The St.Emlyn’s Podcast

Chest pain that sounds like indigestion, feels mild or seems “atypical” can still be myocardial infarction. The difficult question is not whether troponin is useful, but which patients actually need testing — and how much weight we should give symptoms, cardiovascular risk factors and clinical judgement. Professor Rick Body looks at the evidence behind those decisions, drawing on his own research and other studies of patients with suspected acute coronary syndromes. He explores which clinical features genuinely change the probability of myocardial infarction, which are less useful than we might think, and how to balance the risks of missing MI against unnecessary investigation. In this podcast: Why “heavy” or “crushing” chest pain only modestly increased the probability of myocardial infarction in Rick’s study population. Why indigestion-like pain should not automatically reassure us, and why apparently “atypical” symptoms cannot safely exclude acute coronary syndrome. The diagnostic significance of associated features such as vomiting and, particularly, sweating observed by the clinician. Why dividing chest pain into “typical” and “atypical” presentations has limited discriminatory value. Why having no recognised hypertension, hyperlipidaemia, diabetes, smoking history or family history does not rule out acute myocardial infarction. How clinician gestalt does track with risk, but is not sufficiently reliable on its own to rule myocardial infarction in or out. Why none of this means testing everyone: Rick’s practical approach is to seek a convincing alternative explanation and use troponin when MI remains a plausible diagnosis that has not otherwise been adequately explained. The numerical probabilities discussed come from populations already selected for investigation of suspected myocardial infarction, so they should not simply be transferred to every patient presenting with chest pain. About Rick Body Rick Body is Professor of Emergency Medicine at the University of Manchester and an Honorary Consultant in Emergency Medicine at Manchester University NHS Foundation Trust. His research has focused extensively on diagnostics in acute coronary syndromes, including cardiac troponin and strategies for the early rule-out of myocardial infarction. Timestamps 00:00 – Which patients with chest pain need a troponin? 02:00 – What individual symptoms do to pre-test probability 05:00 – Vomiting and observed sweating 08:00 – The problem with “typical” and “atypical” symptoms 10:00 – Do traditional cardiovascular risk factors help? 13:00 – How reliable is clinical judgement or gestalt? 16:00 – Avoiding both under-investigation and over-investigation 17:00 – Rick’s practical approach to deciding when to test Links and resources The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes Examining the signs and symptoms experienced by individuals with suspected acute coronary syndrome in the Asia-Pacific region ‘Chest pain typicality’ in suspected acute coronary syndromes and the impact of clinical experience Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the Emergency Department? Can Emergency Physician Gestalt “Rule In” or “Rule Out” Acute Coronary Syndrome? Multicentre validation study More from St Emlyn’s St Emlyn’s provides free, evidence-based education for the emergency and acute care community. Explore our blogs, podcasts and other resources. If you have an idea you would like to share, would like to write with us, or want to get involved with St Emlyn’s, we’d love to hear from you. Learning from podcasts? If podcasts form part of your CPD, MedPod Learn helps you turn listening into documented learning. You can use it across all your podcasts — not just St Emlyn’s — to record your listening, make notes, answer questions, reflect on what you have learned and create a record of your CPD.

Laura Kocierz, a critical care and anaesthesia consultant with London’s Air Ambulance, explores traumatic cardiac arrest and resuscitative thoracotomy. They discuss how wound location can suggest tamponade or exsanguination, how ECG patterns may indicate arrest duration, and why physiology could matter more than the traditional 15-minute rule. A sharp look at data-driven trauma decisions.

When does a raised troponin signal myocardial infarction, and when is it simply myocardial injury? This practical discussion explores the Fifth Universal Definition, new MI classifications, sex-specific troponin thresholds, imaging, chronic injury, and the complexities of interpreting troponin deltas. It also examines occlusive ECG patterns beyond conventional STEMI.

A rapid tour through trauma care, from smarter bleeding control and chest-drain timing to preparing patients for safe transfers. The discussion explores emergency department crowding, productivity, and why better systems may matter more than mandatory retraining. It also covers structured smoking-cessation support and catheter-directed treatment for selected higher-risk pulmonary embolism.

A rapid tour of new pulmonary embolism guidance and when to image or intervene. Discussion of emergency department capacity and why system design matters. Debate about prehospital whole blood, uneven HEMS resources, and practical limits of advanced prehospital care. Exploration of using echocardiography and arterial pressure to guide CPR and an innovative pericardial drainage report from Gaza.

Sara Crager, an emergency physician, intensivist and medical educator, discusses how expertise is shaped by mental models rather than hours. She explains teaching thinking explicitly, replacing rote mnemonics with organized frameworks, and using deliberate practice and safe failure. Sara also describes Rapid Sequence, a gamified platform that simulates realistic, interrupt-driven clinical work to make reasoning visible and repeatable.

In this episode of the St Emlyn’s Podcast, Iain Beardsell and Simon Carley catch up on the February blog posts, recorded in the rather unseasonal context of a UK heatwave. They begin with congratulations to Simon on his reappointment as Dean of the Royal College of Emergency Medicine, before reflecting on recent conferences including IFEM in Hamburg and Don’t Forget The Bubbles in Glasgow. The clinical focus this month is trauma team leadership, with practical tips on interpreting trauma CT reports, maintaining momentum after the scan, performing safer log rolls, and making feedback more useful for learners and colleagues. Key learning points Look at trauma CT images yourself as part of your own clinical learning and to integrate the scan with your examination findings. Treat the first CT report as a primary survey, not necessarily a definitive final report. Speak to the radiologist and share clinical concerns or uncertainties. Do not lose momentum after CT; this is a vulnerable phase in trauma care. Log rolls should have a purpose and should minimise movement, pain and physiological risk. Use clearer team communication: “Is anybody not ready to move?” and “ready, steady, move.” Feedback sticks when it is specific. Add “because” to positive feedback so the learner knows exactly what to repeat. Leadership and followership skills apply everywhere, not just in formal trauma team leader roles. Learning from podcasts? If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.

In this episode of the St Emlyn’s Podcast, Iain Beardsell speaks with Anna Dobbie, consultant in emergency medicine and pre-hospital care, and Clinical Lead for London HEMS. Recorded at Trauma 2030 at the Royal College of Surgeons in London, the conversation explores what it means to lead exceptional teams in one of the most high-pressure areas of emergency medicine. Anna reflects on six years as Clinical Lead for London HEMS, sharing lessons on leadership, culture, psychological safety, difficult conversations, managing strong personalities, and supporting clinicians to do their best work. The discussion also touches on the unique nature of pre-hospital care, where teams move rapidly between downtime and high-intensity clinical decision-making, and where trust, openness and mutual respect are essential. Anna describes the importance of making sure all voices are heard, not just the loudest, and explains why leaders need to be consistent, approachable and willing to have honest conversations when things do not go as well as they should. Anna also reflects on learning leadership on the job, the value of formal leadership training, the challenge of maintaining boundaries when you care deeply about a service, and the relationship between London’s Air Ambulance and its supporting charity. Finally, Iain and Anna look ahead to the future of trauma care and pre-hospital medicine, including research, ECMO, marginal gains, quality improvement, and the continuing ambition to reduce preventable deaths from trauma. Learning from podcasts? If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing. Trauma 2030 TRAUMA 2030 united experts and innovators to shape the future of trauma care. Over two days, it explored breakthroughs in science, systems, and frontline practice, fostering collaboration across disciplines. The symposium aimed to inspire research, inform policy, and build a bold roadmap for trauma care worldwide.

In this episode, Iain and Simon catch up on the papers, posts, and conversations that have been sitting with us since the start of the year. Some are familiar. Some are uncomfortable. All of them feel relevant on shift. We start with the RSI trial — ketamine versus etomidate. A study that generated a lot of noise, and perhaps more certainty than it deserved. We move through trauma team leadership. Not as a checklist, but as a set of decisions made under pressure — when to call a Code Red, how to structure a handover, and what it means to lead a team that hasn’t worked together before. There’s a discussion about trauma units. Not the big centres. The places where most patients go. Fewer resources. Different pressures. The same expectations. We talk about spinal cord injury and blood pressure targets. Numbers are useful. But they’re still just numbers. And then corridor care. Not a new problem. But one we may have started to accept in ways that should make us uneasy. We discuss: • What the RSI trial actually showed — and what it didn’t • Why secondary outcomes should make you pause, not pivot practice • How and when to activate a massive haemorrhage protocol • Why early senior decision-making matters more than perfect diagnosis • What good trauma handover looks like — and why it often doesn’t happen • How trauma teams function differently in trauma units • The limits of blood pressure targets in spinal cord injury • Why corridor care is not just operational — but ethical This is not a guideline episode. It’s a conversation about practice. About judgement. About the small decisions that shape outcomes long before the data catches up. If you’re listening after a shift, you’ll recognise most of it. If podcasts are part of how you learn, you can log your listening, reflect, and build CPD through MedPod Learn. It works across podcasts, not just this one. As always, thanks for listening. these ideas are tested in practice. Learning from podcasts? If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.  

Rich Carden, an intensive care trainee and trauma sciences PhD with emergency medicine roots, explains shock as cellular oxygen delivery and use. Short segments cover pressure versus perfusion, the “dose” of shock, transitions from hemorrhage to inflammatory and septic states, the glycocalyx’s role, risks of early vasopressors in an underfilled system, and why flawless basics matter.