disaster zones. She shared stories of repairing ventilators with a Swiss Army knife and managing the emotional strain of working in high-stress environments. Nikki’s talk underscored the resilience required in such settings and the importance of mental health support for healthcare workers.

Ashley Shreves then tackled the crucial topic of palliative care, emphasizing its importance in critical care settings. With an aging population, the need for compassionate end-of-life care is increasingly significant. Ashley urged all healthcare providers to engage in palliative care discussions, making it clear that this responsibility should not be left solely to specialists.

Ashley Liebig’s presentation on the emotional toll of pediatric loss brought a sobering perspective to the day. She recounted her experience as a HEMS nurse dealing with the death of a child, highlighting the complexities of interprofessional communication and the emotional aftermath. Her talk emphasized the need for compassion and support within healthcare teams, particularly after traumatic events.

Promoting Gender Diversity and Leadership

The prominence of female speakers in the plenary session was a notable feature of this year’s SMACC conference. The event has made significant strides in promoting gender diversity, ensuring that expert female voices are heard. This inclusion not only enriches the conference content but also reflects a commitment to fostering a more inclusive and representative community in critical care and emergency medicine.

Navigating the Concurrent Sessions

The concurrent sessions offered a wide array of topics, making it challenging to choose which ones to attend. Tom Evans’ talk on the parallels between training as an Olympian and striving for excellence in medical practice was particularly inspiring. He emphasized the importance of mentorship and structured training in achieving clinical excellence.

Adrian Plunkett’s presentation on "Learning from Excellence" stood out as a refreshing perspective on quality improvement in healthcare. He advocated for the recognition of positive events in clinical practice, arguing that celebrating successes can foster a supportive and constructive work environment. This approach not only improves morale but also encourages continuous learning and improvement.

The Unique Contribution of Peter Brindley

Peter Brindley provided a humorous yet insightful take on teamwork and burnout. His engaging style made complex topics accessible and entertaining. Peter’s emphasis on the importance of maintaining a healthy work-life balance resonated with many attendees, highlighting the need for self-care in high-pressure medical environments.

A Light-Hearted Finale

The conference concluded with a light-hearted finale featuring a competition between the Northern and Southern Hemispheres. This engaging and humorous session provided a fun and relaxed end to the conference, contrasting with the previous year’s more somber conclusion. The finale underscored the importance of taking risks and trying new things, a key theme that ran throughout the conference.

Key Takeaways and Looking Ahead

Reflecting on SMACC Dublin 2023, several key themes emerged. The conference showcased the exceptional quality of education and the value of sharing diverse perspectives. It also highlighted the importance of community, reminding us that we are part of a global network of professionals dedicated to improving patient care. The connections made and lessons learned at SMACC are invaluable, offering new insights and strategies to bring back to our daily practice.

As we look forward to SMACC Berlin 2024, we are excited and anticipating. The conference promises another opportunity to learn, connect, and be inspired. For those unable to attend in person, the wealth of content available through SMACC’s online platforms ensures that the knowledge and spirit of the event can reach a global audience.

In conclusion, SMACC Dublin 2023 was a celebration of excellence in critical care and emergency medicine. It challenged us to think differently, embrace new ideas, and connect with colleagues worldwide. The conference’s focus on being the best we can be, both as clinicians and as compassionate individuals, left a lasting impression. We eagerly await the next gathering in Berlin, ready to continue our journey of learning and growth.

Day One Highlights from the Smack Dub Conference: A St Emlyns Overview

Welcome to the St Emlyns blog! We, Iain Beardsell and Simon Carley, are thrilled to report from the first day of the Smack Dub Conference in Dublin. It's been a while since our last update, and we're eager to share the day's experiences, which were filled with emotional moments, innovative presentations, and deep discussions. Here's a summary of the key events and takeaways.

Opening with a Tribute to John Hinds

The conference started early at 8 AM, with the opening session dedicated to the memory of John Hinds, a beloved figure in the Smack community who tragically passed away last year. Known for his engaging presentations and contributions to motorcycle medicine, John was greatly missed. The session began with Vic Brasel discussing the importance of feedback in medical education, setting the tone for a reflective and insightful day.

Meditation and Mindfulness in Medicine

Scott Weingart surprised the audience with a live podcast recording on meditation, an unusual topic for a resuscitation-focused conference. He emphasized the importance of mental exercise alongside physical health, advocating for practices like mindfulness to enhance well-being. Scott's discussion on Stoic philosophy and mental resilience resonated with many attendees, encouraging a broader perspective on personal and professional health.

Advances in Helicopter Emergency Medical Services

Gareth Davies from London Hems delivered a compelling talk on the evolution and future of helicopter emergency medical services (HEMS). He highlighted the ongoing campaign for an air ambulance in Northern Ireland, a cause John Hinds passionately supported. Gareth's discussion emphasized the need for moral authority to drive forward innovative healthcare solutions, especially in areas where traditional evidence can be challenging to gather.

Special Session: Remembering John Hinds

A particularly poignant session featured Janet, John's partner, who shared touching personal stories about John's life and work. Fred McSorley added humor with anecdotes from their time together in motorcycle medicine. This session provided a heartfelt tribute, capturing the essence of John's character and contributions. It concluded with a musical tribute, leaving many in the audience moved and inspired.

Diving Into the Main Conference

The day's formal sessions covered a range of topics, beginning with my talk on the future of emergency medicine. I discussed key factors such as political, demographic, and technological changes shaping the field. Demonstrating new technologies, we explored how these advancements could transform emergency medical practices.

Michelle Johnson's Vision of a Dystopian Medical Future

Michelle Johnson captivated the audience with her presentation on the dystopian future of emergency medicine. Drawing from literature, she explored potential ethical and societal implications of technological advancements in healthcare. Her talk challenged attendees to think critically about the future, offering a blend of caution and inspiration.

Addressing the Challenges of an Aging Population

Suzanne Mason focused on the increasing importance of geriatric care in emergency medicine. She discussed strategies for better managing the healthcare needs of an aging population, emphasizing comprehensive assessments and tailored interventions. Suzanne's talk highlighted the need for improved care models to address this growing demographic's unique challenges.

Diagnostic Processes: The Art of Thin Slicing

Swami's session on thin slicing in diagnosis delved into the cognitive processes behind decision-making in emergency situations. He explored how clinicians can refine their intuition and pattern recognition to improve diagnostic accuracy. This presentation underscored the importance of cognitive skills in high-pressure medical environments.

Afternoon Sessions: A Range of Engaging Topics

The afternoon featured a variety of sessions, with topics ranging from ECMO and Perimortem C-sections to discussions on the future of medical journals. One notable debate featured Jeff Drazen and Richard Smith discussing the evolving role of journals in the digital age. Richard Smith argued for a shift away from traditional publishing, advocating for more open-access models to democratize knowledge.

Live Demonstrations and Innovative Presentation Styles

The "Kickstart the Heart" session showcased a live demonstration of ECMO CPR, highlighting the innovative presentation styles encouraged at Smack. The diversity of approaches, from traditional lectures to interactive demonstrations, provided a rich learning experience.

Sarah Gray's talk on Perimortem C-sections emphasized the importance of preparedness for rare but critical interventions. The session highlighted the necessity of regular practice to ensure readiness in life-threatening situations.

Diverse Presentation Approaches

John Carlisle's creative presentation on detecting fraud in clinical trials used the perspective of his six-year-old daughter, making complex topics accessible and engaging. Meanwhile, Richard Smith's slide-free talk demonstrated the power of effective storytelling in conveying complex ideas, particularly his radical views on the future of medical journals.

Wrapping Up and Looking Ahead

The final session, which Simon participated in, focused on the future of knowledge dissemination. The discussion explored potential post-paper publication models and the increasing role of digital and social media in spreading medical knowledge. The panel highlighted the need for adaptability in a rapidly changing information landscape, with Richard Smith advocating for closing traditional journals in favor of open-access platforms.

As the day concluded, attendees reflected on the depth and breadth of content covered. While some enjoyed Dublin's nightlife, Simon and I prepared for our talks the following day, opting for a quiet evening.

Conclusion

Day one of the Smack Dub Conference was a remarkable success, filled with memorable tributes, innovative presentations, and deep discussions. The event challenged us to think critically about the future of emergency medicine and the role of various communication styles in medical education. We look forward to the rest of the conference and sharing more insights and experiences. Stay tuned to the St Emlyns blog for further updates and detailed session reviews. See you tomorrow!

Navigating Major Trauma in South Africa: An Unforgettable Experience

Introduction

Simon Cowie and Robert Lloyd bring a special episode from Cape Town, South Africa, at the International Conference of Emergency Medicine (ICEM). The focus is on Robert's profound experiences working in South Africa’s emergency departments, particularly dealing with major trauma in challenging environments like Khayelitsha Hospital. This blog post recounts Robert's transformative journey, offering insights into managing severe trauma cases and coping with intense psychological stress.

Experiencing Major Trauma in South Africa

Robert’s elective stint in South Africa aimed to deepen his expertise in major trauma, a specialty for which the country is well-known due to its high rates of violence-related injuries. He worked in New Somerset Hospital in the city and Khayelitsha Hospital in the township, where he faced a staggering volume of trauma cases, especially during "payday weekends"—a time marked by increased violence and accidents due to heightened alcohol consumption.

On his first night shift, Robert encountered an overwhelming number of severe cases, including 32 stab wounds to the chest, seven to the neck, and eight fatalities, six of whom were minors. This immediate immersion into high-stakes trauma care was a stark contrast to his previous experience in Australia and underscored the unique challenges faced by healthcare professionals in South Africa.

The Reality of Community Assaults

A particularly harrowing aspect of Robert’s experience was dealing with the aftermath of community assaults, where residents, in the absence of adequate police presence, took justice into their own hands. This vigilante justice often resulted in severe injuries, adding to the already heavy burden on emergency departments. Patients frequently presented with blunt trauma and crush injuries, showcasing the harsh realities of community-based violence and the critical need for comprehensive emergency care services.

Psychological Impact and Stress Management

The sheer volume and severity of cases led Robert to experience an acute stress reaction, referred to as "Condition Black," a term popularized by Dave Grossman in "On Combat." This state represents a high level of stress-induced impairment, where cognitive and physical functions degrade. Robert felt overwhelmed, his heart racing, hearing muffled, and hands shaking—making even simple medical procedures challenging. This response highlighted the necessity of managing psychological stress to maintain effective performance in high-pressure situations.

Strategies for Overcoming Psychological Barriers

To cope with the intense stress and improve his performance, Robert employed several strategies: overlearning essential skills, engaging in mental rehearsal, and fostering relentless positivity.

1. Overlearning Essential Skills: This involved practicing critical procedures like fast scanning and intercostal drain insertion until they became automatic. He also mastered surgical hand tying, crucial in the resource-limited setting of Khayelitsha Hospital, where suture instruments were often unavailable. This preparation ensured he could perform these tasks effectively, even under stress.

2. Mental Rehearsal: Robert used this technique to visualize and mentally practice the steps of critical procedures, such as rapid sequence intubation (RSI) for severe head injuries. This repeated mental walkthrough helped reduce anxiety and built confidence, making the actual procedures feel familiar and more manageable.

3. Relentless Positivity: Drawing from his experience as a competitive tennis player, Robert cultivated a positive mindset by replacing negative thoughts with positive affirmations. This approach helped him maintain focus and confidence, essential for handling the unpredictable and high-pressure nature of emergency medicine.

The Importance of Stress Inoculation Training

Robert’s experience underscored the value of stress inoculation training (SIT) in medical education. SIT involves gradually exposing individuals to stress in a controlled environment, helping them build resilience and improve their ability to handle high-pressure situations. This training is particularly beneficial for medical professionals, preparing them to remain calm and make sound decisions under stress. Incorporating SIT into medical simulations provides a safe yet realistic training ground for emergency scenarios, enhancing preparedness and performance.

Conclusion

Robert’s journey through South Africa’s emergency medicine landscape was a profound learning experience, highlighting the importance of comprehensive preparation in handling severe trauma cases. His strategies for managing psychological stress—overlearning, mental rehearsal, and maintaining positivity—proved invaluable. These methods not only improved his technical skills but also built the mental resilience needed to thrive in high-pressure environments.

The experience also highlighted the critical need for training programs like SIT to better prepare medical professionals for the realities of emergency medicine. Whether working in high-trauma settings like South Africa or less extreme environments, the lessons learned from managing stress and psychological preparedness are universally applicable.

Call to Action

For further insights into emergency medicine, visit Robert’s blog, Pondering EM, and follow him on Twitter @ponderingem. For those interested in exploring stress management in high-pressure situations, "On Combat" by Dave Grossman is a highly recommended read. Thank you for joining us on the St. Emlyns Podcast. Please subscribe and leave us a review to help us continue bringing valuable content to the medical community.

## Navigating Sepsis in Emergency Medicine: Key Approaches and Insights

Sepsis is a life-threatening condition that occurs when the body's response to an infection injures its own tissues and organs. It is a complex and evolving challenge in emergency medicine, requiring prompt recognition and effective management. This blog post explores the fundamental steps for managing sepsis in the emergency department (ED), emphasizing early identification, appropriate treatment, and the importance of clinical judgment.

### The Complexity of Sepsis Management

Sepsis presents a unique challenge due to its variable presentation and potential severity. Patients may appear relatively stable upon arrival but can rapidly deteriorate if not managed promptly. Recent advancements have introduced new strategies and guidelines, such as the "sepsis six" and SOFA criteria, which are integral to medical education and practice in the UK. Despite these tools, sepsis management remains complex, necessitating a clear and straightforward approach in the ED.

### Early Recognition and Assessment

The initial assessment of a patient suspected of sepsis is critical. Time-sensitive interventions can significantly impact outcomes. For example, consider a typical scenario: a 50-year-old man with a recent cough, a temperature of 39°C, and a pulse rate of 120 arrives in the ED. Initial steps include taking the report seriously, preparing the team and necessary equipment, and promptly assessing the patient upon arrival.

Recognizing sepsis early involves identifying key signs such as fever, tachycardia, hypotension, and altered mental status. Standard criteria like SIRS (Systemic Inflammatory Response Syndrome) and QSOFA (Quick Sequential Organ Failure Assessment) help in early identification. SIRS focuses on physiological responses like temperature, heart rate, and white blood cell count, while QSOFA emphasizes mental status, respiratory rate, and blood pressure.

### Efficient Management through Concurrent Activity

In the ED, efficiency is paramount. Implementing a "concurrent activity" approach, where multiple interventions occur simultaneously, is essential. Upon receiving the patient, administer oxygen, attach monitoring equipment, and begin obtaining observations. The paramedic handover provides critical insights, including the patient's condition at the scene and any initial treatments administered.

Gathering a comprehensive history and conducting a physical examination are also crucial. This includes understanding recent symptoms, potential sources of infection, and any relevant medical history. Identifying the infection source helps tailor the treatment plan, ensuring that interventions are both appropriate and timely.

### The Role of Early Antibiotics

The timing and selection of antibiotics are pivotal in sepsis management. While there is a strong push for early administration of broad-spectrum antibiotics, it is equally important to choose the right antibiotic based on the suspected infection source. This requires a thorough patient assessment and adherence to local microbiology guidelines.

Antibiotic stewardship is vital to combat growing antibiotic resistance. Avoiding indiscriminate use of broad-spectrum antibiotics helps minimize the risk of resistance and side effects. For instance, a suspected urinary tract infection (UTI) requires different antibiotics compared to pneumonia. Clinicians must make informed decisions to provide effective treatment while preserving antibiotic efficacy.

### Objective Measures: SIRS, QSOFA, and Lactate

Objective measures complement clinical judgment in diagnosing and managing sepsis. The SIRS criteria, although useful, are not specific to sepsis and can be elevated in other conditions. QSOFA criteria, focusing on altered mental status, respiratory rate, and blood pressure, provide a more specific indication of sepsis severity and help identify high-risk patients.

Lactate levels are a valuable marker of tissue hypoperfusion and sepsis severity. Elevated lactate levels, particularly above 2 mmol/L, signal a need for aggressive intervention. However, lactate must be interpreted in the context of the entire clinical picture, as levels can be influenced by factors such as physical exertion or alcohol use.

### Treatment and Monitoring

Effective sepsis management involves prompt treatment and continuous monitoring. Key interventions include administering oxygen, ensuring adequate fluid resuscitation, and providing appropriate antibiotics. Fluid resuscitation, particularly with intravenous crystalloids, aims to restore tissue perfusion and prevent organ dysfunction.

Patients with persistent hypotension or altered mental status after initial resuscitation may require admission to a high-dependency unit (HDU) or intensive care unit (ICU). Early involvement of inpatient teams and clear communication across departments are crucial for comprehensive patient management. The goal is to stabilize the patient, address the underlying infection, and prevent complications.

### Avoiding Diagnostic Pitfalls

Not all patients with sepsis-like symptoms have sepsis. Conditions such as pulmonary embolism, myocardial infarction, and viral infections can mimic sepsis, necessitating careful differential diagnosis. Continuous reassessment, thorough investigations, and seeking second opinions are vital to avoid diagnostic errors and ensure appropriate treatment.

For example, a patient with fever, elevated heart rate, and respiratory distress may not have sepsis but rather a pulmonary embolism or acute coronary syndrome. Comprehensive evaluation, including appropriate diagnostic tests, helps clarify the diagnosis and guide treatment.

### The Importance of Clinical Judgment

While objective measures are essential, clinical judgment remains a cornerstone of sepsis management. Understanding the patient's symptoms, history, and overall presentation is critical. Asking the right questions, consulting with colleagues, and involving specialists when necessary enhances decision-making and patient care.

Involving family members in discussions can also provide valuable insights into the patient's baseline health and recent changes. Additionally, leveraging the expertise of specialists, such as infectious disease or critical care consultants, can help manage complex cases.

### The Evolving Landscape of Sepsis Management

Sepsis management is continually evolving, with new research and guidelines refining our approach. Staying informed through continuous education and engagement with current literature is crucial. Notable resources include EMCrit and Foamcast podcasts, which provide valuable updates on critical care topics, including sepsis.

Emerging areas of interest include biomarkers for diagnosis and prognosis, novel therapies, and advanced monitoring techniques. Understanding these developments helps clinicians stay at the forefront of sepsis care and improve patient outcomes.

### Conclusion: Making a Difference in Sepsis Care

Sepsis is a formidable challenge in emergency medicine, but with prompt recognition and appropriate treatment, patient outcomes can be significantly improved. Emergency physicians play a critical role in identifying sepsis early, initiating lifesaving treatments, and collaborating with colleagues for comprehensive care. By maintaining a high index of suspicion, utilizing objective criteria alongside clinical judgment, and staying abreast of the latest developments, healthcare providers can make a real difference in the lives of their patients.

As you approach your next shift, remember these principles. Identify at-risk patients, initiate timely interventions, and follow up on their outcomes. This ongoing process of learning and application not only sharpens clinical skills but also enhances patient care. We hope this blog post has provided valuable insights and practical guidance. Please share your experiences and thoughts in the comments below, and stay tuned for more updates from the St. Emlyns team. Together, we can continue to improve our practice and provide the best possible care for our patients.

Navigating Personal and Professional Boundaries in Healthcare

In this St. Emlyns blog post, Iain Beardsell and Liz Crowe discuss the challenging scenarios healthcare professionals face when their personal and professional lives intersect, particularly in emergency and critical care settings. These situations are complex, requiring careful navigation to maintain ethical standards and patient confidentiality.

Understanding Dual Roles

Healthcare professionals often encounter situations where they have a personal connection with a patient. This could be someone they know vaguely, a close friend, or even a family member. Such instances require careful reflection on whether to act as a friend or a professional. It's crucial to declare any personal connections to colleagues and maintain a clear boundary to ensure unbiased care. The primary duty in these cases is to the patient's confidentiality, regardless of personal ties.

Case Study: Community Members as Patients

A hypothetical scenario is presented where a child from the same school attended by a healthcare professional's children is admitted following a trauma. This situation exemplifies the conflict between professional responsibilities and community ties. Even if the professional knows the community, sharing patient details without consent is unethical. It's important to resist the urge to share information, even when under pressure from friends or community members. The first response should always prioritize the patient's confidentiality and respect for their family's wishes.

Handling Situations Involving Close Friends or Family

When the patient is a close friend or family member, the complexity intensifies. The key is to establish clear boundaries and communicate openly with the healthcare team. If possible, the professional should hand over care to another team member to avoid conflicts of interest. This separation helps prevent emotional turmoil and ensures the patient receives unbiased care. In emergencies where immediate care is needed, the professional should still step back as soon as feasible.

Managing the Desire for Information

Healthcare professionals may feel a natural curiosity about the condition of someone they know personally. However, accessing medical records or sharing information without a professional need is a breach of confidentiality. Professionals must remind themselves that they have no right to this information if not directly involved in the patient's care. The ethical responsibility includes abstaining from looking at records or discussing the patient's condition unless explicitly authorized.

When a Colleague Becomes a Patient

The situation becomes particularly sensitive when the patient is a colleague. This could involve anything from minor injuries to serious, life-threatening conditions. The emotional dynamics in the team can complicate care delivery. It is essential to maintain professionalism, avoid gossip, and ensure that any shared information is with the patient's consent. After the initial crisis, it is vital for the team to discuss how to handle the situation moving forward, including managing information dissemination within the department.

Tragic Outcomes: Death of a Colleague

A particularly difficult scenario is when a colleague passes away while under the care of the healthcare team. This rare event requires a compassionate and professional response. The focus should initially be on supporting the family and the team. Management should be informed immediately, and additional support staff may be needed to maintain department function. A formal debriefing process should be arranged to help the team process the event and plan memorials or support for the family.

The Role of Social Media

In the digital age, social media presents additional challenges for maintaining patient confidentiality. Even vague posts about work events can be considered breaches of confidentiality and may result in disciplinary action. Healthcare professionals must be cautious about accepting friend requests or communicating with patients or their families on social media. Maintaining professional boundaries is essential, and any communication should respect privacy laws and ethical standards.

Conclusion: Upholding Professionalism and Confidentiality

Navigating the intersection of personal and professional lives in healthcare requires strict adherence to ethical standards. Whether dealing with community members, friends, family, or colleagues, the primary responsibility is to maintain patient confidentiality and uphold professional integrity. These situations are challenging, but clear boundaries and proactive planning can protect both the patient and the professional.

Healthcare professionals are encouraged to reflect on these issues and discuss them with their teams. Seeking guidance from senior colleagues and maintaining open communication are key strategies in managing these situations. Patient confidentiality must always be a priority, and maintaining professional boundaries is crucial for sustaining trust and integrity in healthcare.

Key Takeaways:

• Always prioritize patient confidentiality and ethical standards.
• Declare personal connections to patients and avoid involvement in their care.
• Refrain from accessing information or discussing patients without professional necessity.
• Use caution with social media to avoid breaches of confidentiality.
• Plan ahead for handling complex situations involving personal and professional overlap.

This post aims to provide insights into managing the delicate balance between personal and professional responsibilities in healthcare, emphasizing the importance of maintaining professionalism and confidentiality at all times.

Ross Fisher, consultant paediatric surgeon and lead for TARNlet joins Simon Carley at the London Trauma Conference to discuss the challenges in managing paediatric trauma in the UK.

Sandra Viggers and Vic Brazil grace St.Emlyn's with a conference report from Sand Diego and the International Meeting for Simulation in Healthcare (IMSH) #IMSH2016.

Iain Beardsell joins Tim Coats, chair of the UK Trauma Audit Network, to discuss the role of trauma units within major trauma networks.

Simon and Ross Fisher from Sheffield discuss the emerging role of paediatric surgeons in trauma. This podcast was recorded at the London Trauma Conference (so sorry for a bit of background noise at times).

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In this episode of the St Emlyn's podcast, Iain Beardsall and Liz Crowe discuss the unique challenges healthcare professionals face during the Christmas season in emergency and intensive care settings. They delve into how to balance the festive atmosphere with the stark reality of dealing with tragic events, offering practical advice on effective communication and self-care. The conversation emphasizes the importance of acknowledging the season while maintaining professional decorum, the role of humour and camaraderie in the workplace, and strategies for transitioning from work back to family life.

This episode is particularly valuable for doctors, nurses, and medical students seeking to navigate the emotional complexities of working during the holiday season.

00:00 Introduction and Festive Season Challenges

01:05 Acknowledging the Festive Season in Healthcare

02:12 Communicating Bad News During Christmas

04:49 Balancing Work and Personal Life During Festive Times

09:20 Finding Joy and Humor Amidst Challenges

12:09 Conclusion

Our summary of Day 2 of the excellent London Trauma Conference. A unique threesome from Nat, Simon and Iain.....

Greetings from the London Trauma Conference!

As has become our pre-Christmas custom, Iain and I have been hanging out at the fabulous London Trauma Conference, hearing about advances and controversies in trauma care and tracking down some of the speakers to find out exactly what they really think (and recording it, for podcasts we'll release in due course).

The conference extends over four days, incorporating the Air Ambulance and Prehospital Day and the Cardiac Arrest Symposium; unfortunately we can't stick around for those but our colleagues over at the RCEM FOAM network will be podcasting from those days too, so keep an eye on their site and podcast feed too.

We are truly honored to listen and learn from Dr Youri Yordanov from Paris. Youri was the senior emergency physician on duty on the 13/11/15 during the brutal and terrifying terrorist attacks in Paris. Here he joins St.Emlyn's to discuss how they managed a mass casualty incident with lessons for us all.

There is no doubt that without the skills, preparation and response of Youri, his ED team, the wider hospital and the emergency service in general the death rate would have been much worse.

Thanks Youri for your wisdom and reflections.

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My talk from the RCEM conference in Manchester 2015.

Linked blog post here. http://stemlynsblog.org/making-good-decisions-in-the-ed-rcem15/

Slides are here http://www.slideshare.net/simoncarley7/making-good-decisions-rcem-2015-manchester-wednesday

Have fun and enjoy your emergency medicine.

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Simon and Nat talk about how to have that tricky conversation when you have to tell a colleague that they may have made a mistake.

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Mastering the Art of Clinical Referrals: A Guide for Emergency Physicians

Introduction

Effective communication is crucial in the emergency department (ED), particularly when referring patients to inpatient teams. It not only ensures optimal patient care but also enhances professional relationships and personal job satisfaction. In this post, inspired by the St. Emlyns podcast, we'll explore a practical framework for making clinical referrals, emphasizing the importance of clear, structured communication. We'll discuss the SBAR (Situation, Background, Assessment, Recommendation) format, the concept of the "James Bond opening," and strategies for handling difficult conversations, all tailored to the fast-paced environment of emergency medicine.

Why Effective Referrals Matter

Referrals are an integral part of patient management in the ED. Every referral is made with the patient's best interest in mind, whether they need further investigations, specialized treatment, or simply continuity of care. Ensuring that the receiving team understands the urgency and context of the referral is vital. Good communication can influence how the inpatient team perceives the referring physician and can enhance collaborative relationships, leading to better patient outcomes and professional fulfillment.

Setting the Stage: The James Bond Opening

When initiating a referral, it’s essential to grab the attention of the receiving team quickly and effectively. This is where the "James Bond opening" comes in—start with a high-impact statement that summarizes the critical aspect of the patient's condition. For example, instead of saying, "I have a patient with abdominal pain," begin with, "I have a 25-year-old male who likely has appendicitis." This approach not only captures attention but also sets the stage for a focused and efficient conversation.

The SBAR Framework: Structuring Your Referral

The SBAR model provides a structured approach to communication, ensuring all essential information is conveyed succinctly. Here’s how to implement it:

Situation

Begin with a brief description of the patient's current condition. This is where the "James Bond opening" fits perfectly. Clearly state the key clinical concern that necessitates the referral.

Background

Provide context for the situation. This includes relevant medical history, the reason for the current ED visit, and any pertinent findings. For instance, you might say, "The patient has had two days of right iliac fossa pain and a history suggestive of appendicitis."

Assessment

Share your clinical judgment about the patient's condition. This not only demonstrates your understanding but also signals the expected pathway of care. In our example, "Based on the examination and symptoms, I believe the patient has appendicitis."

Recommendation

Conclude with a clear, direct request. Specify what you need from the inpatient team, such as a physical assessment, further diagnostic testing, or specific interventions. For instance, "I'd appreciate it if the surgical team could evaluate the patient for potential appendicitis and consider admission for further management."

Enhancing the Referral Process: Tips and Tricks

Introduce Yourself Clearly

Always start the conversation by introducing yourself with your name and role. For example, "Hi, I'm Ian, one of the ED doctors." This personal touch helps build rapport and sets a friendly tone. If the receiving team introduces themselves by title only, politely ask for their name, fostering a more personable interaction.

Predict and Prepare for Questions

Anticipate the questions the receiving team might ask and prepare your responses. For example, if referring a potential appendicitis case, be ready to discuss symptoms, lab results, and physical findings. This not only streamlines the conversation but also demonstrates your preparedness and competence.

Use the Illusion of Choice

To smooth the referral process, offer options that guide the receiving team towards a decision that benefits the patient. For instance, "Would you prefer to see the patient in the ED or on the ward?" This technique, known as the illusion of choice, empowers the receiver while subtly directing the conversation towards the desired outcome.

Navigating Difficult Conversations

Not all referral conversations go smoothly. Sometimes, the receiving team may be uncooperative or dismissive. Here are strategies to handle such situations:

Stay Calm and Professional

If the conversation becomes contentious, avoid escalating the situation. Remain calm and professional, focusing on patient care rather than engaging in arguments. A useful tactic is to suggest pausing the conversation: "Let me discuss this further with my senior and get back to you."

Seek Support from Senior Staff

If you encounter resistance, consult a senior colleague or consultant. They can provide additional insights or take over the conversation, ensuring the patient receives the necessary care.

Empathize with the Receiving Team

Understand that the receiving team might be under significant pressure, dealing with their own caseloads and challenges. Acknowledging their situation can defuse tension and facilitate a more constructive dialogue.

Conclusion: Practice Makes Perfect

Effective referrals are a skill that, like any other medical procedure, requires practice and reflection. Using the SBAR framework, starting with a strong "James Bond opening," and preparing for potential questions can significantly improve the quality of your referrals. Remember, every interaction is an opportunity to enhance patient care and build professional relationships.

For more insights and discussions on emergency medicine, communication skills, and more, visit the St. Emlyns blog and podcast series. Let's continue to improve our skills and ensure the best outcomes for our patients.

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

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Navigating Grief: Lessons from the St Emlyns Podcast with Liz Crow

In a compelling episode of the St Emlyns podcast, host Ian Bidsel engages in a profound discussion with pediatric social worker Liz Crow about the intricacies of grief, especially within the healthcare sector. This episode was prompted by the tragic loss of John Hines, a respected member of the SMACC community known for his work as a motorcycle doctor. Liz shares her insights into the unique challenges faced by healthcare professionals when dealing with grief, both personally and professionally.

The Unique Nature of Grief

Grief is a deeply personal experience that varies significantly from person to person. Liz Crow emphasizes that there is no "normal" way to grieve; each individual's response is shaped by various factors, including age, personality, and prior experiences with loss. The podcast challenges the traditional Kubler-Ross model, which suggests a linear progression through five stages of grief. Liz argues that grief is a fluid process without a set path, characterized by an unpredictable mix of emotions.

Grieving in the Healthcare Profession

Healthcare professionals often encounter death and suffering, which can complicate their grieving process. The sudden death of John Hines highlighted the vulnerabilities even within a community accustomed to dealing with trauma. Liz and Ian discuss the common practice of compartmentalization among healthcare workers, where emotions are set aside to focus on the task at hand. While this can be a necessary coping mechanism, Liz warns against prolonged avoidance of emotions, as it can lead to long-term psychological issues.

The conversation underscores the importance of self-awareness and self-care. Healthcare professionals are encouraged to acknowledge their grief and seek support when necessary. This may involve adjusting work responsibilities or taking time off to process emotions. Liz stresses that compartmentalization should be temporary and that healthcare workers need to find safe spaces to express and process their grief.

Coping Strategies and Community Support

Liz explores various coping strategies that can help individuals navigate their grief. These include journaling, physical activity, creative expression, and talking with trusted friends or professionals. The key is to find what works best for each person. The SMACC and FOAMed communities provide a supportive network, especially through social media, which has facilitated shared experiences and mutual support. However, Liz notes that online interactions can sometimes lack the depth needed for processing complex emotions.

The podcast also addresses the public aspect of grieving, particularly when the person lost is a public figure like John Hines. For those who admired him, his death serves as a stark reminder of life's fragility. Liz and Ian discuss the discomfort of confronting mortality, especially when it involves someone perceived as larger than life. This public grieving can add another layer of complexity to personal mourning.

The Importance of Open Conversations About Grief

A significant theme in the podcast is the need for open dialogue about grief. Liz encourages listeners to communicate their feelings and to be open about their vulnerabilities. She highlights the cultural stigma against showing emotion, particularly among men, and calls for a shift in how we perceive emotional expression. The healthcare community, often valuing emotional resilience, may need to rethink its attitudes toward vulnerability.

Ian shares his personal experiences of feeling isolated in his grief, particularly in professional settings where the expectation is to maintain a façade of normalcy. Liz acknowledges this common experience and emphasizes the importance of finding supportive communities and being open about one's struggles.

Integrating Grief into Life

Liz suggests that instead of viewing grief as something to "move through," it should be seen as an experience to integrate into one's life. She uses the metaphor of grief as a wound that eventually becomes a scar—while the initial pain may subside, the impact of the loss remains. This perspective encourages compassion for oneself and others, recognizing that grief is an ongoing process rather than a problem to be solved.

For those struggling to cope, Liz recommends seeking professional help, particularly if grief begins to manifest as clinical depression. She distinguishes between the natural process of grief and the symptoms of depression, advising individuals to seek support if they find themselves unable to manage their emotions.

The Role of Professional Support and Self-Care

The podcast highlights the critical role of professional support and self-care for healthcare workers. Liz discusses the importance of accessing supervision and counseling, especially during personal crises. Self-care is not a luxury but a necessity, particularly for those in caregiving roles who may prioritize others' needs over their own. This can include taking time off, engaging in hobbies, or simply allowing oneself to grieve.

Moving Forward with the Community

As the SMACC and FOAMed communities continue to process John Hines' loss, this podcast serves as a reminder of the collective nature of grief and the importance of community support. The conversation provides valuable insights into the complexities of grieving, the significance of open dialogue, and the power of mutual support.

In conclusion, Liz and Ian emphasize that grief is a natural part of life, much like happiness. They encourage listeners to approach their grief with gentleness and understanding, acknowledging that there is no right or wrong way to grieve. Whether through professional support, personal coping strategies, or community connections, the journey through grief is unique to each individual. The key takeaway is to be patient with oneself and others, recognizing that healing is a gradual and ongoing process.

This episode of the St Emlyns podcast offers a deep exploration of grief, providing practical advice and emotional support for those navigating this challenging experience. The conversation encourages healthcare professionals and the wider community to engage openly with their emotions and to support one another through the journey of grief.

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

In this episode of the St Emlyn's podcast, Simon Carley and Iain Beardsell share insights from the SMACC 2015 conference in Chicago, focusing on the holistic experience of being a clinician. Ian delves into a personal and poignant case involving a 14-year-old boy named Charlie, who tragically died from traumatic injuries. Ian discusses the profound emotional impact this case had on him, the lingering doubts it created, and how it influenced his professional and personal life. This episode highlights the emotional challenges faced by emergency medicine practitioners and underscores the importance of mental resilience, compassionate communication, and self-care.

SMACC Chicago: Insights, Learning, and Community at St Emlyn's

The SMACC (Social Media and Critical Care) Conference in Chicago brought together healthcare professionals and thought leaders from around the world. The St Emlyn's team, comprising Iain Beardsell, Simon Carley, Rick Boddy, and Natalie May, participated in various workshops and sessions, sharing their experiences and insights. This blog post captures the essence of the conference, highlighting key learning outcomes and the vibrant community spirit.

Evidence-Based Medicine: From Theory to Practice

Simon Carley kicked off the day with a workshop titled "Gambling with the Evidence," focusing on practical applications of evidence-based medicine (EBM). Unlike traditional EBM sessions that often dwell on statistics and literature reviews, this workshop emphasized how to translate evidence into clinical practice. Simon, alongside Rick Boddy, Rob McSweeney, Ken Milne, and Rory Spiegel, explored how healthcare professionals manage the overwhelming volume of evidence and integrate it into their practice.

Key takeaways included strategies for storing and accessing evidence efficiently, influencing colleagues with evidence-based practices, and the importance of critical skepticism. The workshop stressed the responsibility of individuals to thoroughly understand the evidence before implementing changes in clinical settings. This session underscored the necessity of a balanced approach to adopting new practices, ensuring they are rooted in a comprehensive understanding of available evidence.

FOAM: Creating and Sharing Educational Content

Natalie May joined other prominent figures in the FOAM (Free Open Access Meducation) community for the "Brew Your Own FOAM" session. Alongside Salim Rezé, Rob Rogers, Haney Malamarts, and others, Natalie discussed the creation of blogs, podcasts, and other educational resources. The session, likened to an Apple bar, provided an informal yet informative platform for attendees to engage with experienced content creators.

Participants gained insights into the technical and creative aspects of producing FOAM content. The session encouraged the sharing of knowledge and resources, emphasizing that a diverse range of voices and perspectives enriches the medical community. Natalie highlighted the importance of FOAM in democratizing medical education, making high-quality information accessible to a global audience.

Exploring Chest Pain and Cardiology Pathways

Rick Boddy delved into the nuances of chest pain management and cardiology in his workshops. The morning session on evidence-based medicine included discussions on the values and outcomes in clinical trials, particularly concerning stroke and thrombolysis. Rick emphasized the varying perspectives of patients, doctors, and policymakers, stressing the importance of considering these viewpoints when evaluating clinical outcomes.

The afternoon's emergency cardiology workshop, featuring experts like Steve Smith and Louise Cullen, focused on chest pain pathways. The session covered a range of topics, from ECG interpretation to chest pain algorithms. Rick noted the growing interest in high-sensitivity troponins and the need for tailored chest pain pathways that cater to specific local populations. The discussion also addressed the challenges of implementing standardized pathways and the importance of trusting the evidence.

Getting Creative: Enhancing Communication Skills

Simon Carley also participated in a workshop titled "Getting Creative," which explored creative communication methods in the medical field. The workshop featured three sessions: Michelle Johnson on writing, Grace Slyo on visual presentations, and Rob Rogers on podcasting. Michelle Johnson, a skilled writer, guided participants through the art of crafting compelling narratives, particularly for blog posts. She emphasized the power of language and the importance of clear, concise communication.

Grace Slyo's session focused on improving visual communication, offering tips on graphic design and effective presentation techniques. She provided valuable resources and exercises to help participants enhance their visual storytelling skills. Rob Rogers concluded the workshop with practical advice on creating engaging podcasts, covering everything from content creation to technical aspects. Simon found the workshop incredibly valuable, noting that these skills are essential for effective knowledge dissemination in the medical community.

Pediatric Critical Care: Lessons and Strategies

Natalie May attended the SMACC mini session on pediatric critical care, where experts discussed managing critically ill children in emergency and intensive care settings. The session opened with Fran Lockey and Phil Hyde addressing pediatric airway and breathing management. They emphasized the importance of simple airway maneuvers and two-handed bag-valve-mask ventilation, debunking the myth that intubation is always necessary.

Lisa McQueen provided a poignant presentation on children in shock, referencing the case of Rory Staunton, a child who tragically died from sepsis after being discharged from the emergency department. The session highlighted the critical role of thorough reassessment and face-to-face evaluations in pediatric care. The importance of vigilance in monitoring children's progress before discharge was a key message.

Pre-Hospital Care: Excellence in Action

Iain Beardsell shared his experience from the pre-hospital care workshop, led by Carol Harbig from Greater Sydney Hems. The workshop featured a range of topics and speakers, providing an in-depth look at pre-hospital emergency medicine. The highlight of the day was a presentation by Ashley Leibig, who delivered a powerful talk on the emotional challenges faced by pre-hospital care providers and the importance of peer support.

Iain emphasized the value of visualization and mental rehearsal in preparing for high-stress situations. The workshop underscored the importance of practicing difficult scenarios mentally to ensure readiness when faced with real-life emergencies. This approach helps clinicians develop a clear action plan, reducing the likelihood of hesitation or error during critical moments.

The SMACC Community: Beyond Clinical Knowledge

One of the standout features of the SMACC Conference is its holistic approach to medical education. The conference not only covers clinical and technical topics but also addresses the emotional and psychological aspects of healthcare. Ashley Leibig's talk, reminiscent of Liz Crowe's impactful presentations, reminded attendees of the need for compassion and self-care in a field often dominated by high-stakes decision-making.

The conference provided ample opportunities for networking and community building. The St Emlyn's team noted the importance of connecting with peers, sharing experiences, and learning from each other. The collaborative spirit of the FOAM community was palpable, with participants eager to exchange ideas and support one another in their educational endeavors.

Preparing for the Big Stage: Final Thoughts

As the day drew to a close, the St Emlyn's team prepared for their presentations at the conference. The anticipation and nerves were palpable, reflecting the high regard in which the opportunity to speak at SMACC is held. The team emphasized the importance of thorough preparation, including practicing presentations and ensuring all details are in order.

The St Emlyn's team encouraged attendees and followers to engage with them, highlighting the value of these interactions in enriching the conference experience. They looked forward to meeting new people and deepening connections within the medical community.

Conclusion

The SMACC Conference in Chicago provided a rich and varied learning experience for the St Emlyn's team. From evidence-based medicine to pediatric critical care and pre-hospital medicine, the workshops offered valuable insights and practical knowledge. The conference also underscored the importance of creative communication, emotional resilience, and community support in the medical field.

For those unable to attend, the St Emlyn's team hopes this blog post offers a glimpse into the vibrant and dynamic environment of SMACC. The team is committed to sharing the knowledge and experiences gained at the conference, contributing to the broader medical community's growth and development.

As always, the St Emlyn's team encourages feedback and engagement from their readers. Whether you're interested in evidence-based medicine, FOAM, pediatric care, or any other topic, there's something for everyone in the rich tapestry of SMACC. Stay tuned for more updates and insights as the conference continues to unfold.

Managing Back Pain in the Emergency Department: A Comprehensive Overview

In the emergency department (ED), back pain, particularly lower back pain without a traumatic cause, is a common and complex presentation. This condition can range from benign to life-threatening, requiring a thorough and systematic approach to ensure accurate diagnosis and effective management.

The Challenge of Back Pain in Emergency Medicine

Back pain patients often come with preconceived notions, especially when they seek pain relief. However, it's crucial to avoid jumping to conclusions, as back pain can result from various underlying issues, including serious conditions like ruptured abdominal aortic aneurysms (AAA) or infections. Therefore, clinicians should avoid hastily labeling cases as "musculoskeletal" without thorough evaluation.

Key Diagnostic Considerations

1. Broad Differential Diagnosis:
The differential diagnosis should begin with more severe and potentially life-threatening conditions. For example, an AAA can present with subtle back pain, particularly in the elderly, and missing this diagnosis can be catastrophic. Hence, abdominal examinations and bedside ultrasounds are essential tools for detection.

2. Pain Chronology and Characteristics:
Understanding the pain's duration and nature is vital. Chronic pain may suggest long-standing issues, while acute pain can indicate new, potentially severe conditions. Atypical symptoms like pain that worsens at night or at rest, as opposed to musculoskeletal pain that improves with rest, could signal neoplastic or infectious processes.

3. Multi-System Evaluation:
A comprehensive assessment, including vital signs and a review of systems, is critical. For instance, signs like tachycardia, fever, or hypotension can indicate systemic issues such as sepsis. Conditions like pyelonephritis, especially in immunocompromised patients, can manifest as back pain, necessitating a thorough evaluation.

Specific Conditions and Red Flags

Ruptured Abdominal Aortic Aneurysm (AAA):
In elderly patients, AAA must always be considered, especially with sudden onset back pain. This condition can be rapidly fatal, and quick diagnosis via ultrasound is crucial.

Neoplastic Disease:
Symptoms such as unexplained weight loss, persistent night pain, or a history of cancer necessitate evaluation for metastatic disease. Cancers known to metastasize to bone, like breast or lung cancer, may present with back pain, requiring thorough imaging and lab work.

Infectious Causes:
Spinal infections, such as osteomyelitis or epidural abscess, are serious conditions often presenting with back pain. Risk factors include intravenous drug use or immunocompromised states. High suspicion is necessary in patients with concurrent systemic symptoms.

Cauda Equina Syndrome (CES):
CES is a neurosurgical emergency, presenting with symptoms like severe lower back pain, saddle anesthesia, and bowel or bladder dysfunction. A meticulous neurological examination, focusing on lower limb function and perineal sensation, is necessary. MRI is the preferred diagnostic tool, providing detailed images of the spinal cord and nerve roots.

Imaging and Laboratory Tests

Imaging:
Imaging choices should be guided by clinical suspicion. MRI is preferred for evaluating soft tissues, especially in suspected CES cases. For older adults, plain X-rays can reveal fractures but are limited in detecting soft tissue issues. CT scans are useful for complex cases like suspected tumors or infections, while nuclear medicine imaging may detect metastatic lesions or stress fractures.

Laboratory Tests:
Blood tests are essential in cases where red flags suggest systemic involvement. Tests like a full blood count (FBC), inflammatory markers, and bone profiles can provide critical diagnostic information. Elevated inflammatory markers may indicate infection or inflammation, while abnormal calcium levels could suggest a paraneoplastic syndrome.

Management of Non-Specific Back Pain

Once serious conditions are ruled out, management focuses on non-specific, likely musculoskeletal back pain. This involves patient education, mobilization, and appropriate pain management.

Patient Education and Mobilization:
Patients should be informed about the importance of staying active to prevent muscle stiffness and worsening pain. The role of muscle spasm in pain should be explained, and patients encouraged to maintain activity despite discomfort.

Pain Management:
The WHO pain ladder guides pain management, starting with simple analgesics like paracetamol and NSAIDs. For more severe pain, moderate opioids like codeine may be considered. The goal is to provide sufficient pain relief to facilitate mobilization and prevent the development of chronic pain.

Controversial Treatments:
The use of benzodiazepines is controversial. They are not true muscle relaxants but can reduce anxiety and distress, potentially aiding pain management. However, they should be used sparingly and for short periods. The use of gabapentin for acute back pain is also debated, as it is primarily indicated for neuropathic pain.

Chronic Pain Management

For chronic pain patients, management focuses on a multidisciplinary approach, involving pain specialists, physiotherapists, and primary care providers. The goal is to manage the physical, psychological, and social aspects of chronic pain.

Collaborative Care:
Close collaboration with primary care providers ensures consistent messaging and management plans. Pain specialists can offer additional support, especially in complex cases requiring advanced pain management techniques.

Non-Pharmacological Interventions:
Non-pharmacological interventions, such as physical therapy and cognitive-behavioral therapy (CBT), are crucial. These therapies help strengthen muscles, improve posture, and manage the psychological impacts of chronic pain.

Conclusion

In conclusion, managing back pain in the ED requires a comprehensive, systematic approach. Clinicians must prioritize ruling out serious conditions, use appropriate diagnostic tools, and provide effective pain management and patient education. Collaboration with primary care and pain specialists is essential for managing chronic pain, ensuring a holistic approach to patient care. By following these guidelines, healthcare professionals can provide compassionate, evidence-based care, leading to better patient outcomes and a more efficient emergency department.

Red flag symptoms and analgesia advice below.