The St.Emlyn’s Podcast

The Paradox of a Good Day in Emergency Medicine: Key Insights 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. Don’t Forget the Bubbles Conference: A Valuable Resource for Pediatric Emergency Medicine 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 and Psychological Impact of Emergency Medicine 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. Bridging the Gap in Adolescent Medicine 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. Continuous Learning: Beyond ATLS and Traumatic Cardiac Arrest 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. The Reality of Intraosseous (IO) Blood Sampling 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. Conclusion: Moving Forward with Insights from June 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. Workplace Safety: A Pressing Concern 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. Leadership in Education: Simon Carley’s New Role 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. Pediatric Status Epilepticus: Evaluating Second-Line Agents 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. Understanding Clinical Trials: The Importance of Statistical Literacy 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. Prolonged Field Care in the ED: Learning from Military Medicine 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: Reassessing Cardioversion Strategies 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. Traumatic Cardiac Arrest: Reevaluating Chest Compressions 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 in Pain Management: An Emerging Tool 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. The Power of Peer Review: Enhancing Clinical Practice 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. Conclusion 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.

The Evolution of Traumatic Cardiac Arrest Management: Military Insights and Civilian Applications 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. Traumatic Cardiac Arrest: Insights from Military Experience 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. From the Battlefield to the Emergency Room: Evolving TCA Management 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: External Hemorrhage Control involves ensuring that tourniquets are properly applied and functioning, alongside other measures to control external bleeding. Oxygenation and Ventilation: Rapid intubation and ventilation to maintain oxygen delivery to vital organs. Bilateral Thoracostomies: Decompressing the chest on both sides to manage potential tension pneumothorax. Rapid Volume Replacement: Administer warm blood and blood products intravenously or intraosseously to quickly replace lost volume. Pelvic Binding: Applying a pelvic binder in cases of blunt trauma to reduce pelvic volume and control bleeding. 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. Challenging Old Assumptions: New Data on TCA Survival 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. The Controversy Around Chest Compressions in TCA 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. Key Findings: Prioritizing Blood Over Compressions 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. Translating Research into Practice 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. Conclusion: A New Paradigm for Traumatic Cardiac Arrest 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. Understanding the Crisis Point 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. Preparing for a Crisis Before It Happens 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. What to Do 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. The Path to Recovery 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. Dealing with Shame and Guilt 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. Moving Forward 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. Conclusion 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.

St. Emlyn's April 2019 Podcast Highlights 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. Andromeda Shock Trial: A New Perspective 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. Enhancing Learning with Minimal Effort 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. Aortic Emergencies: Key Insights from George Willis 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. Ambulatory Care for PEs: Dan Horner's Expert Insights 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. Coping with Clinical Tragedies: Liz Crowe's Personal Journey 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. Final Thoughts 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.  

Highlights from March 2019: Key Insights and Updates 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. Management of Adult Congenital Heart Disease 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. Common Issues in ACHD Patients 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. Key Takeaways for Emergency Physicians 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. A Deeper Dive into Fontan Circulation 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. Top Trauma Papers from the Trauma UK Conference 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 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. Bougie Use in the ED 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. Late Presenting Head Injury Patients 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 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. Responsible Volunteering Overseas 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. The Ethics of Volunteering 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. Volunteering Responsibly 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. Case Study: Volunteering in South Africa 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. The Future of SMACC: CODA 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: A New Beginning 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. Looking Ahead 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. What to Expect from CODA 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. Additional Highlights from March Critical Appraisal Nuggets (CANS) on P-values 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. Dual Coding in Medical Education 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. The Impact of Reboa in Trauma Care 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. The Role of Evidence-Based Practice 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. Final Thoughts 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. Stay Connected 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. vb S 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