The St.Emlyn’s Podcast

In this episode, Dr Tim Warlow, a consultant in Paediatric Palliative Care, explores the complexities of caring for children with life-limiting conditions in the emergency department (ED). The discussion highlights the increasing prevalence of paediatric life-limiting conditions and the growing medical complexity of these cases, which pose significant challenges for ED staff.

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

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

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

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

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

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

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

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

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

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

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

As the UK enjoys its unpredictable summer, with everything from sunshine to hailstorms, we bring you a mix of updates and discussions on emergency medicine, blog content, upcoming conferences, and insightful research reviews. So, whether you're basking in the sun or sheltering from the rain, sit back and enjoy our latest insights into the world of emergency medicine.

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

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

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

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

In this podcast from the PREMIER conference 2024, Francesca Stedman, a consultant paediatric surgeon from Southampton Children's Hospital discusses the care of the child who has ingested a button battery. 

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

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

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

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

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

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

More details are available on the blogpost here. 

In this St. Emlyn's podcast, Rick Body and Greg Yates, continue our exploration of diagnostic test accuracy, shifting our focus to positive predictive value (PPV) and negative predictive value (NPV). These concepts are vital for anyone preparing for exams or looking to enhance their application of diagnostic tests in clinical practice. While our last podcast discussion centred on sensitivity and specificity, PPV and NPV offer a different, arguably more clinically practical perspective on interpreting test results.

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

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

In today's episode, taken from live recordings at PREMIER 2024, we dive into an increasingly common treatment for type 1 diabetes: hybrid closed loop insulin pumps. We'll begin with a brief overview of traditional insulin pumps and explain how hybrid closed loops are different. The core of our discussion will be centered around three case studies, illustrating potential scenarios you might encounter in a pediatric emergency department and how to manage them effectively.

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

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

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

It was a huge pleasure to sit down with Steve Smith, a name synonymous with ECG expertise. Steve, renowned worldwide for his influential ECG blog, has been a pivotal figure in advancing our understanding of ECGs. Many of us have honed our ECG skills thanks to Steve’s insights. I had the opportunity to meet Steve about a decade ago at one of the SMACC conferences. Today, we delve into the fascinating world of occlusive myocardial infarction (OMI) and its comparison to STEMI (ST-elevation myocardial infarction), and explore the promising future of artificial intelligence in ECG interpretation.

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

00:00 Introduction

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

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

03:55 Challenges and Resistance to the OMI Paradigm

07:10 Key Indicators of Occlusive Myocardial Infarction

09:25 The Role of Artificial Intelligence in ECG Diagnosis

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

14:28 Clinical Studies and Real-World Applications

21:10 Future Prospects and Final Thoughts

A comprehensive blog post with references is available here

In this episode of the St Emlyn's podcast, Iain Beardsell introduces a talk by Anna Kyle, a consultant paediatrician from Somerset, delivered at the Premier conference in June 2024. Anna explores the complexities of assessing and managing eating disorders in young patients, including young adults. Highlighting the critical nature of eating disorders, she notes a 90% increase in admissions over five years and emphasizes the deadly risks, particularly anorexia nervosa with its 10% lifetime mortality rate. Kyle provides detailed guidance on recognizing symptoms, conducting risk assessments, and the importance of a thorough medical evaluation. She also touches on the MEAD guidance for managing eating disorders, stressing effective communication with patients and their families, and the critical role of empathy and support throughout the treatment process.

00:00 Introduction to the Podcast

01:03 The Deadly Nature of Eating Disorders

02:23 Medical Complications of Eating Disorders

05:08 Cardiovascular and Other Systemic Effects

07:22 Risk Assessment and MEAD Guidance

10:23 Communication and Management Tips

15:24 Conclusion and Final Thoughts

Comprehensive notes can be found here

Welcome to the St Emlyn's Monthly Podcast, your go-to source for the latest insights, developments, and discussions in emergency medicine and critical care. Each month, Simon and Iain will bring you in-depth analysis, evidence-based practices, and practical advice to enhance your clinical practice and professional development. 

In this round-up of May 2024, we talk about a wide range of issues relating to emergency medicine, including highlights from the RCEM conference, including the future management of head injury, crowding, RATing and what it takes to be an awesome ED for training. There's also advice on how to be a epic Emergency Physician In Charge, as well as discussion about the use of ChatGPT for medical exams, serratus anterior blocks for rib fractures, whether first pass success matters and the return of measles.

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

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

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

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

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

Welcome to St Emlyn's Monthly Round Up Podcast, your go-to source for the latest insights, developments, and discussions in emergency medicine and critical care. Each month, Iain and Simon bring you in-depth analysis, evidence-based practices, and practical advice to enhance your clinical practice and professional development. 

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

This month's content includes...

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

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

RCEM Annual Scientific Conference

After the bumper double paper review episode, we fit two months of blog content into one episode. Iain and Simon discuss the management of the patient with chronic liver disease who has an acute decompensation, global health connections, whether mechanical CPR is more effective than human CPR and the potential effects on elderly patients staying in the ED overnight.

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

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

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

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

RCEM Annual Scientific Conference

In this second of a two part podcast special Iain and Simon go through twenty of the top papers from the last year or so, as presented by Simon at the Big Sick Conference in Zermatt earlier this year. All the details and more discussion can be found on the blog site.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In this two part podcast special Iain and Simon go through twenty of the top papers from the last year or so, as presented by Simon at the Big Sick Conference in Zermatt earlier this year. All the details and more discussion can be found on the blog site.

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

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

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

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

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

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

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

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

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

It's episode one of season 11 and Simon and Iain chat through the blog content from St Emlyn's from January 2024. There's discussion about New Year resolutions and how to make them habits, intubating poisoned patients with a decreased conscious level and what we can possibly do to improve the working conditions in our Emergency Departments.

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

It's the last episode of season 10 and Iain and Simon discuss December 2023's blog posts. In a packed podcast they discuss prehopsital blood transfusion decision making, E-scooter injury patterns, the potential for AI in medicine and selective aortic arch perfusion.

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

Mentioned in the podcast

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

In this bumper double edition Simon and Iain chat through all the recent content on the St Emlyn's blog site, including a review of CRYOSTAT-2 and the DAShED study, a review of the new ILCOR guidelines, flow in the ED and why silence might just be the tonic we all need.

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

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

One of the benefits of the use of online platforms for meetings is the ability to record and disseminate talks more widely. This is an edited version of a talk given by Dr Andy Curry, Consultant Cardiothoracic Intensive Care Consultant at University Hospital Southampton, covering the origins of Extra Corporeal Membrane Oxygenation (ECMO) right up to the present day. Throughout the talk, he gives real world experience, coupled with a knowledge of the literature to communicate all you could ever want to know about this fascinating and potentially very exciting therapy. 

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

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

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

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

The Alfred ECPR Role Cards

The Bottom Line ECMO Reviews

An EBM-packed episode where Iain and Simon go over ten of the top papers from the last year discussing all manners of things Emergency Medicine, including TXA in trauma, use of video laryngoscopy, defibrillation strategies in refractory VF, and ten-second triage in major incidents. There's also a very pertinent discussion about whether the age of your Emergency Physician might affect your outcome...

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

After a long, hot and relaxing summer (!) Simon and Iain return with all the content from the St Emlyn's blog in July and August. They discuss four papers in detail, including the ARREST trial about cardiac arrest centres, whether clinical examination can identify life threatening injuries in trauma, the TOP-ART study looking at a novel agent in trauma management and the use of REBOA. 

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

Welcome to a bumper edition of the podcast discussing content from St Emlyn's for June 2023.

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

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

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

Take care. 

The clue to these is very much in the Title – BRUE is a diagnosis in itself. Children often do weird stuff, but they rarely do weird scary stuff.

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

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

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

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

As a Wessex ST7 in Paediatric Emergency Medicine (RCPCH), Jilly Boden currently works in Queen Alexandra Hospital (Portsmouth).  Her specialist interests include acute stabilisation and transfer of the critically ill patient, having spent a year with the 'Southampton & Oxford Retrieval Team' (SORT) and hopes to find a way of combining this with her future PEM career.

Jilly has a passion for education, particularly 'PEM to the non-paediatrician', including international teaching of the tri-service military GPs, and being on the national committee to write a new standardised paramedic paediatric curriculum.

In her free time (you know, apart from the kids and all that) she works as part of the track medical team for the 'British Motorcycle Racing Club', providing pre-hospital care to high velocity polytrauma patients in the 'golden hour' following collisions often exceeding 120mph. 

This episode of the podcast is a live recording from the PREMIER Conference of John O Neil discussing penetrating injuries with learning points that are useful for clinicians who look after both adult and paediatric patients. 

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

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

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

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

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

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

Chris brought us his reflections amnd knowledge from some of his extensive experience as a military EM consultant in two wars. Blast injury could be blunt, penetrating, may involve major haemorrhage: you have to expect any injury possible. It’s worldwide and it’s getting more common. 

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

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

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

This is the second in our series of talks recorded live in June 2023 at the PREMIER conference.

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

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

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

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

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

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

This is the first in a series of podcasts, recorded live at the Premier Conference in Winchester.

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

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

More information at these excellent websites

• PIER Network
• Southampton Oxford Retrieval Team
• Healthier Together

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

The monthly round up of all the blog posts at St Emlyn's, including a deep dive into HALO (high acuity, low occurrence) procedures and blood transfusion. 

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

Our monthly podcast round up from St Emlyn's Blog. This month Simon and Iain discuss the prehospital use of troponin measurement in the assessment of patients with chest pain and the use of AI in medicine, as well as an update about St Emlyn's WILD.

Please do like and subscribe

This is the first podcast in our new series from St Emlyn's Medical School. They are specifically aimed at healthcare students and focus on the Medical Licensing Assessment (UK) presentations in particular but will be useful wherever you listen in the world. 

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

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

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

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

The latest CAN is one of our brand-new 'revision editions' -- brief podcasts aimed at covering the essentials of critical appraisal for medical students and junior doctors preparing for exams.

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

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

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

In this CAN, we use D-Dimer as an example of a very sensitive investigation: it’s positive in nearly 100% of cases of venous thromboembolism. Specificity describes the likelihood that the test will be negative if your patient does not have the disease. We use HbA1c as an example of a highly specific investigation: it’s rarely used in the emergency department, but if it’s elevated, we can be almost certain that the patient is diabetic. HbA1c is almost never (

Our regular monthly round up and chat from the St Emlyn's blog. We talk about the use of artificial intelligence in research and the use of remifentanil instead of neuromuscular blockade in rapid sequence intubation. Plus more about the StEmlynsWILD conference and Simon's new role as Dean of RCEM and how you can get involved. 

Long term listeners to the St Emlyn’s podcast may remember our series entitled ‘Critical Appraisal Nuggets’ (CANs). We are absolutely delighted to reinvigorate this project under the leadership of Professor Rick Body, with the episode on semi structured interviews.

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

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

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

Lots of chat about St Emlyn's WILD and just what you can expect if you join us in the Lake District in June, as well as discussion about ECMO in cardiac arrest and just how many of our patients with 'minor head injuries' will actually have ongoing symptoms weeks and even months later. 

Click here to buy tickets for #StEmlynsWILD

A special double edition covering the blog posts from November and December and more. We discuss evidence based medicine with the DoseVF trial, and more from RECOVERY, discussion about 'what is downtime' and how we organise follow up for patients who don't live in our area and what happened at the amazing London Trauma Conference

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

Wellbeing is very complex, as it is an individual construct that is strongly aligned and interpreted through a lens of personal values, philosophy, culture, faith, and goals for life. Most importantly, wellbeing is dynamic rather than homeostatic and a subjective state determined by the individual.

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

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

Please do like and subscribe. Thanks for listening.

Burnout is a term that seems to be used a lot these days, but what does it really mean? In this episode Dr Liz Crowe explains all, and will almost certainly change the way you view burnout. 

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

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

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

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

In our new regular slot of the middle Monday of the month we're delighted to bring you the highlights from the St Emlyn's blog this month.,

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

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

Join Iain and Simon for this month's round up of September's blog content from St Emlyn's. They discuss managing harm in the ED; management of traumatic brain injury; Head Up mechanical CPR and fentanyl in RSI.

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

This is our round up of all that happened on the St Emlyn's blog in August 2022 (yes - we know it's a bit late, but there's been a lot going on!).

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

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

Simon and Iain run through the latest highlights from the St Emlyn's blog and podcast, including the FORCE study, the EXIT study and more about Vitamin C in sepsis...

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

Our monthly round up of all from the St Emlyn's blog. We discuss pathways into emergency care research, pad positioning in cardioversion of AF and possible gender differences in the presciption of TXA in trauma.

We also chat about travel in Lithuania, memories of defibrillating with hand held paddles and Simon's recent forst infection with COVID.

We mention a post on Lyme disease which you can read here (especially if you live near the New Forest...)

After a brief hiatus we're back with more from the St Emlyn's Blog. We discuss a wide range of topics from crowding in Emergency Departments and the RePHILL trial to breastfeeding, genetic testing and diagnosing DVTs, as well as our highlights from the recent RCEM CPD Conference in Bournemouth. There really is something for everyone! 

We made it! A double century of podcasts. In this month's update Iain and Simon talk through myth busting in resuscitation, Rick Body's airway expertise (with a side mention for high sensitivity troponin), a paper about resuscitative thoracotomy, ACPs in EM and how we all could set future research priorties.

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

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

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

Simon and Natalie discuss some of the complexities of feedback when it involved different specialities and patients. We also review our general rules of feedback.

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

The first episode of our 9th Season with discussion about Calcium in cardiac arrest, a deep dive into the physiology of exsanguinating haemorrhage, a comparison of ketamine and etomidate for induction of anaesthesia and the ECG Thrust. 

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

The Season Finale that you've all be waiting for. Our last episode of season 8 includes discussion about racial bias in sats monitoring, CT scans to investigate subarachnoid haemorrhage and the  importance of (consensual) touch. 

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

Iain and Simon

Iain is flying solo this month, with discussion about narrative story tellling, airway management in the ED and using pigtail catheters in management of haemothorax. 

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

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

Take care all. 

Our round up of all the blog had to offer in October 2021. There's discussion about evidence based medine in the REST and CTCA for intermediate chest pain trials, more about cauda equina and highlights from the Paediatric Colloquium in Australia, as well as the good humoured chat.

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

The round up of the St Emlyn's blog posts in August 2021, featuring discussion about therapeutic anticoagulation in hospitalised COVID-19 patients, non invasive ventilation vs usual care for critically hypoxic COVID-19 patients and the recent EMTA (Emergency Medicine Trainees Association) survey. Oh, and Simon's mid-life crisis. 

Iain and Simon discuss the best from the blog in June and July. There's COVID chat (of course). thunderstorm asthma, a glance into the future and much, much more. 

It's been a busy month on the blog with plenty for Iain and Simon to talk about. The Manchester Arena bombing, new guidelines for Anaphylaxis management, Adult Congenital Heart Disease, Calcium in Major Haemorrhage and Spontaneous Coronary Artery Dissection all get a mention alongside the usual witterings of two middle aged emergency physicians. 

This is the second in a two part podcast series discussing Adult Congenital Heart Disease (ACHD) and how these patients may present to the Emergency Department (ED). Dr Sam Fitzsimmons, our guest on the podcast, is a Consultant in Adult Congenital Heart Disease at University Hospital Southampton. There is more information in this blog post.

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

This is the first in a two part podcast series discussing Adult Congenital Heart Disease (ACHD) and how these patients may present to the Emergency Department (ED). Dr Sam Fitzsimmons, our guest on the podcast, is a Consultant in Adult Congenital Heart Disease at University Hospital Southampton. There is more information in this blog post.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A podcast with Iain and Simon summarising all the latest content from the St Emlyn's blog in April 2021. Topics discussed include Vaccine Induced Thrombocytopenic Thrombosis, how our own biases can effect our critical appraisal and whether we need to worry about grading the quality of FOAMed resources.

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

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

Simon joins Ankur Verma from Delhi, to talk about the impact of COVID in the latest wave devastating India.

A discussion about all the latest from the St Emlyn's blog, including a hot off the press article about vaccine induced thrombocytopenic thrombosis and the new FRCEM revision guide. 

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

An audio review of a paper in the Journal of Intensive Care Medicine with two of the authors.

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

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

Our regular podcast round up from February 2021. Iain and Simon highlight the key learning points from this month on the St Emlyn’s blog and podcast.

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

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

Our regular round up of the best of the blog and podcast from January 2021 with Iain and Simon. The St Emlyn's blog posts from January 2021 are discussed, including plenty about Coronavirus as well as other topics relevant to anyone interested in Emergency Medicine and evidence based care. 

Going into hospital as an emergency during the COVID-19 pandemic must be extremely scary for patients and their relatives. With no relatives allowed to visit and staff dressed in full PPE, the experience must be so much more unnerving than usual. Add to that the incredible worry about catching COVID-19 for those who don’t already have it; or the worry about what might happen for those who do. Will they pull through? Could this be the end?

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

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

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

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

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

Rick

A vaccine update with Rick Body, Simon Carley, Pam Vallely, Paul Klapper and Charlie Reynard. Bringing RCEM, St Emlyn's and the University of Manchester together for the latest thoughts and wisdom on the vaccines that might get us out of this pandemic.

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

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

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

#vaccines #COVID19 #coronavirus

A special festive edition of our round up podcast featuring six weeks of blog posts and plenty more besides.

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

Take care,

Simon and all the team

Rick leads the FALCON and CONDOR studies that are currently evaluating COVID-19 studies in the UK. Nobody knows more about how we can practically use COVID-19 testing than Rick and in this podcast he takes us through what is available and how we might use it in the future. 

A great listen and lots to learn. 

A bumper edition of the podcast where Iain and Simon discuss TXA (twice), antibiotics in appendicits, VTE, Blood products in trauma, use of ultrasound in cardiac arrest and plasma in traumatic brain injury. Oh, and COVID19 (but not for long)...

An evidence based cornucopia of aural pleasure.

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

Take care,

Iain

In this special edition of the podcast, Liz Crowe discusses with Iain how we can find contentment, despite the relentless nature of COVID19 and the impending second wave. She gives practical, realistic advice that everyone can consider and encourages us all to be kind to ourselves in these strange and difficult times. 

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

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

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

Take care,

Iain

Interview with Ian Roberts on the pharmacokinetic trial of intramuscular tranexamic acid.

Blog link here

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

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

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

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

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

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

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

Our own version of Buy One Get One Free* this month, where you get a round up of two months of blog content.

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

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

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

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

Take care,

Iain

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

We are delighted to introduce you to the "St Emlyn's Lesson Plans", which we hope will help structure some of your education sessions over coming months (and years).

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

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

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

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

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

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

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

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

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

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

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

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

St Emlyn's three professors, Carley, Body and Horner* critically appraise the Press Release regarding Dexamethasone in the treatment of COVID-19.

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

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

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

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

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

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

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

Take care

Iain

Podcast edited by Izzy Carley

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

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

The live event took place on Tuesday 26th May.

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

This will be the last weekly journal club, but we will be back with more EBM goodness very soon. Do let us know what you like to be included at [email protected]

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

Welcome to our sixth COVID-19 Journal Club Podcast.

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

References

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

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

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

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

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

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

The various organisations mentioned by Rick can be found here:

The Innovation Agency Webinar Series

The NHS Accelerated Access Collaborative

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

The Draft NICE recommendations

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

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

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

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

References

Podcast edited from a live webinar by Izzy Carley 

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

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

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

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

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

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

Take care

Iain

Podcast edited by Izzy Carley

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

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

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

Edited by Izzy Carley and Iain Beardsell

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

Welcome to our second webinar on recent research about COVID-19, hosted by the University of Manchester, Manchester Royal Infirmary and Royal College of Emergency Medicine in collaboration with St Emlyn’s.

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

The live event took place on Tuesday 21st April 2020

References: 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

S

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

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

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

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

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

vb

S

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

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

The latest from the St Emlyn's blog

St Emlyn's October 2019 Round-Up: Key Insights from Conferences and Research

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The CRASH-3 Trial: Revolutionizing Head Injury Management with Tranexamic Acid

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Welcome to St Emlyn’s blog and podcast, where we reflect on the key topics and research from August 2019. In this review, we’ll explore the most impactful discussions and studies, providing valuable insights for emergency medicine professionals. From managing lower GI bleeding and addressing climate change in anaesthesia to examining PTSD in emergency services and the future of diagnostics, this post summarizes essential takeaways that are shaping our field.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

St Emlyn’s July 2019: Key Highlights

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Emergency medicine is a field full of paradoxes, where the definition of a "good day" can differ starkly between healthcare professionals and their patients. This contradiction was a central theme in the discussions from June, which included reflections on the Don’t Forget the Bubbles (DFTB) conference, as well as key topics like the emotional toll of emergency medicine, the evolving nature of adolescent healthcare, and the importance of continuous learning.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Exploring the Latest in Emergency Medicine: February 2024 Edition

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

A Journey to Jeddah: Bridging Borders in Emergency Medicine

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

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

PTSD and the Road to Recovery: Insights from Rusty Carroll

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

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

Understanding Trauma Mortality: A Shift in Focus

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

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

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

Reevaluating PE in Syncope: A Fresh Perspective

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

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

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

Philosophy of Emergency Medicine: Workplace Relationships Matter

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

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

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

Ventilation During RSI: Revisiting Established Practices

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

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

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

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

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

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

Reflecting on February: A Busy Month in Emergency Medicine

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

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

Supporting the St Emlyn's Podcast: Your Contribution Matters

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

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

Conclusion

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

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

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

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

Exploring the Latest in Emergency Medicine: February 2024 Edition

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

A Journey to Jeddah: Bridging Borders in Emergency Medicine

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

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

PTSD and the Road to Recovery: Insights from Rusty Carroll

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

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

Understanding Trauma Mortality: A Shift in Focus

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

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

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

Reevaluating PE in Syncope: A Fresh Perspective

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

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

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

Philosophy of Emergency Medicine: Workplace Relationships Matter

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

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

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

Ventilation During RSI: Revisiting Established Practices

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

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

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

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

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

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

Reflecting on February: A Busy Month in Emergency Medicine

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

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

Supporting the St Emlyn's Podcast: Your Contribution Matters

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

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

Conclusion

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

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

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

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

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

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

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Also check out these excellent #FOAMed resources.

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

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

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

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

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

When we calculate a P value, we express the probability of obtaining a result as extreme as the one observed, assuming the null hypothesis is true. For instance, a P value of 0.05 suggests a 5% chance that the observed difference is due to random variation alone.

The threshold of 0.05 has become a benchmark in research. A P value below this threshold is often considered statistically significant, while one above is not. However, this binary approach oversimplifies statistical analysis. The figure 0.05 is arbitrary and does not imply that results just above or below this threshold are vastly different in terms of practical significance.

Distinguishing between statistical significance and clinical significance is crucial. A statistically significant result with a very small P value may not always translate into clinical importance. For example, a large study might find that a new treatment reduces blood pressure by 0.5 millimetres of mercury with a P value of 0.001. While statistically significant, such a small reduction may not be clinically relevant.

Conversely, a clinically significant finding might not reach the strict threshold of statistical significance, particularly in smaller studies. Therefore, it's essential to consider both the magnitude of the effect and its practical implications in clinical practice.

The fragility index is an alternative measure that addresses some limitations of P values. It calculates the number of events that would need to change to alter the study's results from statistically significant to non-significant. This index provides insight into the robustness of the findings. Surprisingly, even large trials can have a low fragility index, indicating that their results hinge on a small number of events.

Recognizing the limitations of the 0.05 threshold, some researchers advocate for more stringent criteria, such as a P value of 0.02, particularly in large randomized controlled trials (RCTs). This approach aims to reduce the likelihood of false-positive results and improve the reliability of findings. However, it also raises the bar for demonstrating the efficacy of new treatments, which can be a double-edged sword.

A significant challenge in research is multiple testing. Conducting numerous statistical tests increases the probability of finding at least one significant result purely by chance. This issue is particularly relevant in exploratory studies where multiple outcomes are assessed.

One method to address this problem is the Bonferroni adjustment, which adjusts the significance threshold based on the number of tests performed. While this approach helps control the risk of false positives, it can be overly conservative and reduce the power to detect true effects. Therefore, it should be used judiciously.

Interim analysis is a crucial aspect of clinical trials, allowing researchers to assess the effectiveness or harm of an intervention before the study's completion. However, performing multiple interim analyses can increase the risk of false-positive findings. To mitigate this risk, researchers use techniques like P value spending functions, which adjust the significance threshold for each interim analysis.

Additionally, the number of interim analyses should be limited and pre-specified in the study protocol. This ensures that decisions to stop a trial early are based on robust evidence and not on arbitrary or opportunistic analyses.

P values alone do not provide a complete picture of the study results. It's equally important to consider the effect size, which measures the magnitude of the difference between treatments. A small P value might indicate statistical significance, but without a substantial effect size, the clinical relevance of the finding remains questionable.

Confidence intervals (CIs) complement P values by providing a range within which the true effect size is likely to lie. A 95% CI means that if the study were repeated multiple times, 95% of the calculated intervals would contain the true effect size. CIs offer valuable context for interpreting P values and understanding the precision of the estimated effect.

1. Understand the Null Hypothesis: Always start with a clear understanding of the null hypothesis and what the study aims to test.
2. Look Beyond the P Value: Consider the effect size, confidence intervals, and clinical significance of the findings.
3. Be Cautious with Multiple Testing: Recognize the increased risk of false positives with multiple comparisons and apply appropriate adjustments.
4. Assess the Fragility Index: Use the fragility index to gauge the robustness of the study's findings.
5. Consider Interim Analysis: Ensure that interim analyses are pre-planned and interpreted with caution to avoid bias.
6. Question the Threshold: Remember that the 0.05 threshold is not a magic number. Interpret P values in the context of the study design, sample size, and practical implications.

P values are a fundamental aspect of medical research, but their interpretation requires a nuanced understanding. By considering the null hypothesis, clinical significance, effect size, and confidence intervals, we can make more informed decisions based on the data. As emergency medicine clinicians, our goal is to apply research findings judiciously to improve patient care.

We hope this deep dive into P values has clarified their role and limitations in research. Remember, the journey to mastering statistical concepts is ongoing, and continuous learning is key. If you have any questions or thoughts, please share them in the comments below. Happy appraising, and stay curious!

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

Hello and welcome to the St. Emlyn’s Podcast. I’m Simon Carley, joined by Rick Body. Today, we’re bringing you our January roundup, sharing the most intriguing and impactful content we've covered this month. From reflecting on 2018 to exploring new guidelines and innovations in emergency medicine, we have a lot to discuss. Let’s dive in!

As we started January, we reflected on 2018, a year filled with significant achievements and insights. One standout discussion was our review of key books that left a lasting impact. A personal favorite of mine is "Why We Sleep" by Matthew Walker. This book has been transformational for me, influencing how I live and advise others on health, well-being, and performance. The insights on sleep’s importance in education, creativity, and overall health are profound.

Rick, did anything from our 2018 review resonate with you?

Rick Body: Absolutely, Simon. The variety of books we discussed was impressive. It was enlightening to hear about others' achievements in 2018 and their goals for 2019. This exercise really focused my mind on what I hope to achieve this year.

As we moved from reflections to aspirations, we set our sights on exciting projects for 2019. One major highlight is the AI incubator for emergency care. This initiative aims to support academic careers and foster partnerships between data and industry to enhance medical technologies. It’s an exhilarating time for advancements in emergency care.

Rick is incredibly busy with groundbreaking work, particularly in diagnostics in Manchester. His research and speaking engagements are making waves in the medical community. For more details on these projects, check out the blog where all the information is comprehensively covered.

We explored New Year’s resolutions with Liz Crowe, who offered a fresh perspective on well-being and resolutions. Instead of focusing on all-or-nothing goals, Liz suggests starting small and seeking rewards rather than punishments. This approach makes significant lifestyle changes more manageable and sustainable. Committing to resolutions publicly or with a friend can enhance accountability and success.

Rick, do you have any New Year’s resolutions?

Rick Body: It’s challenging to pinpoint one or two, but Liz’s advice on avoiding binary thinking is crucial. Recognizing progress rather than dwelling on setbacks can make a big difference.

In January, we delved into updated tetanus guidelines, highlighting significant changes. Previously, a single booster in your early 20s was deemed sufficient, but the new guidelines recommend a 10-year booster. This change stems from the recognition that immunity wanes over time. Interestingly, point-of-care testing is now available to detect active tetanus immunization, allowing for more tailored booster decisions.

These updates are crucial for emergency physicians to ensure compliance with current standards and provide optimal patient care. The blog post simplifies these guidelines, making them accessible and easy to understand.

We featured Claire Richmond, a hero in the emergency medicine community. Claire, who works with Sydney HEMS, delivered an inspiring keynote at the St. Emlyn’s live conference. Her talk focused on excellence, performance, training, and development in retrieval medicine. She emphasized the importance of honesty, feedback, and continuous improvement.

For those aspiring to achieve self-actualization in emergency medicine, Claire’s insights are invaluable. We’ve shared the video and podcast of her talk, and we highly recommend checking them out.

Another highlight of January was Professor Dan Horner’s discussion on serum neurofilament light chains, a promising tool for prognosticating cardiac arrest outcomes. This research, stemming from the TTM trial, suggests that these biomarkers can provide early predictions about patient outcomes. Early identification of patients likely to have poor neurological outcomes can significantly impact family discussions, treatment decisions, and overall management.

This research is groundbreaking and holds potential for future clinical applications, although it’s not yet ready for immediate practice.

We’re incredibly proud of our journal club series at St. Emlyn’s, which advocates for evidence-based medicine. This series highlights the latest research, making it accessible and understandable. To celebrate the contributions over the past year, we’ve compiled an e-book available for free download. This resource is a testament to our commitment to advancing medical knowledge and practice.

One of the intriguing studies we covered this month examined pre-medication with midazolam or haloperidol for ketamine sedation. The randomized control trial suggested that pre-medication could reduce complications like abnormal behaviors and emergence phenomena. However, it also increased recovery time, requiring more resources and nursing time.

While the findings are interesting, they haven’t convinced us to change our current practice. However, it’s essential to stay informed about such research to make informed decisions in clinical practice.

We also discussed the role of HEMS in improving outcomes for traumatic cardiac arrest. The study from the UK highlighted the high-level interventions provided by HEMS teams. However, it raised questions about the overall impact on patient survival. Of the 263 patients attended, only seven survived, and all had achieved ROSC before HEMS arrival. This data suggests that while HEMS interventions are critical, their direct impact on survival needs further evaluation.

This topic is sure to spark debate, and we appreciate the transparency of HEMS services in sharing their data and encouraging open discussions.

As we wrap up January, we’re excited about the plans for the coming months. Simon is heading to Jeddah for a significant event, and we’re considering hosting another St. Emlyn’s live conference and teaching course. We’re exploring innovative formats for medical conferences and welcome your ideas on how we can make these events even more impactful.

Since 2012, we’ve funded the blog and podcast out of our own pockets, but as our audience has grown, so have the costs. If you find our content valuable, please consider making a small donation or subscribing for regular contributions. Your support helps us keep St. Emlyn’s free and accessible to all.

Thank you for your time and continued support. Stay tuned for more updates, and as always, enjoy your emergency medicine practice and take care!

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

00:00 Introduction to the Podcast

00:26 Charlie's Research Background

00:52 Overview of the Research Paper

01:17 Decision Making Under Uncertainty

03:05 Systematic Reviews and Data Collection

03:46 Building the Decision Tree Model

04:48 Results and Key Findings

08:07 Implications for Clinical Practice

09:19 Future Directions and Conclusion

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

You can read more from the event at http://www.stemlynsblog.org 

This is a great presentation for anyone interested in continually developing their own and their colleagues practice, delivered by someone who really knows what they are talking about and who works for one of the best developed resuscitation services in the world.

Clare is an Emergency Physician and specialist in Pre-Hospital Care and Retrieval medicine based in Sydney, with Royal Prince Alfred Hospital and Sydney HEMS. She has completed a fellowship in simulation based education, and enjoys training with “real” people - patients, bystanders and the other clinicians we come across as we treat our patients every day. She is a lecturer with the University of Sydney, and is involved in education for the NSW Institute for Trauma Injury Management. When Clare is not working on helicopters or training teams, she is studying yoga or hanging out with her puppy, Archie. 

Welcome to the St. Emlyn’s Podcast! I’m Simon Carley, and today we’re going to journey through December 2018. This month has been filled with intriguing discussions, significant insights, and top-notch blogs from a variety of experts. As we wrap up the year and get ready to welcome 2019, it’s the perfect time to reflect on the key topics that have shaped our discussions around Christmas and the New Year.

First up, we have an insightful contribution from Ross Fischer, a key member of the St. Emlyn’s team and a Pediatric Surgeon based in Sheffield. Ross has delved into the topic of tribalism in healthcare, a subject we've explored previously but which remains ever relevant.

Tribalism refers to the formation of groups or 'tribes' based on common beliefs and cultures, which significantly influences our behaviour and treatment approaches in healthcare. Ross's blog revisits a remarkable presentation by Vic Brazil at SMACC Gold in 2014, highlighting how tribalism drives our interactions and behaviours within the medical field.

In healthcare, tribes often form around specialities – emergency physicians, surgeons, anaesthetists, etc. While having a strong group identity can be positive, it can also lead to unhealthy competition and misunderstandings. For example, emergency physicians might unfairly label surgeons as uncooperative, which is not only untrue but also counterproductive.

Ross's extensive experience across various medical cultures has given him a unique perspective on this issue. His blog emphasizes the importance of recognizing and mitigating tribalism to foster better cooperation and ultimately improve patient care. Some strategies he suggests include using personal names during referrals, face-to-face communication, being supportive rather than critical when things go wrong, organizing social events across specialities, and calling out tribalism in casual conversations.

Next, I’ve put together a blog on the conservative management of chest trauma, inspired by several presentations I've done this year on torso trauma. The increasing body of evidence suggests that not all chest injuries, such as hemothoraces and small pneumothoraces, require invasive intervention.

Reflecting on my early days in emergency medicine, we operated under the strict guideline that any pneumothorax or hemothorax warranted a chest drain. However, advances in imaging technology, like whole-body CT scans, have revealed that many small pneumothoraces and hemothoraces were previously undetected and thus untreated without significant complications.

Recent studies, including a substantial observational study by Walker, support the safety of conservative management for many of these cases. This shift in practice aligns with our experiences here in Virchester, where we often opt to observe rather than immediately intervene with chest drains, even in ventilated patients. The evidence is still evolving, but it’s encouraging to see data supporting less invasive approaches.

Dan Horner, Professor of Emergency Medicine at Virchester West, has shared three exceptional posts from our time at the Intensive Care Society conference in London. The interface between emergency medicine and ICU is a critical area, and Dan’s insights are invaluable for anyone interested in this field.

One standout topic from the conference was Tom Evans' presentation on exercise physiology. Though I missed it, the demonstration with Olympic rowers on stage, showcasing their lactate levels, was reportedly phenomenal. This type of hands-on demonstration highlights the extraordinary resilience and adaptability of human physiology, insights that are crucial for both emergency and intensive care practitioners.

In addition to exercise physiology, Dan and I covered the continuum of patient care from the roadside to critical care, emphasizing the importance of effective handovers and collaborative work with paramedics. Our discussions included the zero point survey, ATMIST handovers, and the significance of follow-ups to ensure paramedics receive feedback on their patients' outcomes, all crucial elements for improving patient care and professional practice.

Natalie May wrapped up our review of the FemInEM conference, emphasizing the multifaceted nature of medicine. The themes of passion, role models, organization, consistency, persistence, mentorship, and leadership were central to the conference discussions. FIX19, the upcoming FemInEM event, promises to continue this tradition of exploring how medical professionals can impact not just clinical outcomes but also their own lives, colleagues, and the broader community.

Gareth Roberts, a recent addition to our consultant team in Manchester, provided a comprehensive review of HIV management from an emergency physician’s perspective. His blog focuses on post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP), critical areas for emergency physicians to master.

With the ongoing changes in HIV treatment and prevention, understanding the nuances of PEP and PrEP is vital. Gareth also touches on the rise of chemsex and its implications for emergency medicine, emphasizing the need for awareness and appropriate management strategies for patients involved in these practices.

Rich Cardens explored the intriguing findings from his PhD research on trauma laparotomy. Despite significant advancements in trauma care over the past decade, the mortality rate for trauma laparotomy has remained unchanged. This surprising discovery prompts a deeper investigation into the factors influencing these outcomes.

Rich's research compares data from the JTTR military registry and the Royal London Hospital, highlighting the need for a comprehensive trauma emergency laparotomy audit. Understanding why mortality rates haven't improved could lead to better strategies and practices in trauma care.

For a lighter, yet still educational note, Janos Byan Beethar found an entertaining yet insightful study in the Injury Prevention Journal. This study analyzed the mortality of characters in Game of Thrones, a bit of fun that doubles as a critical appraisal exercise. With over half of the 330 characters meeting untimely deaths through injury, burns, or poisoning, the study offers a unique way to engage with epidemiological concepts and cause-effect associations.

Interestingly, the study also suggests that characters who change allegiances have a higher survival rate – perhaps a subtle hint at the importance of adaptability in both fictional and real-world scenarios.

As we close out December, it’s clear that 2018 has been a year of growth, learning, and exciting developments here at St. Emlyn’s. From addressing tribalism in healthcare to exploring conservative management strategies for chest trauma, and from the latest insights in intensive care to the evolving field of HIV management, our blogs have covered a wide range of critical topics.

We look forward to continuing this journey in 2019, bringing you the latest research, discussions, and insights in emergency medicine. Whether through our blogs, podcasts, or live events, we aim to foster a community of continuous learning and professional growth.

Stay connected with us on Twitter, Facebook, the blog, and the podcast. We’re here to support you in your practice and to ensure you stay at the forefront of emergency medicine. Here’s to another great year with St. Emlyn’s!

Hello and welcome to the St Emlyn's Podcast and blog. I'm Simon Carley, and I'll be guiding you through the exciting topics and developments we've covered on the blog in November 2018. From leadership insights to groundbreaking medical research, this month has been incredibly informative. Let's dive into the highlights!

We begin our review in New York, where Natalie May attended the FIX (FeminEM) Conference. In her second post about this event, Natalie explores profound themes, particularly around leadership and motivation in the medical field.

Jennifer Walthall's talk emphasized the importance of acting within the system to drive change. When joining an organization that may not align with your values, you can either work within the system to improve it or fight from the outside. Walthall advocates for influencing change from within, suggesting that once embedded, you can effectively drive improvements.

Lara Goldstein's session on leadership identified four critical attributes of a good leader:

1. Listening: Truly understanding your team.
2. Recognizing the Impact of Small Actions: Little things add up.
3. Conflict Management: Not everyone will like you, and that's okay.
4. Gratitude, Kindness, and Decency: Core values that should guide every leader.

Natalie's detailed reflections on the FIX Conference are a must-read for those interested in these themes. Attending FIX in 2019 should be on your list if possible!

Dan Horner analyzed the POLAR trial in one of our journal club posts. The POLAR trial is a significant randomized control trial investigating the effects of hypothermia in the early stages after a brain injury. This study follows the Eurotherm trial, which explored hypothermia's role in patients with severe brain injuries in the ICU.

The POLAR trial involved 511 patients with severe brain injuries, randomized to either hypothermia (cooling to 33-35°C) or maintaining normothermia for 72 hours. Despite strong pathophysiological evidence supporting hypothermia, the trial found no significant difference in outcomes after six months. Initial results suggest that routine hypothermia for early-stage brain injury might not be beneficial, but long-term data follow-up is crucial. This trial, published in JAMA, is essential reading for anyone involved in emergency medicine or critical care.

Zaf Qasim, a former Manchester trainee now making waves in the US, contributed an enlightening post on the use of whole blood in trauma resuscitation. This approach, which makes intuitive sense—replacing lost whole blood with whole blood—contrasts with the UK practice of separating blood into components for transfusion.

Zaf argues that whole blood could simplify and improve trauma care, reducing the time and complexity of reconstituting blood components in the body. Although not yet standard in the UK, this method is gaining traction in places like London HEMS and various European centers. As data continues to emerge, this could revolutionize trauma care, harkening back to practices from the Second World War and Vietnam.

Natalie May returns with a provocative post challenging the use of the term "sexy" in clinical medicine, especially in resuscitation-related specialties. Often used to describe procedures or equipment, this term can inadvertently perpetuate gender biases and undermine professionalism.

Natalie, supported by her husband Oli May's humorous yet insightful critique, urges us to reconsider such language. The term "sexy" in a medical context is not a compliment and can contribute to a culture that sexualizes women in the workplace. This reflection is especially relevant for departments striving to maintain professionalism and inclusivity.

In the realm of medical education, Nick Smith's debut blog post introduces us to cognitive load theory. As a clinical educator in Manchester, Nick explores how intrinsic, extrinsic, and germane cognitive loads affect learning and teaching.

Nick's post is a valuable resource for educators aiming to optimize their teaching strategies. By understanding and managing cognitive load, we can create more effective and supportive learning environments for our trainees. This post is part of a broader series on educational theories that are crucial for medical educators.

Medical student Claire Bromley shares her transformative elective experience at Mitchell's Plain with the BAD EM team. Working with leaders like Katya Evans and Craig Wylie, Claire's reflections offer deep insights into the challenges and rewards of emergency medicine in South Africa.

Claire highlights the stark differences between UK and South African healthcare systems, particularly the intense workload and resource constraints in the public sector. Her experience underscores the importance of preparation, respect, and adaptability for anyone considering working in a different health economy.

Natalie May's final post for November reflects on promoting diversity and inclusivity in the emergency department. She emphasizes that the ED is unique in its diversity, seeing patients from all walks of life.

Natalie advocates for a broader understanding of diversity beyond ethnicity, including gender, disability, and sexual orientation. Her insights are essential for ED professionals committed to providing equitable care and fostering an inclusive environment.

I had the pleasure of discussing "Learning in the Social Age" at the Emerge 10 conference in Scotland. This presentation, supported by a blog post, explores how the internet and social media are transforming medical education.

We are now competing on a global scale as educators, with learners accessing information from various sources worldwide. This shift necessitates embracing new methods of engagement, ensuring our teaching remains relevant and impactful.

We wrapped up November with a highlight from St Emlyn's Live, featuring Salim Rezaie from the RebelEM blog and podcast. Salim's presentation on "Beyond ALS" challenges us to rethink cardiac arrest management, focusing on advanced techniques and evidence-based practices.

Salim's talk covers crucial aspects such as minimizing shock pauses, effective adrenaline administration, and optimizing IV/IO access. For anyone serious about improving their ALS skills, this blog, podcast, and accompanying videos are indispensable resources.

November was a whirlwind of activity and learning at St Emlyn's, and we have plenty more in store for December. As we approach the holiday season, we hope you find time to explore these posts and integrate their lessons into your practice. Thank you for being part of the St Emlyn's community, and we look forward to continuing this journey of learning and improvement together.

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

Five strategies to improve your resuscitations.

1. Zero point survey

2. Peer review

3. 10 in 10

4. Hot debriefs

5. Fly the patient

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

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

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

Welcome to the St Emlyn's Podcast: October 2018 Highlights

Hello and welcome to this St Emlyn’s podcast. My name is Simon Carley, and today I'm thrilled to take you through all the exciting events and updates we've been involved in this October 2018. This month has been bustling with activities, learning opportunities, and insightful experiences that we are eager to share with you.

We kicked off October with a bang by hosting the first-ever St Emlyn’s live conference in Manchester. This landmark event brought together a diverse group of delegates and speakers, creating a vibrant atmosphere of learning and collaboration. The focus was on the four pillars of emergency medicine as we see it at St Emlyn’s:

1. Emergency and Spades Medicine
2. Excellence in Critical Care
3. Wellbeing
4. The Philosophy of Emergency Medicine

We had an incredible day filled with discussions on why we do what we do and how we can continue to improve our practices. The energy and enthusiasm from the participants were palpable, and we are excited to share all the presentations and insights from this event over the coming months. Stay tuned to our blog and media channels for updates.

One of the highlights from the conference was my presentation on "Five Things You Can Do to Improve Your Resuscitation." Although the video is not yet released, the blog post is available, and I want to give you a sneak peek into some practical tips that can make a significant difference in your practice.

The zero-point survey is a concept introduced by Cliff Reid, emphasizing the importance of preparation before patient contact. Your resuscitation process should begin the moment you hear about the patient, not when you meet them. This preparatory phase includes ensuring your physical readiness, team coordination, and environment setup.

Key Steps:

• Self-preparation: Ensure you are physically and mentally ready.
• Team readiness: Identify team roles and confirm competency.
• Environmental setup: Check equipment, ensure visibility, and prepare necessary tools.

The 10 in 10 concept involves taking 10 seconds every 10 minutes during a resuscitation to reassess and communicate with your team. This regular pause helps in reappraising the situation and updating your mental models, ensuring everyone is on the same page.

In emergency medicine, drawing from aviation, one person should focus on maintaining the basics (aviate) while another makes higher-level decisions (navigate and communicate). In a resuscitation scenario, one team member should follow the algorithm and manage immediate life support, while another considers broader strategies and decisions.

Peer review is essential for growth and self-awareness. Having someone observe your practice and provide feedback can uncover blind spots and improve your performance. This process benefits both the observer and the observed, fostering a culture of continuous improvement.

Adopted from the Edinburgh emergency departments, hot debriefs are quick, five-minute sessions immediately after an event. This practice allows teams to reflect on their performance, discuss what went well, and identify areas for improvement. Implementing hot debriefs can enhance team dynamics and overall performance.

In another educational blog this month, I discussed how to teach and learn effectively in a stretched environment, drawing from a talk at the Royal Society of Medicine in London. Contrary to popular belief, being busy does not preclude learning opportunities. Data from the GMC survey indicates that exposure to relevant cases and support in learning significantly impact trainee satisfaction, rather than workload alone.

1. Post-it Polls: Write down interesting cases or learning points throughout the day and display them on a board for everyone to see and discuss.
2. FOAMed Prescriptions: Share relevant online resources with trainees to reinforce learning through spaced repetition.
3. Social Media Utilization: Use platforms like WhatsApp and message boards to discuss cases and share insights while maintaining confidentiality.

We revisited the controversial topic of cricoid pressure in rapid sequence intubation (RSI) with a journal club post. Despite longstanding debates, recent evidence, including a study published in JAMA, suggests that cricoid pressure may not significantly impact laryngoscopy success rates. However, it might still be beneficial in specific high-risk scenarios. The key takeaway is to make informed decisions based on the latest evidence rather than following traditional practices blindly.

Natalie May attended the FemInEm conference in New York and shared her insights in a detailed blog post. The FemInEm group focuses on promoting gender equity in emergency medicine but offers valuable resources for all practitioners. Natalie’s presentation on avoiding the use of the word "sexy" in emergency medicine was particularly thought-provoking. Stay tuned for more from this inspiring conference.

Natalie May also delivered a keynote presentation at St Emlyn’s Live on the pursuit of excellence. Drawing from her experiences in the UK and Australia, she emphasized the importance of continuous learning and collaboration with colleagues. Her talk highlighted that achieving self-actualization in emergency medicine requires support from a dedicated team, reflection, and a commitment to improvement.

Rusty Carroll continued his series on PTSD, exploring novel therapies such as eye movement desensitization and reprocessing (EMDR), now approved by NICE. This installment provides valuable insights for those dealing with PTSD, offering hope and practical solutions.

As we wrap up October, we have an array of exciting content lined up for November and beyond. We will be releasing more materials from St Emlyn’s Live and sharing insights from our Teaching Co-Op course. The course was a fantastic experience, and we are considering hosting it again due to popular demand.

In the meantime, we encourage you to engage with our blogs, videos, and social media channels. Join us in our journey to improve emergency medicine practices and enhance patient care. Stay connected, stay curious, and enjoy your adventures here at St Emlyn’s.

Thank you for being a part of the St Emlyn’s community!

By following these tips and strategies, you can optimize your practice, foster a culture of continuous learning, and improve patient outcomes. Don’t forget to subscribe to our blog and podcast for the latest updates and insights from the world of emergency medicine.

This presentation was given at the inaugural #stemlynsLIVE conference on the 8th of October 2018 in Manchester. You can read more about the presentation and the conference here. https://www.stemlynsblog.org/in-pursuit-of-excellence/

September Review: Key Insights from the Sentemlyns Podcast

Welcome to the latest edition of the Sentemlyns podcast blog. I’m Simon Carly, and today we're diving into the significant papers and events from September. We're a tad late this month due to the bustling activities surrounding the Sentemlyns conference and the Teaching Court course, both of which were tremendous successes here in Manchester. Stay tuned as we delve into the highlights of September, from groundbreaking studies to enlightening conferences.

Key Studies by Ashley Levy

We kick off with a comprehensive look at two pivotal papers by Ashley Levy, focusing on airway management in cardiac arrest. These studies, eagerly awaited by the medical community, provide critical insights into pre-hospital care.

Published in JAMA in August, the Airways 2 study examined over 9,000 patients in the UK pre-hospital environment who suffered cardiac arrests. The study excluded patients who quickly returned to spontaneous circulation after a couple of shocks. The remaining patients were randomized into two groups: those receiving a supraglottic airway and those receiving an endotracheal tube.

Findings: The study revealed no significant difference in outcomes between patients who received endotracheal intubation versus those with a supraglottic device. This challenges the long-held belief that intubation is superior in cardiac arrest scenarios.

Implications: The findings suggest that in pre-hospital settings, the choice of airway device might be less critical than previously thought. It underscores the importance of managing ventilation effectively, regardless of the airway device used. For many practitioners, this means opting for the quickest and easiest airway device, typically a supraglottic airway. However, in prolonged or complex cases, converting to an endotracheal tube might still be preferable.

Another study published in JAMA, conducted in the US, compared endotracheal intubation with the use of a laryngeal tube. Similar to the Airways 2 study, it found no significant advantage to using an endotracheal tube. Interestingly, this study hinted at a slight benefit for the laryngeal tube, though this requires further investigation.

Conclusion: Both studies indicate that for pre-hospital cardiac arrest, the priority should be securing an airway quickly and effectively. While supraglottic airways may suffice in many cases, endotracheal tubes remain a viable option in more complex scenarios.

Stefan Brujins’ Perspective

Stefan Brujins, a friend and colleague now working in the UK, provided a thought-provoking post on our responsibilities toward global health. Reflecting on his experiences growing up in South Africa, Stefan challenges us to reconsider our assumptions about equality and diversity in healthcare.

He directs us to an impactful presentation by Annette Alenio at SMACC, emphasizing the need for togetherness in global health. This presentation is a must-watch for anyone interested in global health, offering valuable insights on how we can contribute more effectively to the global medical community.

Diverse Learning Experiences

The EUSEM conference, a combined event with the Royal College of Emergency Medicine, held in Glasgow, was a highlight of September. This event is renowned for its diversity and the unique learning opportunities it offers.

Dan Horner kicked off the conference with an insightful presentation on managing massive pulmonary embolism (PE). His update reflects the latest advancements and the complexities involved in clinical decision-making for thrombolysis in emergency settings. The emphasis on shared decision-making between clinicians and patients was particularly noteworthy.

Members of the Sentemlyns team joined the Royal College of Emergency Medicine team in the European Simulation Cup and emerged victorious. This competition, involving around 14 teams, culminated in a major incident simulation. The win was a testament to the team's skill and collaboration.

Simon Carly’s Presentation

I had the opportunity to present on the use of narrative learning and storytelling in emergency medicine. While not a traditional clinical topic, the importance of engaging learners through storytelling cannot be overstated. Case reports, despite being viewed skeptically in literature, remain powerful tools for education when used correctly.

I drew heavily on the work of Jonathan Gottschall, particularly his book "The Storytelling Animal." Understanding the science behind storytelling can transform educational strategies, making them more effective and memorable.

Natalie’s Comprehensive Guide

Neonates, with their unique physiology, often present challenges in emergency medicine. Natalie provided an excellent post on managing sick neonates, using the analogy of micro machines to explain various aspects of neonatal care. From glucose metabolism issues to identifying cardiac problems in premature babies, her guide is invaluable for practitioners who may not regularly deal with neonates.

Janis Byombi’s Expertise

Monkeypox, a relatively obscure virus related to smallpox, has seen a recent outbreak with cases imported to the UK. Janis Byombi, our expert in international and tropical diseases, detailed the symptoms, diagnosis, and management of monkeypox. While generally self-limiting, awareness and proper handling are crucial, especially for healthcare workers who might be at risk.

Innovative Approaches to Learning

Ashley Liebergen shared her experiences from the RecessTO conference organized by Chris Hicks in Toronto. The conference's innovative approach combined traditional knowledge sharing with practical workshops and simulations, enhancing the overall learning experience. This method of building knowledge progressively throughout the day was particularly effective and engaging.

Learning with Leisure

The EMS Gathering in Cork, Ireland, offered a unique blend of formal lectures and experiential learning. This “learning with leisure” approach took attendees to various locations around Cork for hands-on experiences, from airport emergencies to extrications.

Emotional Learning Experience One standout session was a cardiac arrest scenario staged in a theatre, focusing on the interaction between medical teams and the patient's relatives. This emotionally charged and theatrically presented scenario highlighted the importance of communication and empathy in emergency medicine.

Enhancing Resuscitation Preparedness

Finally, I rounded off September with a post on the zero-point survey. This concept emphasizes that resuscitation begins before the patient arrives, utilizing the critical minutes from the initial alert to prepare thoroughly. This proactive approach can significantly improve resuscitation outcomes and efficiency.

September was a month of substantial learning and reflection for the Sentemlyns team. From groundbreaking studies in airway management to innovative approaches in global health and emergency medicine education, we've covered a broad spectrum of topics. As we look forward to October and beyond, we remain committed to bringing you the latest insights and developments in emergency medicine.

Thank you for joining us on this journey. Stay tuned for more updates and have a great day!

Hello and welcome to the St Emlyn’s blog! I’m Simon Carley and today; I’m thrilled to share with you some of the standout moments and key insights from our blog in August. Yes, I know it’s October now, but we’ve been incredibly busy organizing the St Emlyn’s Live and the teaching course in Manchester. More on that in a later post. It’s been a fantastic period for us, and even though we’re a bit behind, it’s perfectly okay. Let’s dive into some spaced repetition and revisit the exciting content from August.

In August, we featured a series of blogs by Natalie May, chronicling her experiences at the Emergency Medicine of South-Os conference in Australia, where she served as a keynote speaker. Natalie covered several essential topics during her time there, providing valuable insights and lessons for emergency medicine professionals.

One of the key sessions she highlighted was about the effective use of apps in emergency medicine. This session was particularly interesting as it covered various clinical applications that can enhance productivity and patient care. Natalie shared top tips from her session, many of which she personally uses. This collection includes clinical tools and productivity apps, making it a must-read for anyone looking to optimize their practice. Many of these tips also tie back to a post by Scott Weingart from a few years ago about getting things done in emergency medicine. Natalie’s update builds on Scott’s foundation, providing new insights and practical advice for today’s busy and complex medical environment.

Another highlight from Natalie’s posts was a session on lessons learned. This session brought together five respected professionals—Gary Birk, Jesse Spur, Natalie herself, Ian Summers, and Tim Lewinburg—who discussed instances where things didn’t go as planned. These stories weren’t just about clinical errors but also about soft skills, which, as we know, are anything but soft.

The panel covered communication issues, handover challenges, and awareness of equality and diversity in the emergency department. One poignant story involved an equality and diversity issue where Natalie acknowledged a consultation that didn’t go as expected. These discussions are crucial as they address elements that are challenging to learn from textbooks but significantly impact patient care and team dynamics.

Moving on, we had an exceptional post by Rick Body on troponin, specifically focusing on high-sensitivity troponin samples. Rick is a leading authority on troponin, and his insights are invaluable. One particularly critical point he raised was the impact of biotin supplements on troponin assays.

Rick explained that patients taking biotin might show negative troponin results even when there is a myocardial infarction. This is a significant finding as it could lead to missed diagnoses. Rick advises emergency departments to either determine the type of analyzer their lab uses or routinely check biotin levels in patients to avoid potentially serious errors. This post is a must-read for anyone involved in emergency medicine as it provides practical advice to enhance diagnostic accuracy.

August was also a month of anticipation for the upcoming SMAC conference. We discussed the excitement surrounding this event, which promises to be an incredible gathering of emergency medicine professionals. If you haven’t registered yet, make sure to do so as this will be the last SMAC, and it’s set to be unforgettable.

We also explored the CESR route in the UK. For those unfamiliar, the CESR (Certificate of Eligibility for Specialist Registration) is an alternative path to becoming a consultant in emergency medicine. Unlike the traditional six-year training program, the CESR route is portfolio-based and has recently undergone some changes. Gareth, who has successfully navigated this process and joined us as a consultant, shared his experiences and offered practical advice. His insights are particularly valuable for anyone considering this path, emphasizing the importance of early preparation and understanding the requirements.

One of the standout academic reviews we featured in August was on the use of intravenous fluids in critical care. Authored by Silam Lam, John Myberg, and Armando Bellomo, it provides a comprehensive overview of current best practices and evidence in fluid management.

The review highlights several key points. Firstly, the evidence base for most IV fluids is surprisingly weak, which is concerning given how widely they are used. The traditional approach of aggressive fluid resuscitation (fill them up until they can’t take any more) is now considered potentially harmful. Instead, a more cautious and mindful approach is recommended.

The review also discusses the importance of choosing the right type of fluid and adjusting the volume based on the type of shock. Dynamic assessment tools like point-of-care ultrasound are emphasized as they provide real-time insights into patient status, making fluid management more precise. The paper also touches on the role of the glycocalyx, an essential barrier between intravascular and extracellular fluid, which plays a critical role in fluid management during illness.

In addition to general fluid management principles, the review provides specific recommendations on which fluids to avoid. Hydroxyethyl starch solutions, for instance, should not be used, a point we have reiterated on the blog before. Gelatin, another fluid type, is also not recommended due to its limited benefits and potential risks.

Human albumin, although used more frequently in critical care, especially for conditions like sepsis, does not show significant advantages in most scenarios and should be avoided in traumatic brain injury. The ongoing debate between balanced solutions and normal saline is also addressed, with the review suggesting that balanced solutions may offer slight advantages in certain contexts.

Finally, we revisited a fantastic paper and podcast on moral injury by Esther Murray. This topic has resonated deeply with many in the emergency and critical care fields. The paper explores the psychological and emotional challenges faced by healthcare professionals, particularly those working in high-stress environments.

Esther’s discussion on moral injury—how the distress from perceived ethical transgressions impacts healthcare workers—is incredibly poignant. Given the increasing focus on mental health and well-being in our profession, understanding and addressing moral injury is crucial for sustaining our workforce. This small but significant study sheds light on an issue that many of us have experienced, even if we haven’t fully acknowledged it.

August was indeed a month packed with valuable insights and crucial updates for the emergency medicine community. From Natalie May’s adventures and lessons learned to Rick Body’s troponin wisdom and the comprehensive review on intravenous fluids, there was a wealth of information to absorb and apply in practice.

We also delved into the practicalities of the CESR route, providing a roadmap for those considering this alternative path to consultancy. The discussion on moral injury, led by Esther Murray, reminded us of the importance of addressing the emotional and psychological well-being of healthcare professionals.

As we move into the latter part of the year, we look forward to bringing you more cutting-edge research, practical tips, and thought-provoking discussions. Stay tuned for the September podcast and the exciting content we have lined up from recent conferences. Thank you for being a part of the St Emlyn’s community, and here’s to continuing our journey of learning and improving patient care together.

EMS Gathering round up 2018 with Simon Carley and Aidan Baron. See www.stemlynsblog.org Apologies for the sound quality on this one, it was all done in a fairly noisy environment.

Don't forget to listen to special guests from 23 mins onwards.

This week we recorded a podcast inspired by a recent publication in the EMJ. Esther Murray aka @EM_Healthpsych is a psychologist working in London.

Her recent paper on whether the experiences of medical students might precipitate moral injury during their pre-hospital experiences gives  an insight into how we all cope with and respond to the clinical work we do. Some of the work we do is traumatic, painful and morally difficult to rationalise. We are witness to the very worst aspects of some of our patient’s lives and there may be a price to pay.

I was delighted to explore some of the concepts around moral injury in this podcast and would really recommend that you read the paper 1 and consider whether this is something that can affect ourselves and our colleagues. The paper is open access at the moment so there is no excuse not to 😉

Although the paper is based on a small number of participants from only one aspect of the healthcare system it does recognise this limitation and alludes to future work with different groups of clinician.

Esther describes ‘moral injury’ as a concept emerging from work with military veterans. It is used to describe the psychological sequelae of ‘bearing witness to the aftermath of violence and human carnage

Hello and welcome to The Sintervenants Podcast. I'm Simon Kelly, and today I’m going to guide you through the exciting developments in July. While we all enjoy the summer weather, there’s a lot more to discuss beyond vacations. Here’s what’s been happening in the world of emergency medicine.

This month, we delve into a fascinating post by my colleague, Craig Ferguson, about game theory and its application in emergency medicine. This concept revolves around finite and infinite games, an idea rooted in game theory, which you might recognize from the film A Beautiful Mind. The book it’s based on is also highly recommended for those interested in deeper insights.

Finite games, such as chess, have known rules, defined endpoints, and players aware of their roles. Conversely, infinite games, like a soccer league, continue indefinitely. In these games, the objective is to stay in the game, continually evolving and adapting until resources are exhausted or other external factors intervene.

In healthcare, particularly emergency medicine, Craig highlights the challenges posed by infinite games. Emergency medicine is an infinite game with no definitive endpoint. The objective is to keep going, continually providing care without a final goal. However, health service management often imposes finite rules, such as performance targets and time-based metrics. These finite measurements can clash with the infinite nature of healthcare, creating challenges and unintended consequences.

For example, measuring patient flow and quality of care through finite metrics in an emergency department doesn’t account for the complex, non-linear nature of healthcare systems. Changes in one area can lead to unforeseen issues in another, complicating the overall performance and outcomes.

Craig’s post has shifted my perspective on my shifts, especially during challenging times. It’s not about meeting arbitrary targets but understanding the infinite game we’re playing. Recognizing this can alleviate some pressure and help focus on continuous improvement rather than finite measures.

Another compelling post this month comes from Rusty Carroll, a clinician who has openly shared his journey with PTSD. His series, "Keep Walking: PTSD and Me," provides a candid look at the early stages of PTSD and the challenges of maintaining a facade of normalcy while dealing with underlying trauma.

Rusty’s experience highlights the temptation and necessity for many clinicians to keep going despite severe emotional and psychological strain. The work-play-sleep-repeat cycle can mask serious issues, preventing individuals from seeking the help they need. This series aims to help those who haven't experienced PTSD understand the lived experiences of those who have, offering insights into coping mechanisms and the importance of addressing mental health openly.

Emergency medicine professionals often face traumatic events, making Rusty’s story particularly relevant. Understanding these experiences can foster empathy and support within the community, encouraging those struggling to seek help without fear of stigma.

In July, we also reviewed a significant trial on the use of epinephrine in out-of-hospital cardiac arrest, published in the New England Journal of Medicine. This British-led trial by the paramedic two collaborators, spearheaded by Gavin Perkins, has been highly anticipated due to ongoing debates about the efficacy of epinephrine (commonly known as adrenaline in Manchester) in such cases.

The randomized controlled trial involved over 8,000 participants and focused on patients who had not responded to initial defibrillation. The primary outcome measured was the survival rate at 30 days, showing a survival rate of 3.2% in the epinephrine group compared to 2.4% in the placebo group.

While this suggests a significant benefit in terms of survival, the secondary outcomes raise ethical questions. Severe impairment, measured by the modified ranking scale, was more common among survivors in the epinephrine group. This finding complicates the interpretation of the results, as it indicates that while more patients survive, many suffer from severe neurological impairment.

The ethical dilemma here is whether increasing survival rates justifies the higher incidence of severe impairment. This question extends beyond medical practice into the realm of medical ethics and societal values. As clinicians, our goal is neurologically intact survival, aligning with public preferences for quality of life over mere survival.

Despite the trial’s insights, it doesn’t provide a definitive answer. As practitioners, we must weigh these findings carefully, considering the broader implications for patient care and quality of life.

We’re excited to announce that the Teaching Power Course in October is almost sold out. By the time this post goes live, it might already be fully booked, which is fantastic news. This course, held in Manchester, promises to be a valuable learning experience for all attendees.

Tickets are still available for the Sintervenants Live Conference on October 9th. We’ve designed this event to be both affordable and enriching, featuring an international faculty that you won’t find at any other one-day course in the UK. Don’t miss this opportunity to join us for an exciting day of learning and networking.

Lastly, I’d like to highlight an insightful post by Natalie May on the management of paronychia. While not as high-profile as other topics, paronychia is a common and painful condition that we don’t always manage effectively in the ED.

Natalie’s review examines the formation of paronychia and the best treatment options. Our previous small randomized control trial suggested that lifting the nail fold is more effective than incision and drainage. Natalie’s findings support this approach, advocating for less invasive methods to alleviate pain and promote healing.

Key tips include soaking the affected area and using appropriate tools to lift the nail fold gently. For more severe cases, inserting a small wick can aid healing by allowing drainage without creating a new wound. Natalie also advises on recognizing conditions that mimic paronychia, such as osteomyelitis or tendon injuries, ensuring comprehensive and accurate treatment.

This practical advice can significantly improve patient care in emergency settings, providing quick relief and better outcomes for those suffering from this common ailment.

July has been a month of significant insights and developments in emergency medicine. From exploring game theory and its application in healthcare to understanding the complexities of PTSD and navigating the ethical dilemmas of epinephrine use in cardiac arrest, we’ve covered a wide range of topics.

These discussions underscore the dynamic and challenging nature of our field. By continually learning and adapting, we can improve our practices, support our colleagues, and ultimately provide better care for our patients.

Thank you for joining us on The Sintervenants Podcast. Keep an eye on our blog and podcast for more updates and insights. If you’re attending our events in October, we look forward to seeing you there. Until then, stay engaged, stay informed, and keep making a difference in the world of emergency medicine.

The Evolution of IV Fluid Therapy: A Critical Review

Welcome to St Emlyn's blog. Today, we explore the evolving landscape of intravenous (IV) fluid therapy in pediatric care. I'm Simon Carly, and I had the privilege of discussing this topic with Dr. Steve Playful at the Royal Manchester Children's Hospital. We delved into the historical context, current practices, and future directions of IV fluid therapy. Here's a comprehensive review of our discussion.

The use of IV fluids in pediatrics has undergone significant changes over the years. Approximately 20 years ago, the standard practice involved administering hypotonic fluids to children. This practice was rooted in research from the 1950s that misjudged children's electrolyte and fluid requirements, leading to widespread use of solutions like 0.18% saline with 5% glucose.

However, this approach had its drawbacks. While individual practitioners might not have frequently observed issues, numerous instances of iatrogenic hyponatremia leading to cerebral edema and death highlighted the risks. This spurred a reevaluation of IV fluid therapy practices in pediatrics.

By the late 1990s, concerns about the dangers of hypotonic solutions grew. In 2006, the National Patient Safety Agency in the UK formed a group to address these concerns. They concluded that most children could safely receive half-normal saline as maintenance fluid, except in high-risk situations, marking a significant shift from previous practices.

The pediatric community started adopting isotonic solutions, such as normal saline. However, normal saline (0.9% sodium chloride) presents its own issues. Despite its name, it is not truly "normal" as its sodium content is slightly higher than plasma levels, and its chloride content is about 60% higher. Moreover, the pH of normal saline is around 5.5, far from physiological levels.

Balanced solutions have emerged as a promising alternative to both hypotonic and isotonic solutions. Designed to more closely mimic the body's natural plasma, solutions like Ringer's lactate and Plasma-Lyte have gained popularity in the UK. These balanced solutions are buffered with substances like acetate or gluconate to maintain a more physiological pH.

Plasma-Lyte, for instance, is available with and without dextrose, making it versatile for different clinical scenarios. These solutions are typically better tolerated and associated with fewer complications compared to normal saline.

The debate over the optimal type of IV fluid for pediatric patients continues. Recent studies, including large international trials, suggest balanced solutions are associated with fewer complications than normal saline. These complications include hyperchloremia, which can lead to acute kidney injury and other adverse outcomes.

Despite these findings, normal saline remains the most commonly administered IV fluid worldwide. This persistence is largely due to tradition and established practices. Changing these deeply ingrained habits requires substantial evidence and updated clinical guidelines.

Several studies highlight the benefits of balanced solutions over normal saline. Research indicates that balanced solutions result in less acidosis and fewer chloride level shifts without demonstrated harm. However, not all studies show significant differences. The SPLIT trial, for instance, did not find a marked difference between the two fluid types, though this study had limitations, including uncontrolled pre-enrollment fluid administration and varying severities of illness among patients.

As we look ahead, several areas of interest in IV fluid therapy emerge. One key question is which balanced solution is optimal for pediatric patients. Current options include fluids buffered with acetate and gluconate versus those buffered with lactate. Further research is needed to compare these solutions directly.

Another potential development is the inclusion of bicarbonates in balanced solutions. Stabilizing bicarbonates in plastic containers has been challenging, but advances in technology may eventually make this possible, offering a more complete balanced solution.

For clinicians, the decision on which IV fluid to use should be guided by the latest evidence and tailored to the patient's needs. Here are some practical considerations and recommendations:

1. Review the Evidence: Stay informed about the latest research comparing saline and balanced solutions. Reflect on the pathophysiological basis for each type of fluid.

2. Consider the Patient's Condition: For most pediatric patients, balanced solutions are likely safer and more effective. However, specific clinical scenarios may require different approaches. For instance, patients with pyloric stenosis or certain nephrological conditions may benefit from tailored fluid compositions.

3. Monitor and Adjust: Fluid therapy should always be closely monitored and adjusted based on the patient's ongoing needs and responses. This includes considering electrolyte levels, acid-base balance, and overall clinical status.

4. Educate and Advocate: Part of the challenge in shifting to balanced solutions is overcoming established practices and resistance to change. Educate colleagues and advocate for evidence-based practices within your institution.

The evolution of IV fluid therapy in pediatrics mirrors broader trends in medical practice: the quest for safer, more effective treatments, and the need to challenge established norms with new evidence. While much remains to be learned, current evidence strongly supports the use of balanced solutions over traditional saline in most pediatric scenarios.

As clinicians, it's our responsibility to stay informed and adapt practices based on the best available evidence. By doing so, we can improve patient outcomes and advance the field of pediatric medicine.

For those interested in further reading, many of the studies discussed are blogged about on our site. Explore these resources for more detailed discussions and links to original research. Stay informed, stay curious, and continue striving for excellence in your practice.

Thank you for joining us on this deep dive into IV fluid therapy. We hope this discussion has provided valuable insights and practical recommendations for your clinical practice. As always, we welcome your thoughts and feedback on this important topic.

Welcome to the St Emlyn's podcast! Today, we're diving into the exciting and insightful experiences from recent conferences in the world of emergency medicine. Join us as we explore the key takeaways and reflections from the BadiM Conference in South Africa and the Resuscitology Conference in Australia. These events not only highlighted innovative approaches to emergency care but also fostered a sense of community and collaboration among healthcare professionals.

As is customary, let's start with a quick weather update. It was a pleasant 16 degrees in Verchester, and similarly, New South Wales enjoyed beautiful blue skies at 16 degrees. The crisp air and clear skies set a perfect backdrop for our discussions on the latest developments in emergency medicine.

The BadiM Conference in Greaten, South Africa, was a truly remarkable event. Located about two hours east of Cape Town, the conference was set in the picturesque hills, creating a beautiful and serene environment for learning and networking. This residential conference was a blend of a festival and a professional gathering, fostering a sense of community among attendees.

One of the standout aspects of the BadiM Conference was its emphasis on community and co-creation. Attendees camped in tents, shared meals, and engaged in discussions in large TP-style tents. This setting broke down traditional power hierarchies and encouraged open and honest conversations. The conference aimed to build a festival atmosphere where learning extended beyond formal sessions to informal interactions over coffee or drinks.

The conference kicked off with a focus on African EMS and the unique challenges faced in delivering emergency care in resource-limited settings. Haikert's talk on African solutions for African problems was particularly enlightening. She emphasized the importance of developing context-specific solutions rather than applying models from high-income countries directly to African contexts. This approach highlighted the need for mutual learning and collaboration, ensuring that solutions are relevant and sustainable.

A thought-provoking concept discussed was "relief porn," which refers to the well-intentioned but often misguided efforts of delivering aid without considering long-term sustainability. The idea is to avoid short-term fixes that may not integrate well into existing systems. Dave Drew's discussion on teaching BLS underscored the importance of building comprehensive systems rather than isolated interventions.

Nat Fertil's talk on the role of clinicians as advocates resonated deeply. Drawing parallels between working in a war zone and addressing complex health needs in urban settings, she emphasized the importance of standing by patients who cannot advocate for themselves. This advocacy extends beyond clinical care to addressing social determinants of health.

Caleb Lachnitz's talk on the Gender Unicorn and caring for LGBTQIA patients was a highlight. He stressed the need for healthcare providers to understand and respect diverse gender identities and expressions. The Gender Unicorn graphic, which differentiates between gender identity, gender expression, sex assignment at birth, and attraction, was a valuable tool in fostering better understanding and care for LGBTQIA patients.

The second day of the BadiM Conference was workshop-focused, providing hands-on learning opportunities.

We conducted a workshop on giving feedback in challenging situations. This session aimed to equip participants with skills to provide constructive feedback, even in difficult scenarios. We discussed techniques for addressing behavioral issues and ensuring feedback is productive and empowering.

Penny Wilson's talk on treating pregnant patients was reassuring, emphasizing that treating the mother is often in the best interest of the baby. Ross Fisher's engaging session on pediatric emergencies, specifically addressing foreskin issues, provided practical insights for managing these conditions in the emergency department.

A session on tracheostomy emergencies in children, led by James Booth and his team, highlighted the importance of patient education and family collaboration. In settings where community services may be limited, working closely with families is crucial to managing chronic health problems effectively.

Ophthalmology in remote settings and trauma care were also significant topics.

William Mapperman's presentation on using the Vula app for managing eye problems in remote areas showcased the power of electronic media in enhancing healthcare delivery. This app has significantly improved the quality of eye care across South Africa and other African nations.

Tim Hardcastle's discussion on chest trauma and the use of drains for autotransfusion was enlightening. This technique, which involves collecting and retransfusing blood from a hemothorax, is a practical solution in resource-limited settings with high rates of penetrating trauma.

Debates on managing coagulopathy and intubating profoundly shocked patients provided valuable insights. Emphasizing the importance of doing the basics well, such as using TXA and maintaining temperature, was a key takeaway. For intubation, using low doses of ketamine and high doses of rocuronium, along with preparing for cardiovascular collapse, were highlighted as best practices.

Human factors and emotional resilience were recurring themes throughout the conference.

Dom Pinnick's talk on gangs and domestic violence in South Africa shed light on the broader societal impact of violence. The discussion underscored the need for emergency departments to be prepared for the complex emotional and physical needs of these patients.

Natalie May's session on sleep hygiene was a timely reminder of the importance of self-care. Sharing personal experiences and practical tips, she highlighted the universal challenges of sleep deprivation in the medical profession and offered strategies to improve sleep quality.

Sardlery's talk on being a "super boss" resonated with many. Emphasizing the importance of amplifying the talents of team members and creating a positive environment, he highlighted the role of compassionate leadership in emergency medicine.

The final day of the BadiM Conference was a half-day, focusing on simulation workshops and additional learning opportunities.

Simulation workshops, including a major incident workshop, provided hands-on learning experiences. Discussions on managing major incidents, such as the Manchester bombing and a fuel tanker explosion in Mozambique, highlighted the importance of having a common language and system for emergency management.

A workshop on venomous plants and animals featuring actual snakes and spiders added a unique and context-specific element to the conference. Understanding local environmental hazards is crucial for providing effective emergency care in different regions.

Dave Thompson's session on organ donation in South Africa and Caroline Lewis's talk on working on cruise ships provided diverse perspectives on emergency medicine. These sessions emphasized the need for specialized skills and adaptability in various medical settings.

Kirsten Kingma's personal story of crashing a paraglider and subsequent injuries provided a poignant reminder of the vulnerability of healthcare providers as patients. Her insights into the patient experience underscored the importance of empathy and effective communication in healthcare.

The Resuscitology Conference, organized by Cliff Reed, was another standout event. Held in the Blue Mountains of Australia, this residential course focused on case-based reflective learning.

Participants brought challenging resuscitation cases, which were discussed in detail using the STEPS approach (Self, Team, Environment, Patient, System). This method facilitated deep learning and practical problem-solving.

The concept of "Friluftsliv" (fresh air life) was integrated into the conference, encouraging outdoor activities and wellness. This holistic approach to learning and self-care was well-received by participants.

One significant takeaway was the idea that breaking bad news does not always have to be the responsibility of the treating clinician. This team-based approach allows for emotional support and cognitive load sharing. The importance of debriefing and support for team leaders was also emphasized.

As we reflect on these enriching experiences, we're excited about upcoming events. The St Emlyn's Live Conference on October 9th promises to be another exceptional gathering, featuring keynote speakers Natalie May and Claire Richmond from Sydney HEMS. Additionally, the Teaching Co-op Course will offer a masterclass in medical education, focusing on practical skills for bedside teaching and departmental learning.

For those interested in Resuscitology, the next event is scheduled for November 15th and 16th. This innovative course will continue to build on the success of its inaugural session, providing a platform for reflective learning and collaboration.

While conferences can sometimes be seen as mere gatherings, the evolving quality and focus on interactive, participant-driven content have transformed them into valuable learning experiences. Events like BadiM and Resuscitology highlight the importance of community, collaboration, and continuous improvement in emergency medicine.

Thank you for joining us on this journey through the world of emergency medicine conferences. We hope to see you at future events, whether in Manchester or Sydney and continue to learn and grow together. Until then, enjoy your practice, stay curious, and keep pushing the boundaries of emergency care.

Welcome to the St Emlyn's blog, where we delve into the latest topics and developments in emergency medicine. Today, we explore a crucial yet often overlooked aspect of our field: acute psychiatric emergencies. This post summarizes a recent conversation between Simon Carley and Kevin McRey Jones, highlighting the significance of addressing psychiatric emergencies within emergency departments. We will shed light on the Apex course, its methodologies, and the vital need for integrating psychiatric care into emergency medicine.

Kevin McRey Jones, a key figure in emergency medicine, recently joined the St Emlyn's podcast to discuss the Apex course, an initiative designed to fill a significant gap in emergency medicine training. Despite considerable advancements in managing various medical emergencies, psychiatric emergencies often remain underemphasized.

The Apex course addresses this gap by focusing specifically on acute psychiatric emergencies. Kevin explained that while many advancements have been made in managing cardiac, trauma, and obstetric emergencies, psychiatry has not received the same systematic approach. This has led to a fragmented care model where physical and psychological components are often treated separately.

The Apex course, originating in 1992 with the Advanced Life Support Group, was created to systematize the training for managing acute psychiatric emergencies. Kevin, who has a long history of organizing and delivering courses in emergency medicine, emphasized the need for a unified approach to patient care. The course aims to bridge the gap between emergency physicians and psychiatrists, promoting a co-ownership model of patient management.

One major reason psychiatric emergencies have not received the same attention as other medical emergencies is the perception that these are problems best handled by psychiatrists or liaison nurses. This mindset leads to a tendency to pass psychiatric cases off to specialists rather than integrating psychiatric care into the emergency department's responsibilities.

Kevin highlighted a common issue where patients with both physical and psychological illnesses are often divided into two separate cases: the physical bit managed by emergency physicians and the psychological bit by psychiatrists. This division can lead to suboptimal care and poor outcomes, as the interconnected nature of these issues is overlooked.

Ignoring the psychiatric component of patient care can have severe consequences. Kevin pointed out that patients with psychiatric diseases often have poor outcomes regarding their physical health. This is largely because their physical ailments can be neglected due to the focus on their psychological issues.

Simon added that the outcomes for patients with psychiatric diseases, in terms of their physical health, are often terrible. This emphasizes the need for a more integrated approach to patient care, where both physical and psychological aspects are managed simultaneously.

Kevin stressed the importance of co-owning the problem rather than treating psychiatric emergencies as the sole responsibility of psychiatrists. By doing so, emergency departments can provide more comprehensive care, addressing both physical and psychological needs. This integrated approach is essential for improving patient outcomes and ensuring that all aspects of a patient's health are considered.

Simon discussed a common practice in emergency departments where patients presenting with apparent psychiatric problems are often assessed solely for physical issues before being referred to psychiatric specialists. This "clear them medically" approach can lead to delays in psychiatric care and inadequate management of the patient's overall condition.

Kevin acknowledged this issue and emphasized the need for emergency physicians to be involved in the psychiatric assessment and management of these patients. This approach ensures that all aspects of the patient's health are addressed, leading to better outcomes.

Simon reflected on the current practices and highlighted the need for change. The idea of dividing patient care into physical and psychological components, with little overlap, is increasingly seen as problematic. Kevin agreed, noting that sometimes organic problems can be overlooked when patients are quickly referred to psychiatric care without a thorough assessment.

The Apex course introduces the AIOU methodology, designed to integrate psychiatric and medical care seamlessly. This structured approach includes:

• A: Assessment of aggression and agitation.
• E: Environment in which the patient is assessed.
• I: Intent of the patient, including suicidal ideation or harm to others.
• O: Objects the patient may use to carry out their intent.
• U: Unified assessment, combining both physical and psychological evaluations.

Kevin explained that the AIOU methodology is a co-created approach by psychiatrists and emergency physicians. This collaboration ensures that both physical and psychological aspects of patient care are addressed. The methodology aligns with the primary assessment, resuscitation, and definitive care phases familiar to emergency physicians.

Rapid tranquilization is a common concern in managing psychiatric emergencies. Kevin emphasized that the goal is to use the minimum level of intervention required, whether that involves oral medication or, if necessary, safe rapid tranquilization. The course teaches a balanced approach to ensure patient safety and effective management.

Psychiatry is a risk-driven specialty, focusing on assessing risks of violence, flight, and harm to self and others. Kevin highlighted the importance of minimizing these risks through a structured, systematic approach. This methodology allows for a comprehensive evaluation and management plan that addresses both immediate and long-term risks.

The Apex course emphasizes a structured approach to both psychiatric and physical assessments. This dual-focus ensures that all aspects of a patient's health are considered, leading to more comprehensive and effective care.

The course promotes collaboration between psychiatrists and emergency physicians, encouraging them to learn from each other and develop joint solutions to patient care challenges. This partnership is essential for providing holistic care and improving patient outcomes.

The course highlights the importance of co-assessment and risk management. By working together, psychiatrists and emergency physicians can provide a more unified approach to patient care, addressing both physical and psychological needs simultaneously.

Substance abuse often complicates psychiatric emergencies. The Apex course takes a symptom-based approach, focusing on the specific challenges presented by patients with delirium, confusion, aggression, and self-harm. This approach allows for a more tailored and effective management plan.

Psychiatric emergencies are more common than many realize. Kevin noted that about 5% of patients in emergency departments present with direct psychological or psychiatric symptoms. Including substance abuse and alcohol-related cases, this number can rise significantly. Addressing these emergencies systematically is crucial for improving patient care and outcomes.

The Apex course represents a significant advancement in the training and management of acute psychiatric emergencies. By promoting a unified approach to patient care, it addresses a critical gap in emergency medicine. Collaboration between psychiatrists and emergency physicians is essential for providing comprehensive care and improving patient outcomes. For more information on the Apex course and upcoming training sessions, visit the Advanced Life Support Group's website.

Reflecting on the discussion, Simon emphasized the importance of integrating psychiatric care into emergency medicine. The dichotomy approach, where physical and psychological issues are treated separately, is increasingly seen as inadequate. The Apex course offers a pathway to more comprehensive, patient-focused care, ensuring that all aspects of a patient's health are addressed.

For those interested in learning more about the Apex course and upcoming training sessions, visit the Advanced Life Support Group's website at www.alsg.org. The course is offered in various locations, providing opportunities for emergency physicians and psychiatrists to enhance their skills and knowledge in managing acute psychiatric emergencies.

By embracing this integrated approach, we can ensure that patients receive the comprehensive care they need, improving outcomes and advancing the field of emergency medicine.

Welcome to the St. Emlyn’s podcast, your monthly source for insightful discussions and reviews from the world of emergency medicine. I’m Iain Beardsell, and alongside me is Simon Carley. In this edition, we're diving into the posts we’ve covered on our blog in April. After a grueling winter, we are finally catching up. We’re recording this in May, and it's a significant achievement for us. Let’s delve into the highlights and key takeaways from April.

Firstly, Simon and I are thrilled to be back on track. The sun is shining, signaling the end of winter here in the UK, and we’re embracing the spring warmth. Before we dive into the specifics, Simon, you’ve been traveling quite a bit recently. Can you share some of your experiences?

Simon: Indeed, Iain. Recently, I had the privilege of visiting Graz, Austria, a beautiful city where I was invited by the NordDoc and the Austrian Society of Emergency Medicine. We attended the ninth Congress, or as they say in German, "Abit's Goermanneshaft for Notfallmedizin." It was an enlightening experience, despite my initial challenges with the language.

The hospitality in Graz was exceptional, and the city itself is stunning. Emergency medicine in Austria is still in its nascent stages, but the enthusiasm and energy among the young physicians were palpable. The simultaneous translation during presentations was a unique experience. I also conducted sessions on feedback and ultrasound teaching, which were well-received.

Iain: That sounds incredible, Simon. It’s always inspiring to see how different countries are integrating emergency medicine into their healthcare systems. Let’s move on to the main topics we covered in April.

Iain: One of the key discussions in April was about feedback and coaching, a topic Simon presented in Austria. Feedback is crucial for continuous improvement in emergency medicine. Simon, can you elaborate on your main messages from the talk?

Simon: Absolutely, Iain. Feedback is essential for growth, and there are three main types: appreciation, coaching, and evaluation. One common issue is when these types are confused. For instance, after a challenging night shift, if a consultant gives a detailed coaching session instead of simple appreciation, it can be demoralizing. It’s crucial to match the feedback to the context and needs of the receiver. This ensures the feedback is purposeful and effective.

Rick's post from April 10th delved into the nuances of diagnostic tests, emphasizing that results are not merely positive or negative but often fall into a gray area. Simon, can you shed more light on this?

Simon: Diagnostic tests in emergency medicine are indeed complex. Take troponin levels, for instance. A troponin of 2000 is vastly different from a troponin of 15, although both might be labeled positive. Understanding the probabilistic nature of diagnostics is crucial. Rick's post does a fantastic job explaining this with examples, especially around acute coronary syndrome. We use a T-max calculator in Manchester to determine the likelihood of ACS based on various factors, including troponin levels. This probabilistic approach is vital for accurate diagnostics.

Another powerful post in April was Ashley Liebig's discussion with Noah Galway about their experiences during the Iraq war. Their insights provide a stark contrast to typical emergency department scenarios. Iain, what stood out to you in this post?

Iain: The personal bond formed between Ashley and Noah through shared traumatic experiences is profound. Unlike the typical patient-doctor dynamic in emergency departments, battlefield medicine creates a deep, enduring connection. This post reminded me that the emotional and psychological impacts of medicine are just as significant as the physical treatments. Noah’s journey, from experiencing trauma to achieving remarkable feats like participating in the US version of Strictly Ballroom, is truly inspiring.

We also discussed the use of whole-body CT in pediatric trauma patients. Simon, can you summarize the findings from this journal club article?

Simon: Certainly. Whole-body CT is a common practice in adult trauma but its utility in pediatric trauma is questionable. A multi-center cohort study from the National Trauma Data Bank in the US found that focused CT is often more appropriate for children. In Manchester, we rarely perform whole-body CTs on pediatric patients unless there's a significant mechanism of injury. The radiation risks and the lower incidence of severe injuries in children make focused CT a safer and more effective choice.

Dan Horner's professorial lecture on the complications of anticoagulation and how to manage them was another highlight. Simon, what were the key takeaways from Dan's talk?

Simon: The sheer number of patients on anticoagulants in the UK, approximately 660,000, underscores the importance of this topic. Bleeding is a significant risk, and managing it, especially with the newer DOACs, is challenging. Dan provided practical advice on handling bleeding complications, including when specific antidotes are unavailable. Understanding these risks and management strategies is crucial for emergency physicians.

In another significant event, I presented the top 10 trauma papers at the Trauma UK conference. This talk was later featured on the Resusary podcast with Simon Lang. It's always a pleasure to delve into the latest research and innovations in trauma care.

Iain: That sounds fantastic, Simon. For those interested, the blog post contains all the details and links to the podcast. If you have any suggestions or think we've missed some crucial papers, do let us know.

Zak Stein, who trained with us in Manchester and now works in Philadelphia, shared insights on penetrating trauma. Interestingly, patients arriving by police or private vehicle have higher survival rates compared to those transported by ambulance. Simon, what are your thoughts on this practice?

Simon: The practice in Philadelphia highlights the time-critical nature of penetrating trauma. Quick transport to the ED, even by police or private vehicle, can significantly improve survival rates. In the UK, scene times can be prolonged, especially if the scene is unsafe. This practice makes us reconsider our approach to time-critical conditions. It's a balance between ensuring safety and providing timely care.

Our final post in April was the launch of "The Resuscitationist’s Guide to Health and Wellbeing," a comprehensive resource compiled from our blog posts. Simon, this has been a significant project for you. Can you tell us more about it?

Simon: This book is part of our ongoing effort to promote wellbeing among emergency medicine professionals. It includes practical tips on managing night shifts, reflective pieces on coping with difficult situations, and much more. Wellbeing is one of the four pillars of St. Emlyn’s, along with the philosophy of emergency medicine, evidence-based medicine, and clinical excellence. We hope this book will be a valuable resource for our community. It’s available for free, so please read and share it widely.

April was a busy month for us at St. Emlyn’s, filled with travel, conferences, and insightful blog posts. We’re excited about what’s coming up in the future. We have a busy summer ahead, including the emergency surgical skills course with Caroline Leach in Manchester and our St. Emlyn’s live and teaching co-op course in October. Tickets are selling fast, so grab yours soon.

Before we sign off, a quick mention of the Bad E.M. Fest, which was a spectacular event. We’ll discuss it in more detail in future posts and podcasts. For now, you can read the four blog posts we’ve published about it so far.

Iain: It’s always fun to chat with you all. We hope everyone is enjoying the spring sunshine and looking forward to the summer. Simon, any final thoughts?

Simon: Just one, Iain. Are we the only emergency medicine podcast that talks about the weather at the beginning and end of every episode? It seems like the most British thing ever.

Iain: It's hugely important, Simon. Maybe next time, we’ll focus entirely on the weather! Until then, enjoy the sunshine and take care, everyone.

Thank you for joining us for this edition of the St. Emlyn’s podcast. Stay tuned for more insights and discussions, and don’t forget to check out our blog for the latest posts and updates.

Welcome to the Centeminine's podcast monthly roundup for March 2018! This post delves into key highlights from our blog, discussing critical topics in evidence-based medicine and sharing exciting upcoming events. Let's dive in!

As the harsh winter fades, we’re catching up with several important topics from March. Despite the seasonal lag, there's a lot happening in the world of evidence-based medicine. Our blog has been buzzing with insightful posts, and we encourage you to explore the rich content we have curated for you.

Before diving into March's blog posts, let's highlight some exciting events on the horizon. We are thrilled to announce St Emlyn's Live and the Teaching Course in Manchester. If you're planning your study leave for the next 12 months, these are opportunities you won't want to miss.

St Emlyn's Live is shaping up to be an unmissable event. Scheduled for October in Manchester, this event promises a blend of learning and fun, with the added bonus of Manchester's unique charm—where the sun always shines (psychologically and philosophically, if not literally). Check our website for more details and secure your spot. We’re putting immense effort into making this event exceptional, ensuring it’s worth both your time and money.

Alongside St Emlyn's Live, we have our renowned Teaching Course in Manchester. As you consider your professional development for the year, keep in mind the benefits of attending a well-structured, impactful course like ours. We're confident you'll find it a valuable investment in your career.

One of the standout topics in March has been the ongoing debate over IV fluids in critically ill patients. This subject stirs significant anxiety and diverse opinions across departments and even within the same hospital.

The crux of the debate revolves around whether to use normal saline or balanced fluids such as Hartmann's or Plasmalyte. The evidence to date has been mixed, leading to differing practices. Our colleagues down under published the SPLIT trial a few years ago, finding no significant difference, but the sample size at the time limited the conclusions.

Recently, two significant trials published in the New England Journal of Medicine have shed more light on this issue. These trials investigated the effects of balanced crystalloid versus saline in critically ill patients and emergency department patients admitted to the wards.

The trials used a cluster randomized design, where units were randomized to administer either balanced crystalloid (lactated Ringer's or Plasmalyte) or saline for a period before crossing over. With over 15,000 participants in each study, the findings are quite robust.

The trials revealed a small but significant difference in major kidney events in the critical care group (14.3% vs. 15.4%), suggesting a potential benefit of balanced fluids. While the mortality difference was not as pronounced, these results could have important implications for global intensive care practices.

As emergency physicians, how do these findings influence our practice? Over the past few years, there's been a shift towards more frequent use of balanced solutions, driven by a sound physiological rationale. Although the exact clinical significance of hyperchloremic acidosis from saline remains debated, the pathophysiological argument for balanced fluids is compelling.

In our practice, preferences vary. For instance, our neurointensive care unit favors saline for patients with specific neurological issues, as explained in a podcast with Dr. John Hell from Southampton. For general use, Hartmann's is often the go-to solution.

We emphasize the importance of fluids in emergency medicine to our new doctors. With only four main treatments—oxygen, analgesia, antibiotics, and fluids—it’s crucial to administer fluids effectively. While the choice of fluid might not be critical initially, ensuring the right volume is given can make a significant difference.

Another highlight from March was the successful teaching course in Cape Town. This course will be replicated later this year in Manchester, offering an excellent opportunity for hands-on learning and professional growth.

The Cape Town course was a resounding success, providing valuable insights and skills to all participants. The feedback was overwhelmingly positive, highlighting the course's effectiveness and the enriching experience it provided.

Chris Weymouth, a UK-trained physician, shared his experience working in a rural South African hospital. His story underscores the importance of structured and well-supported international placements. Such experiences not only enhance clinical skills but also foster personal growth and resilience.

Our final major topic for March revolves around predicting outcomes in cardiac arrest, specifically through pupil responses. This topic, close to our hearts, is critical for making informed decisions during resuscitations.

A recent study from France, analyzing over 11,000 cardiac arrests, examined whether early pupil responses could predict outcomes. The findings were intriguing but not definitive.

The study found that the absence of a pupillary light reflex is a poor prognostic sign, but with only 72% sensitivity and 68.8% specificity, it’s not conclusive enough to base critical decisions on.

Deciding when to stop resuscitation remains one of the most challenging aspects of emergency medicine. While some cases are clear-cut, many fall into a gray area, making it difficult to determine the right course of action.

With emerging technologies like ECPR (Extracorporeal Cardiopulmonary Resuscitation) and reports of remarkable recoveries from prolonged arrests, the decision to stop becomes even more complex. In young patients with no prior morbidity, the stakes are even higher, and the decision requires careful consideration and often consultation with colleagues.

As we wrap up our March roundup, we look forward to several upcoming events and ongoing discussions. The St Emlyn's team will be speaking at the Retrieval Conference in Scotland in April, and we have a variety of summer events lined up.

Don't forget to join us at St Emlyn's Live in October. This event promises to be a highlight of the year, offering a blend of cutting-edge medical insights and networking opportunities. Check our website for all the details and secure your spot today.

We'll be back in May with updates on April's posts and more engaging content. Until then, keep enjoying your emergency medicine practice, take care of yourselves and your patients, and stay connected with the St Emlyn's community.

March has been a month filled with significant developments in evidence-based medicine, exciting course announcements, and thought-provoking discussions. As always, our goal is to provide you with the best possible insights to enhance your practice and support your professional growth. Thank you for being part of the St Emlyn's community. We look forward to engaging with you through our blog, podcasts, and upcoming events.

The Physician Response Unit (PRU) is an innovative service in East London that takes the emergency department to the patient. The PRU is led by Tony Joy, consultant in emergency medicine and prehospital care and is a fairly unique service to the UK.

In this podcast our very own Richard Carden interviews Tony for an in depth understanding of how the service is supporting the entire emergency care system in London.

You can read more about the PRU here https://londonsairambulance.co.uk/our-service/news/2017/10/remodelled-pru-to-be-a-seven-day-service-for-the-first-time and look out for a blog post on the St Emlyn's blog site very soon.

Welcome to the St. Emlyn’s podcast blog! I’m Ian Beardsell, and alongside Simon Cully, we're here to bring you our monthly update. This post will delve into February's content, upcoming events, and the latest discussions in emergency medicine.

Winter has been relentless this year, and we're still feeling its impact. The influx of patients hasn't slowed down, and our departments are buzzing with activity. Up in Manchester, we continue to see a high volume of patients, while down south, the weather has been kinder, though no less busy. As a Yorkshireman, I can empathize with the challenges faced in the North. Hang in there, and let's get through these cold evenings together!

Before diving into February's posts, let's talk about the exciting events we have lined up. This October, we're hosting the St. Emlyn’s Live conference and the Teaching Course in Manchester.

The St. Emlyn’s Live conference is a one-day event focused on our philosophy's four pillars: clinical work, evidence-based medicine, wellbeing, and the philosophy of emergency medicine. With international speakers, this event promises to be an enriching experience for all attendees. Spaces are limited, so make sure to book your spot early via our website.

Following the conference, we have a three-day Teaching Course designed to develop you as an expert teacher in emergency medicine. This comprehensive course covers all aspects of teaching and is an excellent opportunity to enhance your skills. All bookings can be made through the St. Emlyn’s website.

February was a month rich with valuable insights and studies. Let's delve into some of the highlights:

One of the standout studies we reviewed in February focused on the use of intranasal ketamine and fentanyl for managing pain in children. Pain management in pediatric patients is always challenging, especially when IV access is difficult. Traditionally, we've used intranasal diamorphine, but there's been a shift towards using intranasal ketamine and fentanyl, particularly in the US.

This randomized controlled trial compared 1 mg/kg of intranasal ketamine against 1.5 mcg/kg of intranasal fentanyl in children aged 4 to 17 with suspected isolated extremity fractures. The primary outcome was pain reduction, and both drugs performed similarly in this regard.

The key takeaway was the difference in side effect profiles. Ketamine is known to cause dysphoria, vomiting, and dizziness, while fentanyl has fewer unpleasant side effects. Therefore, fentanyl emerged as the preferred choice not because of superior pain relief but due to its more favourable side effect profile.

The study underscores the importance of having a streamlined protocol for intranasal medications in emergency departments. While some departments might still use syringes, investing in mucosal atomizer devices can simplify administration and improve patient care.

We had a guest blog from Claire Bromley, a medical student working with us in Manchester. Claire shared her experiences and insights into why she chose emergency medicine as a career, despite the occasional negativity she faced from other specialties.

Claire's blog is an inspiring read for medical students considering a career in emergency medicine. She highlights the importance of engaging students in the department and ensuring they see the undifferentiated, unwell patients that characterize our specialty. Her experiences as a SMACC volunteer and her early involvement in FOAMed (Free Open Access Medical Education) are testaments to the value of early engagement and online education.

One of the significant challenges we face is balancing the educational needs of students with the operational demands of the department. However, investing time in student education is crucial. These students are our future colleagues, and their early exposure to emergency medicine can shape their career choices and prepare them for the challenges ahead.

A fascinating study we reviewed involved the use of isopropyl alcohol for nausea relief. The concept of sniffing alcohol swabs to alleviate nausea isn't new, but this study provided robust evidence supporting its effectiveness.

The randomized controlled trial compared the effects of isopropyl alcohol sniffing to oral ondansetron in adult patients presenting with nausea in the emergency department. The results were surprising: patients who sniffed isopropyl alcohol swabs reported greater relief from nausea than those who took ondansetron.

While the study's findings are promising, implementing this practice consistently in emergency departments can be challenging. Ensuring that alcohol swabs are readily available and that staff are trained to use them effectively is key. Additionally, clarifying whether a Patient Group Directive (PGD) is required for this intervention could streamline its adoption.

One of the lighter yet insightful pieces this month was a video from the 1970s showcasing a casualty department in Liverpool. Watching historical medical practices can be both amusing and educational, offering a perspective on how far we've come and what future generations might think of our current practices.

While humorous at times, the video also highlights the core principles of emergency medicine that remain unchanged. It reminds us of the importance of continuous learning and adaptation in our field.

As we look forward to the year ahead, we’re excited about the upcoming SMACC conference in Australia in 2019. Planning for study leave and participation in such international conferences is essential for continuous professional development. These events provide unparalleled opportunities for learning, networking, and sharing best practices.

February has been a month filled with valuable insights, studies, and preparations for future events. The emphasis on pain management in children, engaging medical students, and innovative approaches to nausea relief reflects our ongoing commitment to improving patient care and education in emergency medicine.

Welcome to the St. Emlyn's podcast. I'm Iain Beardsell, and I'm Simon Carley. We are delighted to be back with you after what can only be described as a rather tricky winter. The winter season has always been challenging for emergency departments across the UK, but this year felt especially relentless. In this blog post, we will reflect on the past few months, share key insights, and look forward to exciting events on the horizon, including the St. Emlyn's Live conference.

Down south in our emergency department, we have faced significant challenges. Iain shared his experiences: "We have been having a heck of a time. It has been a real struggle. I'm utterly exhausted, and it has only been in the last couple of weeks that it felt like we could breathe again." The situation has been similarly difficult up north. Simon echoed these sentiments: "It's been a bit grim up north, to be honest. This winter felt different, harder. The emergency departments in the UK have always had problems over winter, but it has felt more relentless this year."

We didn't have much of a summer to recuperate, and the winter was relentless day in and day out. Our department saw unprecedented pressure, with patient numbers pushing us to our limits. Interesting statistics from our department showed consecutive days of being over capacity, creating concerns about patient care and safety. Despite the exhaustion, we managed to maintain a high standard of care, with complaints remaining at normal levels and even receiving more compliments than usual.

Maintaining patient care while looking after ourselves has been a challenge. We have implemented various strategies to keep on track, from educational events to incredible clinical work. Reflecting on our achievements, Simon highlighted the importance of continuing education and maintaining healthcare standards even under pressure. "We have done some amazing things over the winter, and it is something we can be really proud of," he said.

The public's understanding of the pressures in the healthcare system has increased, although tolerance for the challenges faced remains limited. Political activity over the winter saw clinical leads writing to the Prime Minister, and emergency medicine frequently made the front pages of newspapers. However, recent events, such as the nerve agent attack in Salisbury, have shifted the focus away from A&E crowded corridors, providing some relief.

We have many exciting events coming up this year, including the highly anticipated St. Emlyn's Live conference. Scheduled for Tuesday, the 9th of October in Manchester, this one-day conference will bring us out from behind our microphones and keyboards to present live. The event promises to be hugely cost-effective, with an incredible lineup of speakers from around the world, including Claire Richmond from Sydney Hems, Natalie May, Salim Rezy from the US, and Kat Evans from South Africa.

We have designed St. Emlyn's Live to be an interactive conference, reflecting everything we aim for in our podcasts and blogs. The conference is priced at £150 for consultants, with discounts available for trainees, registrars, doctors in training, allied health professionals, nurses, and medical students. Given the limited venue size, we expect tickets to sell out quickly, so we encourage early booking.

For those looking for more in-depth learning, we are hosting a teaching course on the 10th and 11th of October, directly after the conference. This course focuses on practical education techniques, helping clinician educators improve their teaching skills. It has been highly acclaimed by previous participants, offering a transformative learning experience.

At St. Emlyn's, we value reflection and evidence-based practice. In January, we covered several important topics on our blog, including devastating brain injuries, dizzy patients, and the adrenal trial. Let's delve into these discussions and see what we can learn.

One of the critical topics we discussed was devastating brain injuries. Historically, decisions about the prognosis of patients with severe traumatic injuries or subarachnoid bleeds were often made too quickly, based on initial CT scans. However, recent guidance suggests that we should not make precipitous decisions about patient outcomes solely based on early imaging.

In summary, it's essential to give these patients at least 24 to 72 hours before making a prognosis. This allows time for clinical outcomes to become more apparent. In our hospital, we transfer these patients to neuro-intensive care and have a proactive organ donation program, ensuring patients and their families receive the care they deserve.

Another challenging area in emergency medicine is dealing with patients presenting with dizziness or vertigo. Differentiating between central causes, such as posterior circulation strokes, and peripheral causes can be difficult but crucial. We highlighted the importance of understanding the difference and utilizing tests like the HINTS exam to aid diagnosis.

As emergency physicians, we must continue to educate ourselves on these diagnostic tools. Utilizing resources like the St. Emlyn's blog, YouTube, and FOAMed can help us stay updated and improve patient care. It's essential to be comfortable revisiting and revising our knowledge to ensure accurate diagnoses and appropriate treatment plans.

Reflection is a powerful tool for lifelong learning and self-improvement. Despite recent controversies, such as the case involving a junior doctor in Leicester, we must not abandon reflection. It helps us increase self-awareness, think critically about our practices, and improve our clinical skills.

Natalie May's blog post on reflection emphasizes that it's not just about ticking boxes but about purposeful and structured thinking. Her insights from Sydney Hems highlight the importance of integrating reflection into our daily practice to enhance our growth as clinicians.

The adrenal trial, reviewed by Dan Horner, examined the use of steroids in septic shock. Published in the New England Journal of Medicine, this trial aimed to determine whether steroids improve outcomes in these patients. The results showed no significant difference in mortality, although some secondary outcomes, such as vasopressor use and ICU days, showed variations.

The trial highlights the complexity of medical treatment and the need for continuous learning and evaluation. It reminds us that while some treatments may show promise, their benefits might not always be clear-cut. This underscores the importance of evidence-based practice and staying informed about the latest research.

Emergency medicine is a dynamic and ever-evolving field. At St. Emlyn's, we are committed to continuous learning, sharing knowledge, and improving patient care. The challenges of winter have tested our resilience, but they have also shown the importance of collaboration, education, and maintaining high standards of care.

We encourage our readers and listeners to stay engaged with our content, participate in upcoming events, and continue striving for excellence in their practice. The St. Emlyn's Live conference and the teaching course are excellent opportunities for professional development and networking with peers from around the world.

As we move forward into the spring and summer, let's take a moment to reflect on the lessons learned and the progress made. The past winter was tough, but it also demonstrated our ability to adapt, innovate, and support one another. With exciting events like St. Emlyn's Live on the horizon, we have much to look forward to.

Thank you for being part of the St. Emlyn's community. Stay connected, stay curious, and let's continue to learn and grow together. Here's to a bright and hopeful future in emergency medicine.

The Importance and Practice of Debriefing in Emergency and Critical Care

Debriefing is a crucial process in healthcare settings, particularly in emergency and critical care units. It involves structured discussions following critical events to help teams learn from their experiences and support each other's psychological well-being. This process is not just about operational reflection but also about addressing the emotional impact of challenging situations on healthcare professionals.

Debriefing can take two primary forms: hot debriefs and formal debriefs. Hot debriefs occur immediately after an event and focus on operational aspects, such as what happened, what went well, and what could be improved. They are concise and do not delve into the psychological aspects of the incident. These debriefs are valuable for capturing immediate lessons and determining if further, more comprehensive discussions are necessary.

Formal debriefs, on the other hand, are conducted five to seven days post-event. This delay allows participants to process initial emotions, making it a more suitable time for in-depth discussions. Formal debriefs cover both operational details and psychological reactions, providing a safe space for staff to express their feelings and thoughts. They are essential for long-term learning and emotional healing, ensuring that the team can move forward positively.

The timing of debriefing is critical. While hot debriefs capture immediate reflections, formal debriefs should not be rushed. Conducting them too soon can be ineffective, as participants might still be too emotionally charged to engage constructively. In our hospital, formal debriefs are usually organized when an event causes significant distress among the staff, whether due to a clinical situation, a tragic incident involving a colleague, or a complex ethical dilemma.

The setting for a debrief should be carefully chosen to ensure a conducive environment for open communication. We often use teaching rooms, which are formal enough to maintain the seriousness of the discussion but comfortable and private enough to encourage honesty and confidentiality.

Selecting the right facilitators is crucial for a successful debrief. Typically, a social worker, like Liz, and a senior medical consultant co-facilitate. The consultant provides a comprehensive overview of the clinical aspects, while the social worker manages the psychological and emotional discussions. This balance ensures that all relevant facets of the event are covered.

A formal debrief generally follows a structured format:

1. Introduction and Ground Rules: The facilitator sets the stage by explaining the purpose of the debrief and establishing ground rules, such as maintaining confidentiality and focusing on constructive feedback.

2. Narrative of the Event: A detailed recount of the incident is provided, clarifying what happened and why certain decisions were made. This helps participants understand the context and avoid misunderstandings.

3. Operational Discussion: The team discusses the operational aspects, identifying what was done well and what could be improved. This is critical for learning and improving future responses.

4. Emotional and Psychological Impact: Participants share their emotional reactions, providing a space for acknowledging the psychological effects of the event. This aspect of debriefing is vital for team support and individual well-being.

5. Closing and Follow-Up: The debrief concludes with a summary and any agreed-upon actions. Facilitators also provide information on additional support resources, if necessary.

Debriefing can be challenging, especially in navigating sensitive topics or when there are conflicting opinions. It's essential to create a safe space where all participants feel comfortable sharing. Facilitators must manage the discussion to ensure that dominant personalities do not overshadow quieter voices, encouraging everyone to contribute.

In some cases, separate debriefs for different groups involved in the event—such as pre-hospital staff, nurses, and doctors—may be necessary. This approach ensures that discussions are relevant to each group's experiences and prevents unnecessary exposure to distressing details that may not be directly applicable.

Debriefing should not be limited to negative or critical incidents. Regularly debriefing both positive and challenging events fosters a culture of continuous improvement and support. It helps normalize the practice, making it an integral part of the workplace rather than an extraordinary event.

It's important to recognize that not all staff may want to participate in debriefings, and that’s acceptable. Debriefing should always be voluntary, with alternative support mechanisms available for those who need them.

The long-term benefits of debriefing are substantial. It helps prevent burnout by providing a space for staff to process their experiences, supports continuous learning, and improves patient care outcomes. A well-implemented debriefing process can enhance team cohesion, reduce staff turnover, and foster a positive workplace culture.

Debriefing is a vital component of healthcare practice in emergency and critical care settings. It provides a structured approach to reflect on critical events, offering both operational and psychological support to healthcare teams. While it requires time and effort, the benefits for staff well-being and patient care are invaluable.

We encourage healthcare professionals to integrate regular debriefing into their practices, not just for critical incidents but as a routine part of their work. This approach helps build a resilient and supportive workplace culture, where staff feel valued and heard. Sharing experiences and learning from each other strengthens the team and ultimately leads to better care for patients.

We invite you to share your experiences with debriefing in your hospital. What strategies have worked well? What challenges have you encountered? Connect with us through the St. Emlyn's blog or Twitter, and let's continue the conversation about improving our practices and supporting each other in this challenging yet rewarding field of healthcare. Stay tuned for more insights from St. Emlyn's as we explore the complexities of working in emergency and critical care. Until next time, take care and keep supporting each other.

In the St Emlyn's podcast, hosts Simon Carley and Rick Bodey explore the crucial aspects of diagnostic test accuracy studies, particularly relevant for emergency medicine. This discussion revolves around the PICTR framework, a tool for structuring research questions and critical appraisals in diagnostic studies. PICTR stands for Patient group, Index test, Comparator, Target condition, and Reference standard.

The patient group is the specific population in which the diagnostic test is evaluated. It's essential to select a relevant group to ensure the study's findings are applicable to real-world settings. For example, a cardiac marker tested in a specialized cardiology clinic may not perform identically in the diverse environment of an emergency department. In practice, the patient group should include all individuals who present with symptoms indicative of the condition the test aims to diagnose, providing a broad and pragmatic study population.

The index test is the new diagnostic tool being evaluated. Key factors include how and when the test is applied, the conditions under which it is used, and the training of the clinicians administering it. For example, if evaluating a new troponin test, the timing of sample collection and the level of operator training are crucial, as these can significantly influence the test's accuracy and reliability. Understanding these details ensures that the study results can be replicated in different clinical settings and with various levels of clinician expertise.

The comparator is an existing diagnostic test or standard used to measure the new test's effectiveness. This comparison helps determine whether the new test offers improvements over current practices. For instance, when comparing a new scoring system for assessing chest pain against the TIMI risk score, researchers can evaluate which method more accurately identifies patients at risk for acute coronary syndromes. However, not all studies include a comparator, especially if the new test is intended to replace an existing standard entirely.

The target condition refers to the specific illness or condition that the test aims to diagnose. Defining this condition involves setting clinical criteria or thresholds. For example, the criteria for diagnosing myocardial infarction have evolved with advancements in biomarker sensitivity, such as the use of high-sensitivity troponins. A meaningful target condition is one that impacts clinical decision-making and patient management, ensuring that the diagnosis leads to actionable insights that improve patient outcomes.

The reference standard, often called the "gold standard," is the most accurate method available for confirming whether a patient has the target condition. It serves as the benchmark against which the new diagnostic test is measured. However, reference standards can have limitations, such as false negatives or positives. For example, while a CT pulmonary angiogram (CTPA) is a common reference standard for diagnosing pulmonary embolism, it is not perfect. In some cases, a new test may outperform the reference standard, highlighting the need for careful interpretation of study results.

Applying the reference standard uniformly across all patients can be challenging, especially when the standard is invasive or carries risks. For example, diagnosing subarachnoid hemorrhage typically involves a CT scan followed by a lumbar puncture. However, not all patients may undergo these procedures due to their invasive nature. In such cases, researchers may use follow-up data as a proxy, assuming that if no adverse outcomes occur during the follow-up period, the patient likely did not have the target condition.

This approach helps mitigate the ethical concerns and practical challenges associated with applying invasive reference standards to all study participants. It also highlights the importance of being pragmatic when appraising diagnostic studies, focusing on the clinical relevance and applicability of the findings rather than striving for methodological perfection.

Critical appraisal of diagnostic studies involves evaluating the study's design, including the selection of the patient group, the application of the index test, and the choice of the reference standard. Researchers and clinicians must also consider the study's limitations, such as potential biases or the imperfect nature of the reference standard. These factors can affect the study's conclusions and their relevance to clinical practice.

Understanding and applying the PICTR framework helps ensure that diagnostic studies are comprehensive and provide valuable insights for clinical decision-making. It allows for better evaluation of new diagnostic tools, ensuring they are safe, effective, and applicable in real-world clinical settings.

The PICTR framework provides a structured approach to designing and evaluating diagnostic test accuracy studies. By focusing on patient groups, index tests, comparators, target conditions, and reference standards, researchers can produce more accurate and clinically useful results. This approach is crucial in emergency medicine, where timely and accurate diagnoses can significantly impact patient outcomes.

For clinicians, mastering the principles of PICTR enhances the ability to critically appraise research and make informed decisions about the implementation of new diagnostic tests. As diagnostic technologies continue to evolve, the importance of robust, evidence-based assessments will only grow, ensuring high-quality patient care and optimal use of healthcare resources.

Understanding Devastating Brain Injury: Key Insights and Guidelines

In a recent episode of the St Emlyn's podcast, Simon Carley hosted experts Dan Harvey and Mark Wilson to discuss the intricacies of managing devastating brain injury (DBI). The conversation covered new guidelines, the challenges in prognostication, ethical considerations, and practical approaches in clinical settings. This blog post provides a comprehensive summary of their insights, focusing on the importance of standardized care, ethical decision-making, and the role of family involvement.

Devastating brain injury encompasses severe brain damage that often leads to significant long-term impairment or death. These injuries can result from various causes, including trauma, subarachnoid hemorrhage, hypoxic brain injury, and intracerebral hematomas. The term "devastating" highlights the severity of these injuries, but as discussed, the perception of devastation can vary, complicating management and prognostication.

One of the core issues in managing DBI is the variability in clinical practice across different healthcare settings. This inconsistency can lead to different outcomes depending on where the patient is treated. Dan Harvey emphasized that the new guidelines aim to standardize care, providing a consistent approach regardless of location. The guidelines recommend an observation period of up to 72 hours to gather comprehensive clinical data, crucial for making informed decisions.

Mark Wilson highlighted the difficulty in early prognostication, noting that initial presentations can be misleading. Factors such as intoxication, medication effects, or pre-existing conditions can obscure the true extent of brain injury. The term "perceived devastating brain injury" underscores the subjective nature of these assessments, stressing that what appears catastrophic on imaging may not always align with clinical outcomes.

Radiological findings, while essential, must be interpreted alongside clinical assessments. A severe CT scan may not always correlate with poor clinical outcomes, and vice versa. The discussion stressed the importance of not rushing to judgment based solely on initial imaging or clinical presentation. Recent studies, including those by Hanni Marcus and Mark Wilson, have shown that some patients with poor prognostic indicators can recover better than expected, particularly those with extra-axial hematomas.

Ethical considerations are paramount in managing DBI. The definition of a "good recovery" can vary widely among patients and families. For example, elderly patients with significant impairments may still value life, even with extensive care needs. The guidelines emphasize the importance of involving families in discussions about prognosis and treatment, ensuring decisions align with the patient's values and preferences.

Understanding the patient's and family's perspectives is crucial in determining the appropriate course of action. This holistic approach ensures that care decisions are not only medically sound but also ethically and personally appropriate. The discussion also highlighted the need for clear communication, helping families navigate complex and emotionally charged situations.

The guidelines advocate for a period of observation to avoid hasty decisions based on incomplete information. This period, typically up to 72 hours, allows for the identification and management of reversible factors, collection of comprehensive medical history, and better communication with the family. The aim is to reduce the risk of prematurely withdrawing life-sustaining treatment.

Determining the level of care for DBI patients involves deciding whether to transfer them to neurocritical care units or manage them in general ICUs. While specialized care offers advanced interventions like intracranial pressure (ICP) monitoring, evidence does not conclusively show that these measures always improve outcomes. The discussion acknowledged the limitations of resources and the importance of considering logistical factors, such as proximity to the patient's family.

The guidelines encourage clinicians to make informed decisions based on available evidence and specific case circumstances. They stress that not all DBI patients require transfer to specialized centers, especially when prognosis remains uncertain. The focus should be on providing essential life-saving therapies and monitoring the patient's condition.

When recovery is deemed unlikely, transitioning to palliative care becomes a compassionate and appropriate choice. The guidelines stress the importance of clear communication with the family, ensuring they understand the prognosis and rationale behind limiting or withdrawing aggressive treatment. Palliative care focuses on symptom management, comfort, and supporting the patient and family, addressing not only physical but also emotional and psychological needs.

Organ donation is an important consideration for DBI patients when the prognosis is poor. The guidelines recommend discussing this option with the family as part of end-of-life care planning. These discussions should be handled sensitively, providing clear information and respecting the family's wishes. Organ donation can provide hope and purpose in the face of tragedy, potentially saving other lives.

The St Emlyn's podcast episode on devastating brain injury provides crucial insights into the complexities of managing this challenging condition. The newly published guidelines offer a structured approach, emphasizing comprehensive assessment, ethical considerations, and family involvement.

Key Takeaways:

1. Standardize Practice: Reduce variability in DBI management by adhering to standardized guidelines, ensuring consistent and high-quality care.

2. Comprehensive Assessment: Utilize both clinical and radiological assessments to inform prognosis. Avoid premature conclusions based on incomplete data.

3. Ethical and Family Considerations: Engage with families to align treatment decisions with the patient's values and wishes. Provide clear, compassionate communication throughout the process.

4. Observation Period: Allow an appropriate observation period to clarify the patient's condition and potential for recovery.

5. Palliative Care: Transition to palliative care when necessary, prioritizing patient comfort and dignity.

6. Organ Donation: Discuss organ donation as part of end-of-life planning, handling these conversations with care and respect.

By following these guidelines, healthcare professionals can navigate the complexities of managing DBI with greater confidence and compassion, ultimately improving patient outcomes and supporting families through challenging times. For more detailed information and resources, visit the St Emlyn's blog and stay updated with the latest in emergency and critical care.

Introduction

In the latest Sentiment podcast, Simon Carly and Natalie May review the December highlights from St Emlyn's and provide a preview of exciting upcoming events in 2018. The month featured a range of content, including clinical insights, wellbeing initiatives, and journal club discussions, while the upcoming year promises numerous educational opportunities.

1. Insights from the Intensive Care Society Meeting

Dan Horner attended the Intensive Care Society meeting in Liverpool, where Paul Young from New Zealand emphasized the scarcity of high-quality evidence for many intensive care interventions. He urged practitioners to critically evaluate the evidence behind their practices. Another notable topic was contrast-induced nephropathy (CIN), with debates on its clinical significance. This post is essential for those in intensive care, providing a thorough overview of the current challenges and evolving practices in the field.

2. Updated Guidelines for Managing Paracetamol Overdose

A significant update discussed new guidelines for handling accidental therapeutic excess of paracetamol. The new approach moves away from automatic hospitalization, advocating for a more measured response based on clinical assessments and specific blood test results, such as INR and liver function tests. This shift is crucial for emergency medicine practitioners, helping to avoid unnecessary hospital admissions and focus resources on patients who need them most.

3. The ED Wellness Spa Initiative

Laura highlighted the innovative ED Wellness Spa initiative in Manchester, designed to support clinician wellness. The spa provides a dedicated space in the ED for staff to relax and rejuvenate, featuring elements like a gratitude tree and wall, wellness literature, and mindfulness tools. It also includes team-building activities, such as raft building, aimed at fostering a supportive and cohesive team environment. This initiative is a pioneering effort to address healthcare provider burnout, promoting a holistic approach to staff well-being.

4. Pain Management in Minor Trauma

Gareth reviewed a study from the Annals of Emergency Medicine comparing the effectiveness of paracetamol, NSAIDs, and their combination in treating minor musculoskeletal trauma. The study found no significant difference in pain relief among the groups, suggesting paracetamol alone is sufficient. This challenges the routine use of combination therapies and supports a simpler, safer approach to pain management in emergency settings.

5. The Marcy Pan Guidelines on Anorexia Management

Vicki Vella discussed the Marcy Pan guidelines for managing severe anorexia, emphasizing the condition's high mortality rate and the need for careful clinical management. The guidelines include the use of the SUSS (Sit-Up Squat Stand) test to assess physical health and identify critical cases. Vicki also highlighted the issue of diabulimia, where individuals with type 1 diabetes manipulate insulin to lose weight, underscoring the importance of screening for eating disorders in these patients.

1. Teaching Cooperative Course in Cape Town

The year kicks off with the Teaching Cooperative Course in Cape Town from March 20-21. This course aims to transform medical education by moving away from traditional lectures to interactive, hands-on learning experiences. It is an excellent opportunity for educators to refine their teaching methods and engage more effectively with students.

2. BAD-EM Fest and St. Emlyn's Live

Following the Cape Town course, the BAD-EM Fest will be held from March 22-25, offering a unique blend of academic and creative sessions. Later in the year, St. Emlyn's Live will return to Manchester on October 9, providing another chance for professionals to delve into critical topics in emergency medicine.

3. FIX Courses in New York

The FIX (FemInEM Ideas eXchange) conference, set for October 17-18 in New York, focuses on gender equity in emergency medicine. The event features diverse speakers and workshops aimed at promoting inclusivity and equity in the medical profession. It's a must-attend for those committed to fostering a more equitable work environment.

4. RISUS Litology Course in New South Wales

In New South Wales, the RISUS Litology course will offer advanced training in resuscitation. The course, featuring experts like Cliff Reed and Karl Harbig, will focus on high-quality, evidence-based techniques through case-based discussions. This event is ideal for advanced practitioners seeking to deepen their knowledge and skills in resuscitation.

The St. Emlyn's team expresses gratitude to its community for their continued engagement and support. While not everyone can attend these conferences, the team remains committed to sharing key learnings through their blog and podcast, ensuring that valuable knowledge is accessible to all. The upcoming year promises further opportunities for learning and professional growth, fostering a global community of compassionate and informed emergency medicine professionals.

As the St. Emlyn's community looks forward to 2018, the team is excited to continue offering high-quality content and engaging with healthcare professionals worldwide. Here's to another year of growth, learning, and sharing in the vibrant field of emergency medicine.

Natalie and Simon discuss reflections, e-books and life at Sydney HEMS. This week we have added Lorikeets in the background (Nat recorded at Coogee Bay in NSW). We think they sound cute so we've kept them in (or rather we could not edit them out).

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Reflections from November: Key Discussions on Triage, TXA, and Challenges in the ED

In November, the St. Emlyns team, led by Natalie May and Simon Carley, explored a variety of critical topics in emergency medicine. These ranged from the complexities of triage in emergency departments to the debated use of tranexamic acid (TXA) and the daily challenges faced by ED professionals. This post encapsulates the key discussions, insights, and upcoming events that shape our understanding and practice in emergency medicine.

Laura’s post on triage revisited its historical origins, particularly Dominique Jean-Larry's battlefield practices. Traditionally, triage involves categorizing patients by the severity of their conditions. However, Laura emphasized a crucial, often overlooked aspect: prioritizing patients based on actionable interventions. This approach challenges us to consider not just the severity of conditions but the potential impact of timely treatments.

This nuanced perspective is particularly relevant in pediatric trauma triage, where no existing tools perfectly balance sensitivity and specificity. The discussion raised an essential question: In major incidents, should we prioritize resources for patients with severe but untreatable injuries, or those with treatable conditions at risk of deterioration?

The post also addressed the unrealistic diagnostic expectations placed on triage systems. For example, can triage systems accurately distinguish between a tension pneumothorax and a panic attack? This issue highlights the importance of understanding the specific purposes for which triage tools are designed. For instance, the Manchester Triage System (MTS) was not intended to predict ICU admissions or sepsis but to prioritize immediate care needs.

A significant debate in emergency medicine revolves around the management of patients without ST-segment elevation myocardial infarction (NSTEMI) after out-of-hospital cardiac arrest. A meta-analysis reviewed whether these patients should be directly taken to the cath lab. While findings indicated a potential reduction in mortality, the decision to proceed with angiography must be nuanced.

Simon Carley noted that not all patients benefit from immediate cath lab access, especially when the issue might be electrical rather than structural. In Sydney, the two-tier trial leans towards early cath lab interventions, even prioritizing them over initial CT scans in suspected subarachnoid hemorrhage cases. This proactive stance contrasts with more conservative approaches in other regions, highlighting the importance of tailored patient care.

The discussion emphasized the need for collaboration with cardiologists to determine the best course of action based on the patient's clinical presentation and suspected pathology. This careful selection process ensures that patients receive appropriate and potentially life-saving interventions.

The use of tranexamic acid (TXA) in trauma care remains a critical topic. A recent reanalysis of TXA trials underscored that earlier administration is linked to better outcomes, particularly in reducing mortality due to bleeding. The CRASH-2 trial supports the early use of TXA, particularly within three hours of injury, for its anti-fibrinolytic effects.

However, concerns about "mission creep"—where TXA is administered to all trauma patients regardless of bleeding risk—were raised. The St. Emlyns team advocates for a more selective approach, administering TXA primarily to patients likely to require blood transfusions. This strategy not only aligns with evidence-based practices but also prevents unnecessary treatment and optimizes resource use.

Janos Baynham addressed the increasing pressures in emergency departments, highlighting how growing patient numbers and resource constraints strain healthcare professionals. Janos offered practical tips to improve morale and resilience, including maintaining a positive attitude, expressing gratitude, and supporting colleagues.

Open communication about the stresses and challenges of the job is vital. Creating a supportive environment where team members can share their experiences helps mitigate burnout and fosters a more cohesive work culture. Janos emphasized that small actions, like saying thank you and acknowledging hard work, can significantly boost team morale.

This discussion serves as a reminder that while the demands of emergency medicine are high, there are practical ways to manage stress and support each other. Recognizing and addressing these challenges is crucial for maintaining a healthy and effective workforce in the ED.

Gareth Roberts highlighted the importance of routine HIV screening in emergency departments, especially in areas with high HIV prevalence. EDs often serve as the primary healthcare contact for at-risk populations, such as young men who may not regularly visit other healthcare providers.

Routine HIV screening in the ED can identify undiagnosed cases, facilitating early treatment and reducing transmission risks. This proactive approach also helps normalize HIV testing, reducing stigma and encouraging more people to learn their status. By integrating HIV screening into routine care, EDs can play a crucial role in public health efforts to control the spread of the virus.

The blog also discussed exciting upcoming events, such as the BadEM Fest in Cape Town and the teaching cooperative, formerly known as the teaching course. These events promise immersive learning experiences, focusing on community and shared knowledge.

BadEM Fest, in particular, offers a unique format that emphasizes participatory learning and co-creation. Attendees engage in discussions, workshops, and shared storytelling, enriching their professional knowledge and skills. This type of conference represents a shift towards more interactive and inclusive professional development opportunities, fostering deeper connections and practical learning.

November’s reflections highlight the multifaceted nature of emergency medicine, from complex clinical decisions to the everyday challenges of working in a high-pressure environment. Whether it's refining triage processes, debating the best use of TXA, or addressing public health issues like HIV, the St. Emlyns team continues to explore critical topics that impact our practice and patient care.

As we move into December, staying connected and engaged with these discussions is essential. The upcoming events offer further opportunities for professional growth and learning. Thank you for joining us on this journey through November’s highlights. Stay tuned for more updates and insights from the St. Emlyns team, and continue to thrive in the ever-challenging world of emergency medicine.

A quick summary on how you can use group messaging systems in a major incident. A vast improvement on telephone cascades BUT you have to set this up in advance. If you make it up on the day it will be a disaster. Here's the tips and tricks from the Virchester team. You can read more here http://stemlynsblog.org/tag/whatsapp/

Navigating the Landscape of Emergency Medicine: Insights from St. Emlyn's

Welcome to St. Emlyn's, your go-to resource for the latest in emergency medicine. Our recent discussions cover a range of topics, from evolving communication strategies in major incidents to the nuances of managing chronic health issues among healthcare professionals. Let's dive into key insights and updates from our blog and the recent College of Emergency Medicine conference.

Traditionally, emergency departments relied on landlines and telephone trees for major incident alerts. However, modern digital tools like WhatsApp, Facebook, and Twitter offer more efficient solutions. Inspired by incidents like the Manchester bombing, our recent blog post details how to set up a robust communication system using WhatsApp. This involves configuring specific alert tones and ensuring confidentiality, providing a quick and reliable way to mobilize staff during crises.

Clot management, especially in the context of immobilization, remains a critical area of study. Dan Horner's work, including the Tilly study, explores whether prophylactic low molecular weight heparins should be used for patients with injuries like Achilles tendon ruptures. Current guidelines suggest a nuanced approach, advocating for patient-specific discussions based on individual risk factors for DVT. This research highlights the importance of personalized treatment and continuous guideline updates.

The management of superficial vein thrombosis (SVT) has been another focus. Using ultrasound, as Dan Horner suggests, can help assess the extent of SVTs and determine the need for anticoagulation, particularly when SVTs are near the saphenofemoral junction. This approach ensures comprehensive care and prevents complications from missed DVT diagnoses.

Our collaboration with UK physicians working in South Africa provides a global perspective on emergency medicine. Despite resource limitations, the dedication to delivering quality care remains consistent across continents. This exchange of knowledge reinforces the universal principles of emergency medicine, emphasizing adaptability and resourcefulness.

A guest post by Harriet, a Manchester-based emergency physician with rheumatoid arthritis, offers insights into managing chronic health issues while working in emergency medicine. Harriet's story highlights the physical demands of the job and the need for supportive workplace practices. It encourages a more inclusive approach, ensuring that all healthcare professionals can perform at their best, regardless of health challenges.

Evidence-based medicine is at the heart of St. Emlyn's, and the DETO2X-AMI study has sparked significant discussion. This study suggests that supplemental oxygen may not always benefit patients with acute coronary syndromes, particularly those with normal oxygen saturation levels. This finding prompts a more tailored approach to patient care, aligning treatments with the latest evidence.

Cardiac myosin-binding protein C has emerged as a promising new marker for early myocardial infarction diagnosis. However, Rick Body cautions that despite its potential, the transition from research to clinical practice involves numerous hurdles. The practical application of new biomarkers requires rigorous testing and regulatory approval.

Chris Gray's exploration of tetanus management emphasizes the need for accurate administration of vaccinations and immunoglobulin. Despite being a well-known disease, misunderstandings about treatment protocols persist. Chris's post clarifies who needs boosters and who requires immunoglobulin, ensuring patients receive appropriate care.

Zafira Kasim’s insights from the AAST meeting highlight critical lessons from mass casualty incidents like the Florida nightclub shooting and the Boston bombings. These experiences underline the importance of preparedness and the continuous updating of major incident protocols. The blog post provides practical strategies for refining emergency response plans.

The recent College of Emergency Medicine conference in Liverpool provided a comprehensive overview of the state of the specialty in the UK. Despite challenges like burnout and systemic pressures, the conference showcased a resilient and dedicated community. Presentations highlighted the importance of mental health, resilience, and compassion in maintaining quality care. Caroline Leach’s discussion on compassion underscored the emotional journey of healthcare professionals and the need for empathy in the workplace.

The conference also stressed the importance of increasing academic involvement in emergency medicine. The UK currently has a low number of emergency medicine professors compared to other specialties. There is a strong call to foster the next generation of academic leaders, with initiatives like new NIH positions offering opportunities for growth.

As winter approaches, emergency departments anticipate increased patient volumes and complexity. At St. Emlyn's, we emphasize resilience and preparedness, supporting healthcare professionals through these demanding times. Our aim is to provide resources and knowledge to enhance patient care and professional satisfaction.

St. Emlyn's remains committed to keeping you informed and passionate about emergency medicine. Our upcoming podcast project will further engage and update you on the latest developments. We encourage you to explore our blog for the most recent posts, research findings, and expert opinions.

In conclusion, the field of emergency medicine is both challenging and rewarding. At St. Emlyn's, we are proud to contribute to this dynamic community, supporting the ongoing professional development of our colleagues. As we navigate the complexities of modern healthcare, we remain dedicated to providing the best possible care for our patients and ensuring the well-being of our medical community. Stay connected with us for continuous updates and insights into the ever-evolving world of emergency medicine.

Hello, and welcome to the St. Emlyn's podcast. I'm Simon Carley, and today, I'm sharing insights from a fascinating experience at the Emergency Medicine Society of South Africa (EMSSA) conference in Sunsetty, Johannesburg. The vibrant city became a backdrop for an enriching exploration into the challenges and rewards of practicing emergency medicine in a vastly different healthcare environment.

This blog post builds on Robert Lloyd's impactful blog about his tough yet enlightening experience at Khayelitsha Hospital. Our journey takes us through candid conversations with UK emergency medicine trainees currently working in South Africa. These discussions reveal not only the clinical and emotional challenges they face but also the profound personal growth they experience.

Our conversation begins with a roundtable introduction. Each trainee shares their background and reasons for embarking on this journey. Jen, known as Coffee Headaches on Twitter, is currently working at Khayelitsha Hospital outside Cape Town, having moved from London. Chris and Chloe, both F4s, are working in Benedictine Hospital, Nongoma, and in Malawi, respectively. Sam, Jen's partner, is also at Khayelitsha, while Emma and Jacob, both F5s, are experiencing South African healthcare from different vantage points.

The primary motivation for these trainees to come to South Africa is to gain exposure to cases they rarely see in the UK. This includes a high prevalence of infectious diseases and trauma cases, providing a rich learning environment. The desire to challenge themselves and see how they react in a high-pressure environment is a compelling draw.

The conversation quickly shifts to the realities of working in this challenging environment. Despite extensive preparation, the reality of dealing with penetrating trauma, community assaults, and other interpersonal violence in South Africa is stark. As described by Jen and Chris, it's like managing a major incident every weekend night, with a constant flow of young male patients suffering from multiple stab wounds, often brought in by friends or local EMS.

The lack of resources and the necessity to make do with what's available forces a departure from UK-standard protocols. For instance, performing chest drains without the usual monitoring or resources becomes a norm. This scenario is a mental and emotional challenge, as it requires adapting to an environment where the ideal care isn't always possible.

One of the key discussion points is the mental toll of practising in such a different environment. The trainees express that the most stressful aspect is not being able to provide the level of care they are accustomed to in the UK. The overwhelming number of patients and the lack of resources mean they must often prioritize care based on immediate necessity rather than best practice. This situation requires them to accept that they can't always do everything they would like to, a reality that is difficult to reconcile with their training.

Yet, they also speak of the incredible support network among South African doctors. These professionals guide the UK trainees, helping them navigate the practical challenges and the emotional landscape of emergency medicine in South Africa. This mentorship is invaluable, offering a buffer against the intense stress of the environment.

The blog also delves into the unique clinical skills gained in South Africa. Many procedures and techniques, such as the Joburg knot for chest drains, are tailored to the local context, where resources are limited, and patients often face harsher post-treatment conditions. The trainees note that while these methods may not always align with UK standards, they are practical and effective in the South African context.

Moreover, they discuss the necessity of quick decision-making and improvisation. With patients often arriving in critical condition and space at a premium, immediate action is needed, often in less-than-ideal conditions. This experience contrasts sharply with the UK, where procedures are typically performed with more resources and time.

Despite the challenges, the trainees describe the experience as overwhelmingly positive. The highs of successfully managing complex cases and the lows of resource limitations create a unique learning environment. The exposure to severe trauma cases, particularly penetrating injuries, has significantly reduced their anxiety about these scenarios. This newfound confidence is something they plan to bring back to their practice in the UK.

The trainees also express deep admiration for their South African colleagues, who demonstrate remarkable skill and resilience in a resource-limited setting. The ability of these professionals to provide high-quality care despite significant challenges is both inspiring and humbling.

As the discussion winds down, the trainees share advice for others considering similar experiences. They emphasize the importance of understanding the expectations and conditions of the placement. The experiences can vary widely depending on whether one ends up in a well-supported trauma unit in a city or a rural hospital with minimal resources and support.

They recommend a minimum stay of three months to truly understand and contribute effectively to the healthcare setting. Shorter stays, they argue, don't provide enough time to adapt to the environment or make a meaningful impact.

Our conversation concludes with a reflection on the broader implications of this experience. The trainees agree that the skills and resilience developed in South Africa are not only invaluable but also applicable to emergency medicine practice in the UK. The experience underscores the need for adaptability, resourcefulness, and a deep understanding of the human aspects of healthcare.

South Africa, with its unique challenges and vibrant culture, offers an unparalleled learning experience for emergency medicine trainees. The personal and professional growth that comes from working in such a diverse and demanding environment is immense. As the trainees prepare to return to the UK, they carry with them not only new clinical skills but also a deeper understanding of themselves as clinicians.

This experience has been a powerful reminder that the essence of emergency medicine transcends geographical and cultural boundaries. It's about providing the best possible care under any circumstances, a lesson that resonates deeply with the core values of St. Emlyn's.

If you're considering a similar journey, take the plunge. The highs and lows are part of a journey that will not only shape your medical career but also broaden your perspective on healthcare and humanity. As we say goodbye to South Africa, the stories and lessons from this experience will undoubtedly inspire and inform the future of emergency medicine practice, both in the UK and beyond.

Comprehensive Guide to Managing Foreskin Issues in Pediatric Emergency Care

In pediatric emergency departments, foreskin-related issues frequently present significant challenges. This guide provides a thorough overview of common conditions such as balanitis, paraphimosis, and Balanitis Xerotica Obliterans (BXO), offering evidence-based strategies for their effective management.

Definition and Presentation: Balanitis refers to inflammation of the glans penis, often accompanied by inflammation of the foreskin (balanoposthitis). Symptoms include redness, swelling, and discomfort. It is a common presentation in emergency departments (EDs) and can cause significant concern among parents and caregivers.

Management Approach:

• Avoid Over-Treatment: Many cases of balanitis resolve spontaneously without the need for aggressive treatment. Over-treatment often includes unnecessary antibiotics and topical creams. Most cases are due to simple inflammation rather than bacterial infection.

• Antibiotics: Routine use of antibiotics is generally unnecessary unless a clear bacterial infection is identified. Antibiotics do not significantly impact the natural course of uncomplicated balanitis and may contribute to resistance.

• Topical Treatments: Using topical treatments like chloramphenicol eye ointment is discouraged. These treatments can cause additional pain and discomfort, exacerbating symptoms rather than alleviating them.

• Reassurance: Educating parents about the self-limiting nature of balanitis and advising them to avoid unnecessary treatments is crucial. Most cases improve with minimal intervention, and reassurance can significantly reduce anxiety.

Definition and Causes: Paraphimosis occurs when the foreskin is retracted behind the glans penis and cannot be returned to its normal position. This condition can lead to swelling, pain, and potential complications if not managed promptly.

Management Techniques:

• Gentle Reduction: The primary approach involves applying firm, consistent pressure to the glans penis to reduce swelling and facilitate the repositioning of the foreskin. This technique is often successful and avoids the need for surgical intervention.

• Lubrication: Using lubrication can assist in the reduction process. Avoid home remedies like ice or sugar, which lack scientific support and may not be effective.

• Reassurance: Communicate to parents that paraphimosis is usually manageable with conservative techniques and that surgical intervention is rarely needed. Educating families about the condition and its management can help alleviate concerns.

Definition and Characteristics: BXO is a chronic condition characterized by a white, shiny scar at the tip of the foreskin and glans penis. It primarily affects boys over the age of five and can lead to ballooning of the foreskin due to scarring.

Diagnosis:

• Clinical Examination: Diagnosis involves looking for a white, shiny scar at the end of the foreskin, indicative of BXO. This scarring distinguishes BXO from other forms of balanitis.

• Age Consideration: BXO is uncommon in children under five. Accurate diagnosis based on age and symptom presentation is essential for appropriate management.

Management:

• Specialist Referral: Severe cases of BXO often require referral to a specialist. Treatment may involve circumcision or other interventions depending on the severity of the condition.

• Conservative Measures: For less severe cases, topical steroids may be used, but definitive treatment often involves surgical options to address scarring and prevent further complications.

Common Issues: Post-circumcision complications include minor bleeding and concerns about the appearance of the circumcised penis. These issues can cause anxiety and prompt visits to the ED.

Management Strategies:

• Bleeding: Minor bleeding is a common post-circumcision issue. Apply direct pressure to control bleeding. If bleeding persists, topical treatments such as tranexamic acid or adrenaline can be used, but most cases resolve with basic first aid.

• Appearance Concerns: The appearance of the circumcised penis may look bruised or inflamed initially but typically improves as healing progresses. Reassure parents that these changes are normal and part of the healing process.

Community vs. Hospital Circumcision: Circumcisions performed in the community often have fewer reported complications compared to those done in hospitals. This difference is due to the larger number of community circumcisions and the varying rates of complication reporting.

Key Considerations:

• Age and Diagnosis: Always consider the child’s age when diagnosing and managing foreskin issues. Conditions like BXO are rare in younger children, while balanitis and paraphimosis are more common.

• Conservative Management: A conservative approach is usually effective for most foreskin issues. Avoid unnecessary treatments and focus on reassurance and education.

• Parent Education: Educate parents about the nature of the condition, expected outcomes, and appropriate management strategies. This helps reduce anxiety and prevent over-treatment.

• Specialist Referral: For conditions requiring specialized care, such as BXO or severe post-circumcision complications, timely referral to a specialist is crucial for optimal management.

Summary: Managing foreskin issues in pediatric emergency care involves understanding common conditions such as balanitis, paraphimosis, and BXO. Adopting a conservative, evidence-based approach helps avoid over-treatment and ensures effective management. Reassure families, provide appropriate care, and refer to specialists when needed. By following these practices, clinicians can enhance patient care and contribute to better outcomes for young patients with foreskin-related issues.

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Key Advice for Medical Professionals in Emergency Medicine

Navigating daily challenges in the demanding field of emergency medicine requires a blend of technical skills, emotional intelligence, and personal well-being. Drawing from the wisdom shared with the Class of 2017, here’s a comprehensive summary of essential advice for healthcare professionals in emergency settings.

Among the many pieces of advice, the most crucial is the emphasis on sleep. Scientific research underscores the importance of adequate rest for cognitive function and overall health. For medical professionals, sufficient sleep is vital for maintaining alertness and making sound decisions, both of which are critical in high-pressure environments like emergency departments.

Each day, strive to be the best version of yourself when you come to work. However, it’s important to recognize that everyone has off days. If you’re struggling, communicate with a senior colleague. They understand the pressures of the job and can offer support. Practising kindness towards yourself, patients, and colleagues fosters a positive work environment and enhances patient care.

Your conduct in the workplace sets a standard for others. Newer staff and peers observe and learn from your actions. Therefore, it’s essential to lead by example and exhibit a professional behaviour that you would want others to emulate. This principle helps maintain high standards of care and professionalism within the department.

The fast-paced nature of emergency medicine makes it tempting to overlook proper nutrition. However, maintaining a balanced diet and staying hydrated is crucial. Avoid fad diets and focus on eating nutritious meals and drinking plenty of fluids. Regular breaks are not just a right but a necessity for recharging and sustaining your energy levels throughout the shift.

Emotional contagion—the phenomenon where emotions are transferred from one person to another—plays a significant role in healthcare settings. A simple smile can positively influence the emotional climate of the department. By maintaining a positive demeanour, you can uplift the morale of both your colleagues and patients, contributing to a more supportive environment.

Clear communication is fundamental in emergency medicine. Always introduce yourself to patients and colleagues with a clear “Hello, my name is...” During patient assessments, address three key questions:

1. Does the patient need resuscitation?
2. Does the patient need pain relief?
3. Will the patient require further care as an inpatient?

These questions help prioritize and guide the patient’s treatment plan effectively.

When patients present with pain, provide analgesia early in their care. This step should precede a detailed history and examination. Addressing pain promptly not only improves patient comfort but also establishes a foundation for a more comprehensive evaluation.

In emergency medicine, formulating differential diagnoses is crucial. Consider at least three possibilities for each case, such as pulmonary embolism (PE), aortic dissection, or sepsis. Understanding the range of potential diagnoses helps guide your treatment decisions. It’s important to remember that diagnostic challenges are part of the job, and outcomes may vary based on the limited information available.

Engage with patients to understand their expectations and needs. Knowing what patients hope to achieve from their visit helps tailor your approach and makes their experience more manageable. Always seek to improve their day, even if your own is challenging. Empathy and understanding are key to providing compassionate care.

Emergency medicine relies heavily on teamwork. You’ll frequently undertake tasks that extend beyond your specific role, such as checking vital signs, transporting patients, or administering medications. Embrace these tasks as part of a collective effort to enhance patient care. Teamwork ensures that all aspects of patient care are covered and supports a cohesive work environment.

Before discussing a patient case with a senior, develop your own plan. Present your questions and concerns early rather than waiting for investigations. Effective decision-making often relies on history and examination, so keeping your senior and nursing team updated with your plan is essential. This approach facilitates timely and informed decision-making.

Aim to learn three new things each day. Your senior colleagues possess a wealth of experience and knowledge. Don’t hesitate to ask questions and seek their advice. Their insights can help you navigate complex cases and improve your practice. As a fresh perspective, your observations and suggestions for improvement are valuable.

Despite the inherent challenges of emergency medicine, find joy in your role. Being part of patients’ lives during their moments of crisis is a profound privilege. Maintain a positive outlook and remember that your work, though demanding, makes a significant difference in people’s lives. And always ensure you get enough sleep to perform at your best.

Navigating the world of emergency medicine requires balancing personal well-being, professional behavior, and effective patient care. By prioritizing sleep, maintaining a balanced diet, practicing kindness, and embracing teamwork, you can enhance your performance and job satisfaction. Clear communication, prompt pain management, and ongoing learning are essential components of providing high-quality care. Above all, remember the privilege of being part of patients' lives during critical moments and strive to make a positive impact every day.

Child Protection in Pediatric Emergency Medicine: A Comprehensive Guide

Child protection is a crucial aspect of pediatric emergency medicine, encompassing the identification and response to suspected cases of child abuse or neglect. As healthcare professionals, it is our responsibility to recognize the signs of abuse, conduct thorough assessments, and approach these sensitive issues with empathy and diligence. This guide provides a comprehensive overview of the key aspects of child protection, including identifying signs of abuse, handling difficult conversations, and collaborating with social services and law enforcement.

Identifying potential child abuse involves looking for physical, behavioural, and situational signs. Physical indicators include unexplained injuries, such as bruises, burns, or fractures, especially those inconsistent with the child's developmental stage. For instance, long bone fractures in non-mobile children are particularly concerning and should prompt further investigation. Behavioural signs can include excessive fearfulness, withdrawal, or inappropriate sexual behaviours, while situational signs may involve frequent hospital visits or inconsistent explanations for injuries.

Emergency department (ED) staff, including triage nurses, radiographers, and even receptionists, play vital roles in spotting these signs. Their initial observations and interactions can often be the first indicators of potential abuse. It is essential to document all findings meticulously, including descriptions of injuries, the child's behaviour, and parental explanations, to build a comprehensive case for further action.

Child protection in the ED is a collaborative effort. Every team member, from doctors to nurses and ancillary staff, contributes to the safeguarding process. Radiological assessments can be particularly revealing, as certain injuries, like rib fractures or metaphyseal lesions, are strong indicators of abuse. These findings, combined with clinical observations, help form a clearer picture of the child's situation.

Thorough documentation is crucial in these cases. It provides a detailed account of the observed injuries and behaviours, which is vital for legal and social services investigations. This documentation should include specific details about the injuries, any discrepancies in the provided history, and observations of the child's and parents' behaviour.

Discussing suspicions of child abuse with parents is challenging and requires a sensitive, non-judgmental approach. It is essential to communicate concerns in a way that prioritizes the child's safety while being respectful to the parents. A suggested approach is to explain that while the observed injuries or behaviours are concerning, the primary goal is to ensure the child's well-being. Phrases such as, "We sometimes see injuries that don’t make sense, and we have to ask more questions to help the children who need it," can help frame the conversation as a protective measure rather than an accusation.

Despite the careful approach, some parents may react defensively or even attempt to leave with the child. In these cases, it is important to remain calm, explain the legal responsibilities, and, if necessary, involve law enforcement to ensure the child's safety. The primary focus should always be on protecting the child and ensuring that proper protocols are followed.

Non-accidental injuries (NAIs) are a key concern in suspected abuse cases. These injuries, inflicted intentionally by someone else, can include fractures, burns, or bruises that do not match the child's developmental abilities or the provided history. For example, a spiral fracture in a non-mobile child should raise immediate concern.

In addition to physical assessments, radiological evidence is critical in confirming NAIs. Certain injuries, such as specific fracture patterns, are often seen in cases of abuse. However, healthcare providers must also be mindful of other medical conditions that could mimic abuse, such as osteogenesis imperfecta, which can cause brittle bones.

The HEADS assessment is a valuable tool for evaluating various aspects of a child's life that may indicate risk factors for abuse. HEADS stands for Home environment, Education/employment, Activities, Drug use, Sexuality, and Suicide/depression. This comprehensive approach helps clinicians understand the broader context of a child's situation, including potential stressors and risk factors.

It is important to conduct these assessments in a private setting where the child feels safe to speak openly. For younger children or those who cannot articulate their experiences, careful observation and interaction with the parents can provide crucial insights.

Child protection involves navigating complex cultural and social landscapes. Different cultures have varying norms regarding child-rearing practices, which may be misunderstood as neglect or abuse. It is essential to approach each case with cultural sensitivity and avoid making assumptions based on stereotypes.

Engaging with cultural liaisons or social workers who understand the family's background can help bridge communication gaps and provide context. However, the child's safety must always remain the top priority, regardless of cultural practices.

Collaboration with social services and law enforcement is often necessary in suspected abuse cases. These agencies play a crucial role in investigating allegations and ensuring the child's safety. Healthcare providers are responsible for reporting their concerns to these authorities, who can then conduct thorough investigations.

Understanding local reporting protocols and mandatory reporting laws is essential for all healthcare providers. Even in the absence of mandatory reporting, it is best practice to err on the side of caution and involve child protection services when there are concerns.

Handling cases of child abuse can be emotionally challenging for healthcare providers. The nature of these cases often leaves providers feeling uncertain and distressed. It is important for healthcare professionals to seek support, whether through colleagues, supervisors, or professional counselling services.

Regular debriefings and reflections on these cases can help improve practices and ensure better preparedness for future cases. Continuous education and training in child protection are also vital for maintaining a high level of competence and confidence in handling these sensitive situations.

Child protection is a shared responsibility that requires vigilance, empathy, and collaboration. As healthcare providers, we are often the first to identify and respond to child abuse cases. By staying informed, following best practices, and approaching these cases with sensitivity and professionalism, we can play a crucial role in safeguarding the well-being of children. At St Emlyn's, we are committed to providing ongoing education and support for healthcare professionals in all aspects of emergency medicine, including child protection. Together, we can make a difference in the lives of vulnerable children.

Introduction
In the high-stakes world of critical care, the topic of burnout has become increasingly prevalent. This blog post explores the complexities of burnout, compassion fatigue, and meaning-making among healthcare professionals, particularly those working in critical care environments. The discussion delves into how these issues manifest, their impact, and practical strategies for addressing them.

Burnout is a complex and often misunderstood phenomenon characterized by emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment. It's typically measured using tools like the Maslach Burnout Inventory (MBI), which assesses the risk rather than confirming outright burnout. However, the MBI's broad questions, such as feeling tired after work, can sometimes blur the line between normal stress and clinical burnout.

Context plays a crucial role in understanding burnout. Studies indicate that burnout rates can vary significantly based on geographical location and working conditions. For example, healthcare workers in Poland or Spain may experience different levels of burnout compared to those in the UK, Australia, or the United States, influenced by factors like pay, working hours, and work environment.

Despite the challenges, many healthcare professionals find deep meaning in their work, which can mitigate the effects of burnout. Meaning-making refers to the sense of purpose and value individuals derive from their professional roles. Even when experiencing high levels of burnout, healthcare workers often continue to find their work fulfilling and significant. This intrinsic motivation is crucial for sustaining resilience in demanding work environments.

Research has shown that even when burnout indicators are high, many healthcare professionals report a strong sense of purpose. This paradox highlights that burnout and job satisfaction can coexist. The positive aspects of meaning-making can serve as a buffer against the negative impacts of burnout, helping professionals maintain a sense of fulfillment and motivation.

Compassion fatigue differs from burnout and is specifically related to the emotional exhaustion from continuous caregiving. It arises from the intense emotional engagement required in healthcare settings, particularly when dealing with patient suffering. Unlike burnout, which develops over time, compassion fatigue can occur suddenly and can manifest as a diminished capacity to empathize or care.

Fortunately, compassion fatigue is manageable and often reversible with appropriate interventions. Recognizing its signs—such as feelings of helplessness, exhaustion, or a sense of detachment—allows for timely action. Healthcare professionals experiencing compassion fatigue may feel guilty for not meeting their own caregiving standards, which can exacerbate the problem.

While distinct, burnout and compassion fatigue often intersect, especially in critical care settings. The intense emotional and physical demands can lead to both conditions simultaneously. For instance, the constant exposure to trauma and suffering can trigger compassion fatigue, which in turn can accelerate the onset of burnout. This interplay complicates the management of these conditions, requiring a comprehensive approach that addresses both emotional and physical well-being.

Individual Strategies:
Healthcare professionals must prioritize self-care to mitigate burnout and compassion fatigue. Essential practices include maintaining a healthy lifestyle, setting boundaries to ensure adequate rest, and engaging in activities that provide joy and relaxation. Mindfulness practices, such as meditation and yoga, can also be beneficial in managing stress and enhancing emotional resilience.

Organizational Strategies:
Organizations have a critical role in supporting their staff. Creating a supportive work environment, offering mental health resources, and ensuring reasonable workloads are fundamental steps. Regular debriefing sessions and fostering a culture of appreciation can significantly improve workplace morale and reduce burnout risk. Additionally, flexible scheduling and adequate staffing are crucial in preventing overwork and ensuring a manageable workload.

Reflective Practice:
Incorporating reflective practices into daily routines helps healthcare professionals process their experiences and emotions. This can be done through journaling, meditation, or team discussions. Reflective practice allows for a deeper understanding of one's emotional responses, helping to build resilience and reduce the risk of emotional exhaustion.

Leadership Role:
Healthcare leaders play a pivotal role in mitigating burnout and compassion fatigue. They should model positive behaviors, such as work-life balance and self-care, and advocate for systemic changes that address the root causes of these issues. Leaders should also foster an environment where staff feel safe to discuss their challenges and seek support.

Team Dynamics:
Positive team dynamics can buffer against stress and reduce the likelihood of burnout. Encouraging open communication and mutual support among team members fosters a supportive work environment. Activities that build team cohesion, such as team-building exercises and regular check-ins, can strengthen relationships and enhance collaboration.

Addressing burnout and compassion fatigue in critical care requires a comprehensive approach that involves both individual and organizational efforts. Recognizing these conditions, understanding their manifestations, and implementing practical strategies are essential steps toward fostering a resilient and supportive healthcare environment. At St Emlyn's, we are committed to exploring these critical issues and sharing strategies to help manage the demands of our profession. By focusing on both personal well-being and systemic changes, we can create a healthier, more sustainable work environment for all healthcare professionals.

Hello and welcome back to the St Emlyn's blog! We've just wrapped up an incredible few days in Copenhagen, and we're excited to share our experiences and insights from the latest teaching course. It's been a whirlwind of learning, reflection, and connection, and we can't wait to dive into the details.

We kicked off the day with a recap of the previous sessions, employing the powerful technique of spaced repetition. This method has been a cornerstone of our course, allowing us to reinforce key concepts and ensure they stick with our learners. It's an approach we've found invaluable in enhancing the educational experience, and one we're keen to continue exploring.

One of the highlights of the day was our deep dive into presentation design, specifically the PQP theory. This framework, consisting of three key elements—P1: Developing the Story, P2: Supportive Media, and P3: Delivery—offers a comprehensive approach to crafting effective presentations. Inspired by Ross Fischer's work, we guided participants through the process of creating compelling narratives, choosing the right media, and delivering their messages with impact. For more on this, check out the detailed resources on Ross Fischer's site (also known as "Foliate").

Interactivity was a major focus, particularly in our sessions on giving and receiving feedback. We explored various types of feedback, from constructive criticism to positive reinforcement, and emphasized the importance of specificity and non-judgmental language. One standout activity was the "finding the ball" game, a powerful exercise in feedback that has consistently elicited strong emotional and intellectual responses from participants. This exercise, first introduced in our New York course, remains one of our most transformative educational interventions.

A unique feature of this course was our emphasis on meta-education. We stepped outside the traditional teaching framework to reflect on our educational strategies. This "meta" approach encouraged participants to think critically about the activities they were engaging in and consider how these methods could be adapted to different teaching contexts. It was a valuable opportunity for both novice and experienced educators to enhance their teaching techniques and understand the underlying principles of effective education.

We also introduced the Giraffe technique for handling challenging conversations, particularly those involving behavioral or attitudinal issues. This four-step process involves agreeing on the facts, expressing personal perceptions and emotions, articulating needs, and setting actionable tasks. It's a practical framework that empowers educators to address sensitive issues constructively and empathetically.

No St Emlyn's course would be complete without a vibrant social program. This time, we had a blast at the karaoke night, where George impressed everyone with his angelic voice. Even though my rendition of "Taylor Swift's Love Story" might have faltered at the key change, the camaraderie and laughter made it a memorable evening.

As we wrapped up the course, it was clear that this experience was about more than just imparting knowledge. It was about building friendships, sharing experiences, and growing together as educators. Whether reconnecting with old friends or forging new connections, the journey of learning and teaching continues to inspire us. We're grateful to everyone who participated and made this course a success.

Thank you for joining us on this journey. We look forward to seeing you at our next event, wherever in the world it may be. Until then, keep learning, keep teaching, and keep inspiring.

Stay tuned for more insights and updates from the St Emlyn's team!

The St Emlyn’s team, comprising Simon Carley, Nathalie May, and Chris Nixon, recently conducted an in-depth teaching course in Copenhagen, focusing on medical education, simulation training, and learning theories. This blog post encapsulates the key insights and experiences from the event, offering valuable reflections for medical educators and practitioners.

Copenhagen provided an ideal setting for the course, which was designed to accommodate a range of interests through specialized sessions on simulation (SIM) and educational theories. The modular structure allowed participants to select sessions based on their professional needs, ensuring a dynamic and tailored learning experience.

The course began with a review of the previous day’s content, addressing participant questions and reinforcing key concepts through retrieval practice, spaced repetition, and testing. This review session, a rare but valuable practice, set a solid foundation by enhancing understanding and retention of the material.

Jesse led a session exploring the concept of expertise in medicine, challenging the traditional notion of expertise as purely individualistic. The discussion emphasized that true expertise often involves effective teamwork, particularly in complex fields like healthcare. The analogy of a football team highlighted that medical teams, like sports teams, thrive on diverse skill sets and collaboration rather than the prowess of a single individual. This perspective is crucial for fostering successful medical teams, where complementary skills are essential for optimal patient care.

Simulation training was a central theme, with an emphasis on constructivist learning environments. Participants were encouraged to develop their own simulation scenarios, facilitating hands-on practice and learning from mistakes. This approach, while potentially risky for educators due to its open-ended nature, proved effective as participants met and exceeded learning objectives, discovering additional insights in the process.

The sessions also underscored the importance of aligning simulation exercises with clear, functional objectives. Authenticity in these exercises, regardless of equipment sophistication, ensures relevance to real-world medical situations, bridging the gap between theoretical knowledge and practical application.

While Crisis Resource Management (CRM) remains a key component of team training in medicine, the course explored additional methods such as stress inoculation training and cross-training. These methods expand team members' understanding of each other's roles and improve overall team performance. By diversifying training approaches, medical professionals can be better prepared for various high-pressure scenarios.

Debriefing sessions were highlighted as essential for reflective learning. These sessions provided a platform for participants to discuss their experiences, acknowledge successes, and identify areas for improvement. This reflective practice not only consolidates learning but also fosters a supportive and collaborative environment. Effective debriefing addresses both technical performance and emotional aspects, promoting resilience and well-being among healthcare professionals.

A significant takeaway was the importance of including all levels of medical professionals in simulation training. Engaging senior staff and administrative teams fosters a culture of continuous learning and breaks down professional silos. This inclusive approach enhances communication and teamwork, leading to better patient outcomes. It also reinforces the idea that learning is a lifelong process, valuable at all stages of a medical career.

The afternoon sessions focused on the science of learning, bridging educational theory with practical applications. Influenced by books like "Make It Stick" and "Mindset," the discussions explored how theories such as the growth mindset can be applied to medical education. Understanding these theories provides educators with frameworks to address various challenges, fostering a more effective and engaging learning environment.

Practical exercises demonstrated that even without formal educational theory knowledge, participants could derive key educational principles through discussion. This exercise highlighted that while theoretical knowledge is beneficial, practical experience and intuition can also guide effective teaching.

Constructive feedback, a critical component of effective teaching, was a major focus. By emphasizing effort over innate ability, educators can cultivate a growth mindset in learners, encouraging continuous improvement. This approach not only enhances individual performance but also contributes to a positive and productive learning environment.

The importance of tailoring teaching strategies to meet the needs of individual learners was also discussed. Personalized education is particularly crucial in medical training, given the diverse backgrounds and varying levels of experience among learners. By adapting educational methods, educators can create more impactful and relevant learning experiences.

The course concluded with a preview of upcoming sessions on presentation skills and feedback techniques, crucial for medical professionals in both educational and clinical settings. Effective communication and the ability to provide constructive feedback are vital for fostering a positive learning environment and ensuring high-quality patient care.

The course in Copenhagen was a success, characterized by dynamic sessions, active participant engagement, and a collaborative atmosphere. The variety of educational methods and the inclusive environment addressed the diverse needs of participants, equipping them with practical tools for their professional practice. The experience underscored the importance of continuous adaptation and learning in medical education, preparing professionals to meet the evolving challenges of the healthcare field.

The St Emlyn’s team invites readers to explore more on these topics through their blog, offering ongoing updates, resources, and insights into medical education and training. Whether a seasoned professional or a newcomer, there’s always more to learn and discover in the ever-evolving field of medicine.

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.

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.

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.

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.

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 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.

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.

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

In the field of medical research, the distinction between prospective and retrospective studies is fundamental. These study designs differ primarily in the timing of data collection relative to the occurrence of outcomes, which significantly influences the quality, reliability, and applicability of the research findings. This detailed exploration aims to elucidate the characteristics, strengths, and limitations of each design, offering practical insights into their use in clinical research and practice.

Prospective Studies involve the identification and enrollment of participants before the outcomes of interest occur. This design allows researchers to follow participants over time, observing events as they happen. For instance, in a study focused on chest pain, researchers would enrol patients at the onset of symptoms and monitor them to see if they develop conditions like myocardial infarction (MI). The prospective nature of these studies provides a structured approach to data collection, ensuring that all relevant information is captured consistently.

Retrospective Studies, conversely, involve examining existing data after the outcomes have occurred. In this design, researchers typically review medical records or databases to identify patients who have experienced specific events, such as an MI, and then analyze these records to explore potential risk factors or causes. This approach is often more efficient and less costly than prospective studies, as it utilizes data that have already been collected.

The timing of data collection in relation to the occurrence of outcomes is a critical differentiator between these study designs. This temporal aspect influences several key factors, including data quality, potential biases, and the strength of causal inferences that can be drawn.

One of the primary advantages of prospective studies is the ability to standardize data collection. Since the data is collected in real-time, researchers can establish clear protocols for what data to collect and how to collect it. This reduces variability and enhances the reliability of the study findings. For example, in a prospective study on hypertension, researchers can use a standardized checklist to document whether each participant has hypertension, ensuring consistent and accurate data across all participants.

In contrast, retrospective studies depend on the quality and completeness of existing records, which were often not compiled with the current research question in mind. This reliance on historical data can lead to inconsistencies and gaps. For instance, a patient's medical record might not specify whether they had hypertension, either because it was not asked about or not documented. Such missing data can lead to biases and affect the study's conclusions, as the researchers may not have all the necessary information to make accurate assessments.

In prospective studies, participants are observed from the point of exposure or initial symptoms to the outcome, allowing researchers to track changes over time and potentially identify causative factors. This direct observation of the sequence of events enhances the ability to establish a cause-and-effect relationship. For instance, if a prospective study monitors patients presenting with chest pain, it can track the development of MI, thereby strengthening the evidence for an association between initial symptoms and outcomes.

Retrospective studies, however, start with the outcome and work backwards to explore potential causes. This backwards-looking approach can introduce recall bias and selection bias, as the outcomes are already known and may influence which data are emphasized or selected. Additionally, retrospective studies are constrained by the availability and accuracy of past records, which can vary widely and may not cover all variables of interest, potentially leading to incomplete or skewed data.

Both prospective and retrospective studies offer unique benefits and face distinct challenges, making them suitable for different types of research questions and practical considerations.

Advantages:

• High Data Quality: Prospective studies allow for systematic and standardized data collection, minimizing the risk of missing or incomplete data.
• Causal Inference: The temporal relationship between variables and outcomes can be clearly established, supporting stronger causal inferences.
• Real-Time Data Collection: Researchers can monitor the study as it progresses, allowing for adjustments to data collection methods if new relevant variables emerge.

Limitations:

• Resource-Intensive: Prospective studies often require significant time, financial investment, and effort. The need for long-term follow-up can be particularly demanding.
• Long Duration: These studies can take years to complete, especially for conditions with long latency periods, delaying the availability of results.
• Participant Dropout: Over extended periods, there is a higher risk of participant dropout, which can reduce the study's validity and potentially bias the results.

Advantages:

• Efficiency: Retrospective studies can be conducted relatively quickly since they rely on already available data.
• Lower Cost: The use of existing records reduces the need for expensive data collection processes, making these studies more cost-effective.
• Feasibility for Rare Conditions: Retrospective studies are particularly useful for examining rare conditions or outcomes that would require a prohibitively large cohort in a prospective design.

Limitations:

• Data Quality Issues: Relying on existing records can lead to inconsistent data quality, with gaps or inaccuracies potentially affecting the study's findings.
• Bias: These studies' retrospective nature can introduce biases, such as selection bias and information bias, that can compromise the validity of the results.
• Limited Causal Inference: Establishing a cause-and-effect relationship is more challenging due to the lack of temporal clarity between exposure and outcome.

Understanding the strengths and weaknesses of prospective and retrospective studies is essential for effectively interpreting medical literature and applying research findings in clinical settings. For example, a study evaluating the effectiveness of a diagnostic tool for acute coronary syndrome would be assessed differently depending on whether it was conducted prospectively or retrospectively.

Prospective studies are often regarded as the gold standard for clinical trials, particularly when testing new treatments or interventions. Their ability to minimize bias and control for confounding variables makes them invaluable for determining efficacy and safety. However, the high cost and time requirements can be significant barriers, especially in large-scale studies or those requiring long-term follow-up.

While not as robust in establishing causality, retrospective studies are highly valuable for exploring existing data and generating hypotheses. They are especially useful in situations where prospective studies are impractical due to ethical concerns, time constraints, or the rarity of the condition being studied. For instance, retrospective analyses of patient records can provide insights into the natural history of a disease or the effectiveness of treatments in real-world settings.

The HEART score, a tool used in emergency departments to risk stratify patients with chest pain, serves as an illustrative example of the application of these study designs.

In a prospective study, researchers would enrol patients presenting with chest pain and systematically apply the HEART score, following these patients over time to track outcomes such as MI or other adverse cardiac events. This prospective approach allows for a controlled and consistent application of the score, with data collected in real time. Researchers can ensure that all relevant factors, such as patient history and troponin levels, are accurately recorded, providing a clear picture of the score's predictive value.

In a retrospective study, researchers might review existing medical records of patients who presented with chest pain and were tested for troponins. They would calculate the HEART score based on the available data and correlate it with documented outcomes. While this method is more efficient and cost-effective, it is limited by the quality of the records. Incomplete or inaccurately recorded data, such as missing details on patient history, can affect the accuracy of the HEART score's evaluation, potentially leading to less reliable conclusions.

Ethical considerations differ significantly between prospective and retrospective studies. Prospective studies often require informed consent from participants, as they involve collecting new data. This process ensures that participants are aware of the study's purpose, procedures, and potential risks, and they have the right to withdraw at any time. However, obtaining consent can be challenging in emergency settings or when the study involves vulnerable populations.

Retrospective studies typically use anonymized data, which simplifies ethical considerations by removing the need for consent. This approach is particularly advantageous when dealing with sensitive information, as it protects patient privacy and confidentiality. However, researchers must still ensure that data are used responsibly and that individuals' privacy is not compromised. The use of anonymized data also limits the ability to collect additional information that may be relevant to the study but was not included in the original records.

The decision between using a prospective or retrospective study design should be guided by the research question, available resources, and the specific context of the study. Each design offers unique benefits and challenges, and the choice will impact the strength and applicability of the findings.

Prospective studies are preferred when high-quality data and strong causal inferences are needed, despite their higher costs and time requirements. They are ideal for intervention studies, where controlling for confounding factors is crucial.

While limited in establishing causality, retrospective studies provide valuable insights when prospective studies are not feasible. They are particularly useful for exploring existing data, understanding the epidemiology of diseases, and identifying potential risk factors.

In clinical practice, understanding these differences helps healthcare professionals critically appraise the literature, making informed decisions based on the strengths and limitations of the evidence. At St Emlyn's, we emphasize the importance of critical appraisal and evidence-based practice. By familiarizing yourself with these study designs, you can enhance your ability to interpret research findings, apply them in clinical settings, and contribute to the ongoing advancement of medical knowledge.

Thank you for exploring the complexities of prospective and retrospective studies with us. We hope this detailed discussion has provided clarity and practical guidance, empowering you to approach medical research with a critical and informed perspective. For more in-depth analysis and practical insights, continue following St Emlyn's, your trusted source for cutting-edge medical education and research.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Helping Children Understand Tragedy: Guidance for Parents and Professionals

In a recent St Emlyn's podcast, Iain Beardsell and Liz Crowe, an advanced social worker in a pediatric intensive care unit in Brisbane, explored the critical topic of how to communicate with children during tragic situations. The discussion emphasized the importance of honesty and directness when dealing with topics like illness, death, and other forms of hardship.

Understanding the Context

Historically, children in many cultures were more regularly exposed to the realities of life, such as birth and death. In contrast, modern Western societies often shield children from these experiences. However, Liz asserts that children are more perceptive and resilient than we give them credit for, and attempts to protect them from all emotional pain can be detrimental. Shielding children from the truth can lead to confusion and increased anxiety, as they often sense when something is wrong, even if it is not explicitly communicated to them.

The Importance of Honesty

When difficult situations arise, such as a family member being diagnosed with a serious illness or being involved in an accident, adults may feel the instinct to protect children by withholding information. However, research and experience show that children cope better when they are informed and involved. Children, especially those under ten, can mistakenly believe they are responsible for negative events due to their egocentric worldview. Therefore, it is crucial to communicate clearly and truthfully, helping them understand the situation without assigning blame to themselves.

Balancing Protection and Reality

Parents naturally want to protect their children from pain. However, overprotection can prevent children from learning to deal with disappointment and hardship, essential components of developing resilience. Liz argues that by being overly protective, we may contribute to rising rates of depression and mental health issues among young people. It's essential to prepare children for life's challenges by allowing them to experience and understand difficult emotions in a supportive environment.

Practical Approaches to Communication

When faced with the need to communicate difficult news to children, it's important to empower familiar adults—such as parents or guardians—to have these conversations rather than leaving them to strangers. Here’s a suggested approach:

1. Preparation: Prepare the adults involved in the child's life by discussing the importance of honest communication and the possible impacts of the conversation.
2. Setting Expectations: Describe what the child might see, hear, and feel to reduce anxiety and set clear expectations.
3. Use Specific Language: Avoid euphemisms. Use specific medical terms like "neuroblastoma" or "head injury" to describe the situation accurately.
4. Timing and Environment: Choose an appropriate time and setting for the conversation, avoiding moments when the child might be tired or distracted.
5. Stick to the Facts: Provide clear, factual information without overwhelming the child. Keep explanations straightforward and allow time for processing.
6. Encourage Questions: Allow the child to ask questions and answer them honestly. It’s okay to admit if you don’t have all the answers.
7. Ongoing Support: Be available for follow-up conversations, as children may revisit these topics as they process the information.

Using Accurate Language

It’s crucial to use accurate language when discussing severe issues. Avoid using vague terms like "poorly," which can lead to misunderstandings. For example, describing a child as "very sick" without specifying the illness can cause confusion and fear, especially if the child later associates the term with less severe conditions. Using specific medical terminology helps children differentiate between different types of illnesses and their severity.

Long-Term Impact on Children

Many parents and caregivers worry that exposure to tragedy will permanently damage their children. While such experiences can indeed be life-changing, they do not necessarily result in negative outcomes. Children who experience the death of a sibling or parent may grieve and feel pain, but they can also develop greater empathy and understanding of life's complexities. Research indicates that while children in these situations may have higher levels of anxiety, they are not necessarily less successful academically or socially. They often develop a deeper sensitivity and a better understanding of life.

The Role of Counseling and Support

While counseling can be helpful, Liz cautions against making it the default response. Instead, she suggests that families should be encouraged to navigate these challenges on their own, seeking professional help only if they find themselves unable to cope. This approach fosters resilience and self-reliance, teaching children that while therapy is a valuable resource, it's not always necessary.

Conclusion: Building Resilience

Ultimately, difficult conversations with children about tragedy are a necessary part of life. By approaching these conversations with honesty, clarity, and support, we can help children navigate their emotions and develop the resilience needed for future challenges. Whether as parents or healthcare professionals, our role is to guide children through these experiences, providing the tools and understanding they need to grow and thrive.

At St Emlyn's, we believe that while we can't shield children from all of life's difficulties, we can help them face these challenges with courage. The experiences that children go through, even the painful ones, can serve as opportunities for growth and learning. With the right support, children can emerge from these experiences stronger and better equipped to handle life's complexities. Our goal is to create a safe space for children to express their feelings, ask questions, and ultimately, develop the resilience they need to navigate the ups and downs of life

Introduction

Selection bias is a critical issue in medical research that can undermine the validity of study findings. It occurs when there is a systematic difference between the study population and the broader population the research aims to represent. Understanding selection bias is essential for clinicians and researchers, as it can lead to questionable conclusions and affect clinical practice. This summary covers the definition of selection bias, its sources, and ways to mitigate it, along with a case study illustrating its impact.

What is Selection Bias?

Selection bias happens when the participants in a study do not accurately reflect the general population. This discrepancy can result from various factors, including how patients are selected, the setting of the study, and the timing of patient recruitment. Such biases can skew research results, making them less applicable to real-world situations. As medical professionals rely heavily on research to inform clinical decisions, recognizing and addressing selection bias is crucial.

Sources of Selection Bias

1. Study Environment

   The environment where a study is conducted can significantly influence patient selection. For instance, patients in a general practitioner's office might have a lower prevalence of serious conditions compared to those in an emergency department. Additionally, studies in specialized tertiary care centers often include patients with more severe or rare conditions, which may not represent the general patient population. This can lead to overestimating or underestimating the effectiveness of treatments or the accuracy of diagnostic tests.

2. Timing of Patient Recruitment

   The timing of patient recruitment is another source of selection bias. The stage of illness at which patients are recruited can affect study outcomes, especially in diagnostic studies. For example, the diagnostic value of CRP for appendicitis changes depending on when it is measured. Additionally, certain conditions may present differently depending on the time of day or week, potentially leading to an incomplete understanding of a condition's prevalence or severity if the study only includes patients from specific times.

3. Retrospective vs. Prospective Studies

   Retrospective studies, which rely on historical data, are particularly vulnerable to selection bias. These studies may selectively include data from periods with better patient outcomes, leading to skewed results. They may also suffer from incomplete data or changes in diagnostic criteria over time, making it difficult to generalize findings. Prospective studies, while more controlled, also need careful planning to avoid selection bias, especially in defining inclusion and exclusion criteria.

4. Convenience Sampling

   Convenience sampling involves selecting patients based on availability rather than a structured protocol, often due to resource limitations. This can result in a non-representative sample, such as including only daytime patients who might differ from those presenting at night. While convenience sampling can be a pragmatic choice, it often leads to underrepresentation of certain patient groups, potentially biasing study findings.

Mitigating Selection Bias

To mitigate selection bias, researchers should strive for comprehensive sampling strategies, such as random or consecutive sampling. Where complete sampling is not possible, they should transparently report potential biases and the measures taken to minimize them. For instance, using screening logs or adjusting for demographic differences can help address disparities between recruited and non-recruited patients. Sensitivity analyses can also be used to understand the impact of excluding certain patient groups.

Case Study: Thrombolysis in PEA Cardiac Arrest

A recent journal club discussion highlighted a retrospective cohort study by Shereefi et al., examining the efficacy of half-dose thrombolysis in patients with PEA cardiac arrest and confirmed pulmonary embolism (PE). The study raised concerns due to several potential biases. The arbitrary selection of a 23-month inclusion period, without a clear rationale, suggests the possibility of survival bias, as it included only patients who survived long enough to receive a confirmatory diagnosis of PE. This selective inclusion means the findings might overestimate the treatment's effectiveness, as the study only considered patients with a relatively favorable prognosis.

Moreover, the study's setting in a specialized environment and the inclusion of only confirmed PE cases limit the generalizability of the results. In practice, thrombolysis may be administered based on clinical suspicion rather than confirmed diagnosis, which involves a broader and potentially more diverse patient group. The study's focus on survivors also excludes those who may have died before a diagnosis, further skewing the data towards more favorable outcomes.

Implications of Selection Bias

Selection bias can significantly impact the interpretation of study results and, consequently, clinical decisions. It can lead to over- or underestimation of a treatment's effectiveness or the prevalence of a condition. This bias can also affect healthcare policy and practice guidelines, potentially disadvantaging underrepresented patient groups. For example, guidelines developed from biased research may fail to address the needs of older adults or those with comorbidities if these groups are underrepresented in studies.

Conclusion

Selection bias is a pervasive issue that can undermine the credibility of medical research. It arises from various sources, including the study environment, timing of recruitment, study design, and sampling methods. While complete elimination of selection bias is challenging, awareness and careful methodological design can mitigate its effects. Researchers and clinicians must critically appraise studies, considering potential biases and their implications for clinical practice. By doing so, we can make more informed decisions and improve patient care. At St. Emlyns, we continue to explore these critical appraisal topics to support evidence-based practice.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 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.

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.

Optimizing Communication in Healthcare: Key Takeaways from the SMACC Conference

At the recent SMACC conference in Dublin, a notable workshop led by Liz Crowe and Steve Philpott focused on enhancing communication skills in healthcare. This workshop emphasized the importance of understanding one's own communication style and how it impacts interactions with patients, colleagues, and even personal relationships.

The workshop began by highlighting that communication is influenced by personality traits, which shape how we express and receive information. One key distinction is between extroverts and introverts. Extroverts often gain energy from social interactions and tend to speak quickly, sharing ideas readily. In contrast, introverts recharge through solitude and may take longer to articulate their thoughts. Recognizing these traits is crucial in healthcare settings, where both types bring valuable strengths to a team. For instance, extroverts may lead discussions and drive actions, while introverts often provide thoughtful insights after careful consideration.

A critical takeaway was the importance of having a balanced mix of personality types within a team. A group dominated by extroverts might lack depth in decision-making, while a team of introverts might struggle with timely execution. Effective teams combine these traits, ensuring diverse perspectives and approaches. For example, when tackling tasks like developing protocols or organizing events, having both meticulous "get it right" individuals and efficient "get it done" members ensures thorough and timely outcomes.

The workshop provided several practical strategies to improve communication:

Signposting involves clearly highlighting key points throughout a conversation, ensuring they are understood and remembered. In healthcare, this technique is essential for communicating critical information, such as diagnoses or treatment plans. By repeatedly emphasizing important messages, healthcare professionals can help patients and families grasp complex information more effectively.

A simple yet powerful language adjustment discussed was avoiding the word "but." Using "but" can negate the positive aspects of a statement, creating a dismissive tone. Instead, substituting "but" with "and" maintains a constructive dialogue. For example, saying, "You did a great job, and improving your time management will make you even more effective," keeps the conversation positive and forward-looking.

The first and last things said in a conversation are often the most memorable, especially in stressful situations. Setting a serious tone at the beginning of a difficult conversation and summarizing key points at the end ensures that the main messages are clear. This approach is crucial when delivering bad news or discussing sensitive topics, as it helps manage expectations and emotions.

Breaking down complex information into smaller, manageable chunks and allowing pauses helps listeners process and understand better. This technique is particularly useful when communicating with patients and families who may be overwhelmed with medical jargon and stress. Pauses give them time to absorb the information and ask questions, demonstrating empathy and patience.

Discussing sensitive topics, such as poor prognosis or end-of-life care, requires a careful balance of empathy and honesty. The workshop emphasized acknowledging optimism bias—the tendency to hold onto hope even when the prognosis is poor. Healthcare professionals should acknowledge the family's hope while gently grounding them in reality. For example, expressing understanding of their hopes while clearly stating the medical expectations helps families navigate difficult emotions.

The platinum rule, which goes beyond treating others as you would like to be treated, focuses on treating others as they would like to be treated. This involves understanding the communication preferences of patients and families. Some may prefer detailed explanations, while others might want a broader overview. Asking about their preferences and tailoring the communication accordingly enhances their sense of control and satisfaction.

Maintaining a connection with patients and families is crucial, especially in challenging situations. While outcomes may not always be within control, the process of communication is. Ensuring that patients and their families feel heard, respected, and supported can make a significant difference in their healthcare experience. This connection is not just about delivering information but also about showing empathy and understanding.

The SMACC conference workshop provided invaluable insights into improving communication in healthcare. By understanding our own communication styles, appreciating the strengths of different personality types, and employing practical strategies like signposting, avoiding "but," and using the platinum rule, healthcare professionals can enhance their interactions with patients and colleagues. Effective communication is not just about conveying information; it's about building trust, understanding, and a positive work environment.

These skills are essential for providing high-quality patient care and fostering a supportive workplace culture. The workshop highlighted that good communication can prevent misunderstandings, reduce the likelihood of complaints, and ultimately save time. By investing a few extra minutes in effective communication, healthcare professionals can significantly improve patient outcomes and satisfaction.

In summary, the key to effective communication in healthcare lies in understanding ourselves and others, being clear and empathetic, and continuously refining our skills. Whether in patient interactions or team collaborations, these principles help create a more compassionate and efficient healthcare environment.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Trauma handovers are critical transitions in patient care, transferring responsibility from pre-hospital teams to in-hospital teams. These moments are crucial for ensuring patient safety and the continuation of effective treatment. This summary explores the best practices for trauma handovers, focusing on preparation, timing, communication, and the integration of feedback.

Effective trauma handovers begin with thorough preparation. The period between receiving the notification of an incoming trauma patient and their arrival is often called "golden time." This time should be used to organize and prepare the multidisciplinary team, including in-patient specialists, ED staff, nurses, doctors, and radiologists. Key preparatory steps include:

1. Role Allocation: Assign clear responsibilities, such as the trauma team leader, scribe, airway manager, and primary survey conductor. It is crucial to ensure that team members are both competent and confident in their assigned roles, as these attributes, while related, are distinct.
2. Predictive Planning: Use pre-hospital information to anticipate the patient's needs. For instance, a report of a patient with a chest stab wound and hypotension suggests the need to prepare for a thoracotomy.

Timing is essential in trauma care, particularly in avoiding early calls to the trauma team. At Southampton, the recommended practice is to call the team together approximately 15 minutes before the patient’s expected arrival, avoiding exact time estimates. This strategy helps maintain team readiness and focus. The risks of early calls include loss of focus due to prolonged waiting and the potential for team members to become distracted by other tasks.

A comprehensive and unified briefing is vital upon the trauma team’s assembly. This briefing should involve the entire multidisciplinary team, preventing any division into subgroups and ensuring that all members receive the same information. A good practice is for team members to introduce themselves using first names, which helps break down hierarchical barriers and fosters a collaborative environment. The briefing should also include a mission rehearsal, outlining the specific tasks and roles each member will perform upon the patient's arrival.

The actual handover begins when the patient arrives. The in-hospital team leader should introduce themselves to the pre-hospital team and determine if the patient is stable enough for a hands-off handover. This approach, modeled after military practices, ensures that the handover is conducted calmly and clearly. If the patient is unstable, the pre-hospital team should continue leading the resuscitation until it is safe to hand over control.

A structured framework, such as AppMist (Age, Time of injury, Mechanism, Injuries, Signs, and Treatments), should be used to deliver concise and critical information during the handover. This approach ensures that only the essential information is communicated, focusing on the most pertinent details for the ongoing treatment.

The pre-hospital environment is inherently stressful and challenging, with limited resources and a high cognitive load. Pre-hospital teams often face the dual pressures of managing critically ill patients and communicating effectively with the receiving hospital. It is crucial for in-hospital teams to recognize these challenges and refrain from criticizing or undermining pre-hospital efforts during the handover. Instead, the focus should be on receiving and clarifying the necessary information to continue patient care.

Pre-hospital teams should aim to deliver concise, relevant information during the handover. Ending the handover with a clear statement, such as "That completes my handover," followed by an offer to answer any urgent questions, helps ensure clarity and completeness.

Closing the feedback loop is an essential aspect of improving trauma care. Providing feedback to pre-hospital teams about patient outcomes helps refine their assessment and treatment strategies. This feedback should be delivered sensitively, acknowledging the emotional and high-pressure nature of pre-hospital work.

Constructive feedback should focus on confirming or refuting pre-hospital assessments and decisions, providing a learning opportunity for future cases. It is essential to approach feedback with empathy and professionalism, fostering a supportive environment for continuous improvement.

Calling the Full Trauma Team: There is a debate over whether to always call the entire trauma team for every alert. At our hospital, we favor over-calling to ensure that all necessary resources are immediately available, even if it means releasing some staff after assessing the situation.

Pre-Hospital Requests for Specific Interventions: In-hospital teams must use their discretion when responding to pre-hospital requests for specific interventions or specialist involvement. Trust and familiarity with the pre-hospital team's capabilities influence these decisions. For example, while cardiothoracic surgeons are not standard members of our trauma team, they may be involved in cases of traumatic cardiac arrest with penetrating trauma.

Effective trauma handovers are essential for patient safety and optimal care. This process requires careful preparation, clear communication, and seamless coordination between pre-hospital and in-hospital teams. By adhering to standardized practices, fostering a collaborative environment, and integrating constructive feedback, healthcare providers can significantly enhance the quality of trauma care.

We encourage healthcare professionals to share their experiences and insights, contributing to a broader understanding of best practices in trauma handovers. Whether you are working in trauma centers, units, or in different healthcare systems worldwide, your input is invaluable in refining these critical processes.

Thank you for engaging with this discussion on the St Emlyns blog. We look forward to continuing this conversation and exploring ways to improve patient care in emergency medicine.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Highlights from Day Two of SMACC: Exploring Leadership, Fear, and Compassion in Healthcare

Introduction

Welcome to the St. Emlyn's blog! We're Simon Carley and Natalie May, reporting from day two of the SMACC conference in Dublin. This day has been filled with engaging sessions, challenging ideas, and invaluable insights into various aspects of healthcare. From leadership and patient management to emotional resilience and compassion, the sessions have offered a deep dive into the complexities and challenges faced by healthcare professionals.

Ristola Ristup on Leadership and Gender Norms

The day started with Ristola Ristup's powerful plenary session on leadership. Ristup emphasized that leadership is a universal skill that transcends gender. She discussed the importance of both leadership and followership, stressing that everyone in healthcare needs to develop these skills. Her talk also highlighted the significance of mindful communication, noting that even brief comments can have a profound impact on others.

Ristup's insights into gender norms were particularly compelling. She argued that leadership should not be seen as a trait tied to gender but rather as a capability that everyone can and should cultivate. The discussion also covered the importance of creating a supportive environment where mentoring and sponsoring are integral parts of professional development.

Ross Fischer: Facing Fear in Medicine

Ross Fischer followed with a gripping talk on the fears that medical professionals face. He addressed the common anxieties that arise in healthcare, such as the fear of making mistakes and the emotional burden of patient outcomes. Fischer's storytelling was powerful, evoking a strong emotional response from the audience. He encouraged healthcare workers to confront their fears and use them as a source of strength and resilience.

Fischer suggested that his talk be viewed in a quiet setting to allow for personal reflection. His message emphasized that acknowledging fear is not a weakness but a vital step toward personal and professional growth. This session was a reminder that vulnerability is a natural part of the healthcare experience and that facing it can lead to greater compassion and understanding.

Ruben's Dre: Cultural Differences in Managing Agitated Patients

Ruben's Dre's session on managing agitated patients highlighted significant cultural differences in medical practice, particularly between the US and the UK. He discussed the use of physical restraints, a common practice in the US but rare in the UK. Dre's presentation was both humorous and insightful, challenging attendees to reconsider their practices and remain open to different approaches.

This session underscored the importance of cultural competence in healthcare. Dre emphasized the need to critically evaluate our practices and consider evidence-based alternatives. The discussion provided a valuable perspective on how different healthcare systems approach patient management, highlighting the importance of being adaptable and open-minded.

Liz Crow: The Power of Love and Compassion in Healthcare

Liz Crow delivered one of the most moving talks of the day, focusing on the role of love and compassion in healthcare. Crow argued that these "soft" skills are essential for effective patient care. She shared personal experiences from her work in pediatric ICU, emphasizing that empathy and compassion significantly impact patient outcomes.

Crow challenged the audience to consider how often they bring love and empathy into their professional roles. She noted that while healthcare providers may not frequently discuss these emotions, they are fundamental to the patient experience. Her talk highlighted an often-overlooked aspect of healthcare: the emotional and empathetic connection between providers and patients.

Concurrent Sessions: Diverse Topics and Key Insights

The afternoon offered a variety of sessions covering critical care, anesthetics, burnout, and more. Key topics included the risks associated with procedures in confined spaces, with a strong recommendation to avoid them whenever possible. This practical advice emphasized the importance of safety and preparedness in emergency situations.

Sueman Bizwaz's presentation blended humor with educational insights, reminding attendees of the value of engaging, entertaining education. Christina Henren's talk on the Boston attack response provided a sobering look at crisis management, while Mike Ebeneffi discussed the unique challenges of farm-related trauma in rural healthcare settings.

Bare-Knuckle Debates: A Showcase of Expertise

The bare-knuckle debates brought together experts to discuss controversial topics in emergency medicine. Simon Carley and Ryan Radecki highlighted recent research, while Carley and Scott Wein debated the "Fail Paradigm" in medicine. The debates were thought-provoking, exploring different perspectives on what constitutes failure and how it should be addressed.

Maxwell Wein and Chris Fox discussed the growing role of ultrasound in medical practice, debating its benefits and limitations. The final debate on thrombolyzing submassive PE featured compelling arguments from both sides, illustrating the complexities of clinical decision-making.

SMACC Ultrasonic: Fun and Learning Combined

The day concluded with the SMACC Ultrasonic, a fun and educational competition involving teams from Europe, Australia, and the USA. This event showcased the use of ultrasound in various clinical scenarios, providing a mix of competition and practical learning. The highlight was a playful demonstration involving an ultrasound and a leprechaun, emphasizing the innovative ways ultrasound can be taught.

Looking Ahead: SMACC 2024 in Berlin

The day ended with the exciting announcement that SMACC 2024 will be held in Berlin. The conference will take place in a unique venue with a round setup, promising a fresh and engaging experience. This setting is expected to inspire creativity and innovative presentations, continuing SMACC’s tradition of pushing the boundaries of medical education.

A Day of Insight and Reflection

Day two of SMACC was a rich exploration of the many facets of healthcare, from leadership and fear to the practicalities of patient management and the role of compassion. The sessions provided valuable insights and challenged attendees to think critically about their practices. As we look forward to the rest of the conference and the event in Berlin, we are reminded of the importance of continuous learning and empathy in our professional lives.

We hope you found this recap insightful and inspiring. Stay tuned for more updates, and as always, keep pushing the boundaries of what's possible in healthcare. Until next time, keep learning, keep caring, and stay inspired.

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.

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.

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.

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.

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.

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 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.

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.

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.

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.

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.

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.

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.

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!

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.

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.

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

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.

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.

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.

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

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.

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."

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."

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."

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.

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.

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.

Introduction

Effective communication of difficult news is a critical skill in emergency medicine. This guide, based on a discussion between Iain Beardsell and Liz Crowe, explores best practices for delivering challenging information to patients and their families, emphasizing compassion and clarity.

The terminology used when delivering bad news can significantly impact the recipient's perception. Liz Crowe suggests avoiding phrases like "delivering bad news" or "breaking bad news," as they imply a one-time transaction. Instead, "communicating difficult news" emphasizes an ongoing process that includes listening, support, and engagement. This language shift helps set a compassionate tone and encourages continuous dialogue, reassuring families that they are not alone.

The goal of communicating difficult news is not just to convey information but to build a supportive relationship. Unlike a delivery person who leaves after a transaction, healthcare professionals should remain engaged, ensuring that families feel heard and supported. This involves being present, offering a listening ear, and providing continuous support, which helps families process the news and feel significant during a difficult time.

Healthcare professionals must be self-aware of their emotions and biases when delivering difficult news. Liz points out that under stress, professionals might default to using medical jargon, which can distance them from the family. Recognizing one's emotional triggers and managing them is crucial for maintaining a compassionate demeanor. Self-awareness also involves understanding personal limitations and seeking support when needed, ensuring that caregivers can provide the best possible support to families.

The environment where the news is delivered plays a crucial role. A private, quiet space where everyone can sit comfortably helps create a sense of safety and respect. Healthcare professionals should take a moment to prepare mentally before the conversation, organizing their thoughts and emotions. This preparation helps in delivering the news clearly and calmly, reducing the chances of miscommunication.

Nonverbal cues, such as facial expressions and body language, significantly influence the tone of the conversation. Professionals should approach with a serious and empathetic demeanor, setting the expectation for a difficult conversation. A somber expression can help prepare families for the news, as opposed to a smile, which might create false hope. The first and last things said are particularly memorable, so they should be chosen carefully to ensure clarity and compassion.

Clarity is paramount when delivering difficult news. If a patient has died, it is essential to state this clearly and directly, avoiding euphemisms and medical jargon. Information should be given in small, digestible pieces, allowing families to process it. Professionals should also be prepared to repeat or clarify information, as initial shock can make it difficult for families to absorb all details.

Emotional reactions are natural and expected. Liz advises against immediately offering tissues, as this can imply discomfort with the family's grief. Instead, give them space to express their emotions. Healthcare professionals should be prepared for a range of responses, from tears to anger, and maintain a supportive presence throughout. Validating the family's emotions is crucial, as is allowing them time to grieve.

The conversation should not end after delivering the news. Continuous engagement is vital, including checking in with the family periodically and being available for follow-up questions. This ongoing support helps families feel cared for and reassures them that they are not left to navigate the situation alone. Follow-ups can include arranging further meetings, providing written materials, or referring to counseling services.

When children are involved, the information should be age-appropriate and delivered with care. Liz suggests involving children in the conversation, as excluding them can lead to confusion and mistrust. It is essential to use simple, clear language and to be honest about the situation. Reassuring children that it is okay to feel sad or confused helps them process their emotions.

Cultural and religious beliefs can significantly influence how families perceive and process difficult news. Healthcare professionals should respect these beliefs and tailor their communication accordingly. This might involve understanding specific rituals or customs and involving spiritual advisors when appropriate. Respecting these practices provides comfort and shows respect for the family's values.

Communicating difficult news is a challenging but essential aspect of emergency medicine. It requires empathy, clarity, and a commitment to ongoing support. By focusing on these elements, healthcare professionals can help families feel supported and understood during some of the most challenging moments of their lives. The insights shared by Liz Crowe and Iain Beardsell emphasize the importance of a compassionate and structured approach, ensuring that these conversations are handled with the utmost care and respect.

For more insights on navigating complex topics in healthcare, stay tuned to the St Emlyns blog. We are committed to providing valuable information to support healthcare professionals in their journey of delivering compassionate and effective care.

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.

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.

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.

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.

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.

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 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.

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.