The St.Emlyn’s Podcast

Welcome to the St Emlyn's Podcast: October 2018 Highlights Hello and welcome to this St Emlyn’s podcast. My name is Simon Carley, and today I'm thrilled to take you through all the exciting events and updates we've been involved in this October 2018. This month has been bustling with activities, learning opportunities, and insightful experiences that we are eager to share with you. The Inaugural St Emlyn's Live Conference We kicked off October with a bang by hosting the first-ever St Emlyn’s live conference in Manchester. This landmark event brought together a diverse group of delegates and speakers, creating a vibrant atmosphere of learning and collaboration. The focus was on the four pillars of emergency medicine as we see it at St Emlyn’s: Emergency and Spades Medicine Excellence in Critical Care Wellbeing The Philosophy of Emergency Medicine We had an incredible day filled with discussions on why we do what we do and how we can continue to improve our practices. The energy and enthusiasm from the participants were palpable, and we are excited to share all the presentations and insights from this event over the coming months. Stay tuned to our blog and media channels for updates. Five Ways to Improve Your Resuscitation Skills One of the highlights from the conference was my presentation on "Five Things You Can Do to Improve Your Resuscitation." Although the video is not yet released, the blog post is available, and I want to give you a sneak peek into some practical tips that can make a significant difference in your practice. 1. The Zero Point Survey The zero-point survey is a concept introduced by Cliff Reid, emphasizing the importance of preparation before patient contact. Your resuscitation process should begin the moment you hear about the patient, not when you meet them. This preparatory phase includes ensuring your physical readiness, team coordination, and environment setup. Key Steps: Self-preparation: Ensure you are physically and mentally ready. Team readiness: Identify team roles and confirm competency. Environmental setup: Check equipment, ensure visibility, and prepare necessary tools. 2. 10 in 10 The 10 in 10 concept involves taking 10 seconds every 10 minutes during a resuscitation to reassess and communicate with your team. This regular pause helps in reappraising the situation and updating your mental models, ensuring everyone is on the same page. 3. Fly the Patient and Then Think In emergency medicine, drawing from aviation, one person should focus on maintaining the basics (aviate) while another makes higher-level decisions (navigate and communicate). In a resuscitation scenario, one team member should follow the algorithm and manage immediate life support, while another considers broader strategies and decisions. 4. Peer Review Peer review is essential for growth and self-awareness. Having someone observe your practice and provide feedback can uncover blind spots and improve your performance. This process benefits both the observer and the observed, fostering a culture of continuous improvement. 5. Hot Debriefs Adopted from the Edinburgh emergency departments, hot debriefs are quick, five-minute sessions immediately after an event. This practice allows teams to reflect on their performance, discuss what went well, and identify areas for improvement. Implementing hot debriefs can enhance team dynamics and overall performance. Enhancing Education in Busy Environments In another educational blog this month, I discussed how to teach and learn effectively in a stretched environment, drawing from a talk at the Royal Society of Medicine in London. Contrary to popular belief, being busy does not preclude learning opportunities. Data from the GMC survey indicates that exposure to relevant cases and support in learning significantly impact trainee satisfaction, rather than workload alone. Effective Teaching Strategies: Post-it Polls: Write down interesting cases or learning points throughout the day and display them on a board for everyone to see and discuss. FOAMed Prescriptions: Share relevant online resources with trainees to reinforce learning through spaced repetition. Social Media Utilization: Use platforms like WhatsApp and message boards to discuss cases and share insights while maintaining confidentiality. Cricoid Pressure and RSI: Ongoing Debates We revisited the controversial topic of cricoid pressure in rapid sequence intubation (RSI) with a journal club post. Despite longstanding debates, recent evidence, including a study published in JAMA, suggests that cricoid pressure may not significantly impact laryngoscopy success rates. However, it might still be beneficial in specific high-risk scenarios. The key takeaway is to make informed decisions based on the latest evidence rather than following traditional practices blindly. FemInEm Conference Highlights Natalie May attended the FemInEm conference in New York and shared her insights in a detailed blog post. The FemInEm group focuses on promoting gender equity in emergency medicine but offers valuable resources for all practitioners. Natalie’s presentation on avoiding the use of the word "sexy" in emergency medicine was particularly thought-provoking. Stay tuned for more from this inspiring conference. Pursuit of Excellence in Emergency Medicine Natalie May also delivered a keynote presentation at St Emlyn’s Live on the pursuit of excellence. Drawing from her experiences in the UK and Australia, she emphasized the importance of continuous learning and collaboration with colleagues. Her talk highlighted that achieving self-actualization in emergency medicine requires support from a dedicated team, reflection, and a commitment to improvement. Addressing PTSD in Emergency Medicine Rusty Carroll continued his series on PTSD, exploring novel therapies such as eye movement desensitization and reprocessing (EMDR), now approved by NICE. This installment provides valuable insights for those dealing with PTSD, offering hope and practical solutions. Looking Ahead As we wrap up October, we have an array of exciting content lined up for November and beyond. We will be releasing more materials from St Emlyn’s Live and sharing insights from our Teaching Co-Op course. The course was a fantastic experience, and we are considering hosting it again due to popular demand. In the meantime, we encourage you to engage with our blogs, videos, and social media channels. Join us in our journey to improve emergency medicine practices and enhance patient care. Stay connected, stay curious, and enjoy your adventures here at St Emlyn’s. Thank you for being a part of the St Emlyn’s community! By following these tips and strategies, you can optimize your practice, foster a culture of continuous learning, and improve patient outcomes. Don’t forget to subscribe to our blog and podcast for the latest updates and insights from the world of emergency medicine.    

  This presentation was given at the inaugural #stemlynsLIVE conference on the 8th of October 2018 in Manchester. You can read more about the presentation and the conference here. https://www.stemlynsblog.org/in-pursuit-of-excellence/

September Review: Key Insights from the Sentemlyns Podcast Welcome to the latest edition of the Sentemlyns podcast blog. I’m Simon Carly, and today we're diving into the significant papers and events from September. We're a tad late this month due to the bustling activities surrounding the Sentemlyns conference and the Teaching Court course, both of which were tremendous successes here in Manchester. Stay tuned as we delve into the highlights of September, from groundbreaking studies to enlightening conferences. Management of the Airway in Cardiac Arrest Key Studies by Ashley Levy We kick off with a comprehensive look at two pivotal papers by Ashley Levy, focusing on airway management in cardiac arrest. These studies, eagerly awaited by the medical community, provide critical insights into pre-hospital care. Airways 2 Study Published in JAMA in August, the Airways 2 study examined over 9,000 patients in the UK pre-hospital environment who suffered cardiac arrests. The study excluded patients who quickly returned to spontaneous circulation after a couple of shocks. The remaining patients were randomized into two groups: those receiving a supraglottic airway and those receiving an endotracheal tube. Findings: The study revealed no significant difference in outcomes between patients who received endotracheal intubation versus those with a supraglottic device. This challenges the long-held belief that intubation is superior in cardiac arrest scenarios. Implications: The findings suggest that in pre-hospital settings, the choice of airway device might be less critical than previously thought. It underscores the importance of managing ventilation effectively, regardless of the airway device used. For many practitioners, this means opting for the quickest and easiest airway device, typically a supraglottic airway. However, in prolonged or complex cases, converting to an endotracheal tube might still be preferable. Laryngeal Tube vs. Endotracheal Intubation in the US Study Another study published in JAMA, conducted in the US, compared endotracheal intubation with the use of a laryngeal tube. Similar to the Airways 2 study, it found no significant advantage to using an endotracheal tube. Interestingly, this study hinted at a slight benefit for the laryngeal tube, though this requires further investigation. Conclusion: Both studies indicate that for pre-hospital cardiac arrest, the priority should be securing an airway quickly and effectively. While supraglottic airways may suffice in many cases, endotracheal tubes remain a viable option in more complex scenarios. Global Health and Responsibility Stefan Brujins’ Perspective Stefan Brujins, a friend and colleague now working in the UK, provided a thought-provoking post on our responsibilities toward global health. Reflecting on his experiences growing up in South Africa, Stefan challenges us to reconsider our assumptions about equality and diversity in healthcare. He directs us to an impactful presentation by Annette Alenio at SMACC, emphasizing the need for togetherness in global health. This presentation is a must-watch for anyone interested in global health, offering valuable insights on how we can contribute more effectively to the global medical community. Highlights from the EUSEM Conference Diverse Learning Experiences The EUSEM conference, a combined event with the Royal College of Emergency Medicine, held in Glasgow, was a highlight of September. This event is renowned for its diversity and the unique learning opportunities it offers. Treatment of Massive PE by Dan Horner Dan Horner kicked off the conference with an insightful presentation on managing massive pulmonary embolism (PE). His update reflects the latest advancements and the complexities involved in clinical decision-making for thrombolysis in emergency settings. The emphasis on shared decision-making between clinicians and patients was particularly noteworthy. European Simulation Cup Victory Members of the Sentemlyns team joined the Royal College of Emergency Medicine team in the European Simulation Cup and emerged victorious. This competition, involving around 14 teams, culminated in a major incident simulation. The win was a testament to the team's skill and collaboration. Narrative Learning and Storytelling in Emergency Medicine Simon Carly’s Presentation I had the opportunity to present on the use of narrative learning and storytelling in emergency medicine. While not a traditional clinical topic, the importance of engaging learners through storytelling cannot be overstated. Case reports, despite being viewed skeptically in literature, remain powerful tools for education when used correctly. I drew heavily on the work of Jonathan Gottschall, particularly his book "The Storytelling Animal." Understanding the science behind storytelling can transform educational strategies, making them more effective and memorable. Managing Sick Neonates Natalie’s Comprehensive Guide Neonates, with their unique physiology, often present challenges in emergency medicine. Natalie provided an excellent post on managing sick neonates, using the analogy of micro machines to explain various aspects of neonatal care. From glucose metabolism issues to identifying cardiac problems in premature babies, her guide is invaluable for practitioners who may not regularly deal with neonates. Monkeypox Awareness Janis Byombi’s Expertise Monkeypox, a relatively obscure virus related to smallpox, has seen a recent outbreak with cases imported to the UK. Janis Byombi, our expert in international and tropical diseases, detailed the symptoms, diagnosis, and management of monkeypox. While generally self-limiting, awareness and proper handling are crucial, especially for healthcare workers who might be at risk. RecessTO Conference Insights Innovative Approaches to Learning Ashley Liebergen shared her experiences from the RecessTO conference organized by Chris Hicks in Toronto. The conference's innovative approach combined traditional knowledge sharing with practical workshops and simulations, enhancing the overall learning experience. This method of building knowledge progressively throughout the day was particularly effective and engaging. EMS Gathering in Ireland Learning with Leisure The EMS Gathering in Cork, Ireland, offered a unique blend of formal lectures and experiential learning. This “learning with leisure” approach took attendees to various locations around Cork for hands-on experiences, from airport emergencies to extrications. Emotional Learning Experience One standout session was a cardiac arrest scenario staged in a theatre, focusing on the interaction between medical teams and the patient's relatives. This emotionally charged and theatrically presented scenario highlighted the importance of communication and empathy in emergency medicine. Zero Point Survey Enhancing Resuscitation Preparedness Finally, I rounded off September with a post on the zero-point survey. This concept emphasizes that resuscitation begins before the patient arrives, utilizing the critical minutes from the initial alert to prepare thoroughly. This proactive approach can significantly improve resuscitation outcomes and efficiency. Conclusion September was a month of substantial learning and reflection for the Sentemlyns team. From groundbreaking studies in airway management to innovative approaches in global health and emergency medicine education, we've covered a broad spectrum of topics. As we look forward to October and beyond, we remain committed to bringing you the latest insights and developments in emergency medicine. Thank you for joining us on this journey. Stay tuned for more updates and have a great day!

St Emlyn’s Monthly Round-Up: August Highlights and Key Insights Hello and welcome to the St Emlyn’s blog! I’m Simon Carley and today; I’m thrilled to share with you some of the standout moments and key insights from our blog in August. Yes, I know it’s October now, but we’ve been incredibly busy organizing the St Emlyn’s Live and the teaching course in Manchester. More on that in a later post. It’s been a fantastic period for us, and even though we’re a bit behind, it’s perfectly okay. Let’s dive into some spaced repetition and revisit the exciting content from August. Natalie May’s Adventures Down Under In August, we featured a series of blogs by Natalie May, chronicling her experiences at the Emergency Medicine of South-Os conference in Australia, where she served as a keynote speaker. Natalie covered several essential topics during her time there, providing valuable insights and lessons for emergency medicine professionals. One of the key sessions she highlighted was about the effective use of apps in emergency medicine. This session was particularly interesting as it covered various clinical applications that can enhance productivity and patient care. Natalie shared top tips from her session, many of which she personally uses. This collection includes clinical tools and productivity apps, making it a must-read for anyone looking to optimize their practice. Many of these tips also tie back to a post by Scott Weingart from a few years ago about getting things done in emergency medicine. Natalie’s update builds on Scott’s foundation, providing new insights and practical advice for today’s busy and complex medical environment. Lessons Learned at the Conference Another highlight from Natalie’s posts was a session on lessons learned. This session brought together five respected professionals—Gary Birk, Jesse Spur, Natalie herself, Ian Summers, and Tim Lewinburg—who discussed instances where things didn’t go as planned. These stories weren’t just about clinical errors but also about soft skills, which, as we know, are anything but soft. The panel covered communication issues, handover challenges, and awareness of equality and diversity in the emergency department. One poignant story involved an equality and diversity issue where Natalie acknowledged a consultation that didn’t go as expected. These discussions are crucial as they address elements that are challenging to learn from textbooks but significantly impact patient care and team dynamics. Rick Body’s Troponin Insights Moving on, we had an exceptional post by Rick Body on troponin, specifically focusing on high-sensitivity troponin samples. Rick is a leading authority on troponin, and his insights are invaluable. One particularly critical point he raised was the impact of biotin supplements on troponin assays. Rick explained that patients taking biotin might show negative troponin results even when there is a myocardial infarction. This is a significant finding as it could lead to missed diagnoses. Rick advises emergency departments to either determine the type of analyzer their lab uses or routinely check biotin levels in patients to avoid potentially serious errors. This post is a must-read for anyone involved in emergency medicine as it provides practical advice to enhance diagnostic accuracy. SMAC Conference and the CESR Route August was also a month of anticipation for the upcoming SMAC conference. We discussed the excitement surrounding this event, which promises to be an incredible gathering of emergency medicine professionals. If you haven’t registered yet, make sure to do so as this will be the last SMAC, and it’s set to be unforgettable. We also explored the CESR route in the UK. For those unfamiliar, the CESR (Certificate of Eligibility for Specialist Registration) is an alternative path to becoming a consultant in emergency medicine. Unlike the traditional six-year training program, the CESR route is portfolio-based and has recently undergone some changes. Gareth, who has successfully navigated this process and joined us as a consultant, shared his experiences and offered practical advice. His insights are particularly valuable for anyone considering this path, emphasizing the importance of early preparation and understanding the requirements. Intravenous Fluids in Critical Care One of the standout academic reviews we featured in August was on the use of intravenous fluids in critical care. Authored by Silam Lam, John Myberg, and Armando Bellomo, it provides a comprehensive overview of current best practices and evidence in fluid management. The review highlights several key points. Firstly, the evidence base for most IV fluids is surprisingly weak, which is concerning given how widely they are used. The traditional approach of aggressive fluid resuscitation (fill them up until they can’t take any more) is now considered potentially harmful. Instead, a more cautious and mindful approach is recommended. The review also discusses the importance of choosing the right type of fluid and adjusting the volume based on the type of shock. Dynamic assessment tools like point-of-care ultrasound are emphasized as they provide real-time insights into patient status, making fluid management more precise. The paper also touches on the role of the glycocalyx, an essential barrier between intravascular and extracellular fluid, which plays a critical role in fluid management during illness. Avoiding Harmful Fluids In addition to general fluid management principles, the review provides specific recommendations on which fluids to avoid. Hydroxyethyl starch solutions, for instance, should not be used, a point we have reiterated on the blog before. Gelatin, another fluid type, is also not recommended due to its limited benefits and potential risks. Human albumin, although used more frequently in critical care, especially for conditions like sepsis, does not show significant advantages in most scenarios and should be avoided in traumatic brain injury. The ongoing debate between balanced solutions and normal saline is also addressed, with the review suggesting that balanced solutions may offer slight advantages in certain contexts. Moral Injury in Emergency Medicine Finally, we revisited a fantastic paper and podcast on moral injury by Esther Murray. This topic has resonated deeply with many in the emergency and critical care fields. The paper explores the psychological and emotional challenges faced by healthcare professionals, particularly those working in high-stress environments. Esther’s discussion on moral injury—how the distress from perceived ethical transgressions impacts healthcare workers—is incredibly poignant. Given the increasing focus on mental health and well-being in our profession, understanding and addressing moral injury is crucial for sustaining our workforce. This small but significant study sheds light on an issue that many of us have experienced, even if we haven’t fully acknowledged it. Wrapping Up August’s Highlights August was indeed a month packed with valuable insights and crucial updates for the emergency medicine community. From Natalie May’s adventures and lessons learned to Rick Body’s troponin wisdom and the comprehensive review on intravenous fluids, there was a wealth of information to absorb and apply in practice. We also delved into the practicalities of the CESR route, providing a roadmap for those considering this alternative path to consultancy. The discussion on moral injury, led by Esther Murray, reminded us of the importance of addressing the emotional and psychological well-being of healthcare professionals. As we move into the latter part of the year, we look forward to bringing you more cutting-edge research, practical tips, and thought-provoking discussions. Stay tuned for the September podcast and the exciting content we have lined up from recent conferences. Thank you for being a part of the St Emlyn’s community, and here’s to continuing our journey of learning and improving patient care together.

EMS Gathering round up 2018 with Simon Carley and Aidan Baron. See www.stemlynsblog.org Apologies for the sound quality on this one, it was all done in a fairly noisy environment. Don't forget to listen to special guests from 23 mins onwards.

This week we recorded a podcast inspired by a recent publication in the EMJ. Esther Murray aka @EM_Healthpsych is a psychologist working in London. Her recent paper on whether the experiences of medical students might precipitate moral injury during their pre-hospital experiences gives  an insight into how we all cope with and respond to the clinical work we do. Some of the work we do is traumatic, painful and morally difficult to rationalise. We are witness to the very worst aspects of some of our patient’s lives and there may be a price to pay. I was delighted to explore some of the concepts around moral injury in this podcast and would really recommend that you read the paper 1 and consider whether this is something that can affect ourselves and our colleagues. The paper is open access at the moment so there is no excuse not to 😉 Although the paper is based on a small number of participants from only one aspect of the healthcare system it does recognise this limitation and alludes to future work with different groups of clinician. What is Moral Injury? Esther describes ‘moral injury’ as a concept emerging from work with military veterans. It is used to describe the psychological sequelae of ‘bearing witness to the aftermath of violence and human carnage

The Sintervenants Podcast: July Highlights - Game Theory, PTSD, Epinephrine Trials, and More Hello and welcome to The Sintervenants Podcast. I'm Simon Kelly, and today I’m going to guide you through the exciting developments in July. While we all enjoy the summer weather, there’s a lot more to discuss beyond vacations. Here’s what’s been happening in the world of emergency medicine. Game Theory in Emergency Medicine: Finite and Infinite Games This month, we delve into a fascinating post by my colleague, Craig Ferguson, about game theory and its application in emergency medicine. This concept revolves around finite and infinite games, an idea rooted in game theory, which you might recognize from the film A Beautiful Mind. The book it’s based on is also highly recommended for those interested in deeper insights. Understanding Finite and Infinite Games Finite games, such as chess, have known rules, defined endpoints, and players aware of their roles. Conversely, infinite games, like a soccer league, continue indefinitely. In these games, the objective is to stay in the game, continually evolving and adapting until resources are exhausted or other external factors intervene. Application in Healthcare In healthcare, particularly emergency medicine, Craig highlights the challenges posed by infinite games. Emergency medicine is an infinite game with no definitive endpoint. The objective is to keep going, continually providing care without a final goal. However, health service management often imposes finite rules, such as performance targets and time-based metrics. These finite measurements can clash with the infinite nature of healthcare, creating challenges and unintended consequences. For example, measuring patient flow and quality of care through finite metrics in an emergency department doesn’t account for the complex, non-linear nature of healthcare systems. Changes in one area can lead to unforeseen issues in another, complicating the overall performance and outcomes. Craig’s post has shifted my perspective on my shifts, especially during challenging times. It’s not about meeting arbitrary targets but understanding the infinite game we’re playing. Recognizing this can alleviate some pressure and help focus on continuous improvement rather than finite measures. Rusty Carroll's Insights on PTSD Another compelling post this month comes from Rusty Carroll, a clinician who has openly shared his journey with PTSD. His series, "Keep Walking: PTSD and Me," provides a candid look at the early stages of PTSD and the challenges of maintaining a facade of normalcy while dealing with underlying trauma. The Reality of PTSD in Emergency Medicine Rusty’s experience highlights the temptation and necessity for many clinicians to keep going despite severe emotional and psychological strain. The work-play-sleep-repeat cycle can mask serious issues, preventing individuals from seeking the help they need. This series aims to help those who haven't experienced PTSD understand the lived experiences of those who have, offering insights into coping mechanisms and the importance of addressing mental health openly. Emergency medicine professionals often face traumatic events, making Rusty’s story particularly relevant. Understanding these experiences can foster empathy and support within the community, encouraging those struggling to seek help without fear of stigma. The Controversy Over Epinephrine in Cardiac Arrest In July, we also reviewed a significant trial on the use of epinephrine in out-of-hospital cardiac arrest, published in the New England Journal of Medicine. This British-led trial by the paramedic two collaborators, spearheaded by Gavin Perkins, has been highly anticipated due to ongoing debates about the efficacy of epinephrine (commonly known as adrenaline in Manchester) in such cases. Key Findings of the Trial The randomized controlled trial involved over 8,000 participants and focused on patients who had not responded to initial defibrillation. The primary outcome measured was the survival rate at 30 days, showing a survival rate of 3.2% in the epinephrine group compared to 2.4% in the placebo group. While this suggests a significant benefit in terms of survival, the secondary outcomes raise ethical questions. Severe impairment, measured by the modified ranking scale, was more common among survivors in the epinephrine group. This finding complicates the interpretation of the results, as it indicates that while more patients survive, many suffer from severe neurological impairment. Ethical Implications The ethical dilemma here is whether increasing survival rates justifies the higher incidence of severe impairment. This question extends beyond medical practice into the realm of medical ethics and societal values. As clinicians, our goal is neurologically intact survival, aligning with public preferences for quality of life over mere survival. Despite the trial’s insights, it doesn’t provide a definitive answer. As practitioners, we must weigh these findings carefully, considering the broader implications for patient care and quality of life. Upcoming Events and Updates Teaching Power Course We’re excited to announce that the Teaching Power Course in October is almost sold out. By the time this post goes live, it might already be fully booked, which is fantastic news. This course, held in Manchester, promises to be a valuable learning experience for all attendees. Sintervenants Live Conference Tickets are still available for the Sintervenants Live Conference on October 9th. We’ve designed this event to be both affordable and enriching, featuring an international faculty that you won’t find at any other one-day course in the UK. Don’t miss this opportunity to join us for an exciting day of learning and networking. Practical Insights: Managing Paronychia Lastly, I’d like to highlight an insightful post by Natalie May on the management of paronychia. While not as high-profile as other topics, paronychia is a common and painful condition that we don’t always manage effectively in the ED. Effective Treatment Strategies Natalie’s review examines the formation of paronychia and the best treatment options. Our previous small randomized control trial suggested that lifting the nail fold is more effective than incision and drainage. Natalie’s findings support this approach, advocating for less invasive methods to alleviate pain and promote healing. Key tips include soaking the affected area and using appropriate tools to lift the nail fold gently. For more severe cases, inserting a small wick can aid healing by allowing drainage without creating a new wound. Natalie also advises on recognizing conditions that mimic paronychia, such as osteomyelitis or tendon injuries, ensuring comprehensive and accurate treatment. This practical advice can significantly improve patient care in emergency settings, providing quick relief and better outcomes for those suffering from this common ailment. Conclusion July has been a month of significant insights and developments in emergency medicine. From exploring game theory and its application in healthcare to understanding the complexities of PTSD and navigating the ethical dilemmas of epinephrine use in cardiac arrest, we’ve covered a wide range of topics. These discussions underscore the dynamic and challenging nature of our field. By continually learning and adapting, we can improve our practices, support our colleagues, and ultimately provide better care for our patients. Thank you for joining us on The Sintervenants Podcast. Keep an eye on our blog and podcast for more updates and insights. If you’re attending our events in October, we look forward to seeing you there. Until then, stay engaged, stay informed, and keep making a difference in the world of emergency medicine.

The Evolution of IV Fluid Therapy: A Critical Review Welcome to St Emlyn's blog. Today, we explore the evolving landscape of intravenous (IV) fluid therapy in pediatric care. I'm Simon Carly, and I had the privilege of discussing this topic with Dr. Steve Playful at the Royal Manchester Children's Hospital. We delved into the historical context, current practices, and future directions of IV fluid therapy. Here's a comprehensive review of our discussion. Historical Context of IV Fluids in Pediatrics The use of IV fluids in pediatrics has undergone significant changes over the years. Approximately 20 years ago, the standard practice involved administering hypotonic fluids to children. This practice was rooted in research from the 1950s that misjudged children's electrolyte and fluid requirements, leading to widespread use of solutions like 0.18% saline with 5% glucose. However, this approach had its drawbacks. While individual practitioners might not have frequently observed issues, numerous instances of iatrogenic hyponatremia leading to cerebral edema and death highlighted the risks. This spurred a reevaluation of IV fluid therapy practices in pediatrics. Transition from Hypotonic to Isotonic Solutions By the late 1990s, concerns about the dangers of hypotonic solutions grew. In 2006, the National Patient Safety Agency in the UK formed a group to address these concerns. They concluded that most children could safely receive half-normal saline as maintenance fluid, except in high-risk situations, marking a significant shift from previous practices. The pediatric community started adopting isotonic solutions, such as normal saline. However, normal saline (0.9% sodium chloride) presents its own issues. Despite its name, it is not truly "normal" as its sodium content is slightly higher than plasma levels, and its chloride content is about 60% higher. Moreover, the pH of normal saline is around 5.5, far from physiological levels. Emergence of Balanced Solutions Balanced solutions have emerged as a promising alternative to both hypotonic and isotonic solutions. Designed to more closely mimic the body's natural plasma, solutions like Ringer's lactate and Plasma-Lyte have gained popularity in the UK. These balanced solutions are buffered with substances like acetate or gluconate to maintain a more physiological pH. Plasma-Lyte, for instance, is available with and without dextrose, making it versatile for different clinical scenarios. These solutions are typically better tolerated and associated with fewer complications compared to normal saline. The Debate: Saline vs. Balanced Solutions The debate over the optimal type of IV fluid for pediatric patients continues. Recent studies, including large international trials, suggest balanced solutions are associated with fewer complications than normal saline. These complications include hyperchloremia, which can lead to acute kidney injury and other adverse outcomes. Despite these findings, normal saline remains the most commonly administered IV fluid worldwide. This persistence is largely due to tradition and established practices. Changing these deeply ingrained habits requires substantial evidence and updated clinical guidelines. Key Studies and Evidence Several studies highlight the benefits of balanced solutions over normal saline. Research indicates that balanced solutions result in less acidosis and fewer chloride level shifts without demonstrated harm. However, not all studies show significant differences. The SPLIT trial, for instance, did not find a marked difference between the two fluid types, though this study had limitations, including uncontrolled pre-enrollment fluid administration and varying severities of illness among patients. Future Directions in IV Fluid Therapy As we look ahead, several areas of interest in IV fluid therapy emerge. One key question is which balanced solution is optimal for pediatric patients. Current options include fluids buffered with acetate and gluconate versus those buffered with lactate. Further research is needed to compare these solutions directly. Another potential development is the inclusion of bicarbonates in balanced solutions. Stabilizing bicarbonates in plastic containers has been challenging, but advances in technology may eventually make this possible, offering a more complete balanced solution. Practical Recommendations For clinicians, the decision on which IV fluid to use should be guided by the latest evidence and tailored to the patient's needs. Here are some practical considerations and recommendations: Review the Evidence: Stay informed about the latest research comparing saline and balanced solutions. Reflect on the pathophysiological basis for each type of fluid. Consider the Patient's Condition: For most pediatric patients, balanced solutions are likely safer and more effective. However, specific clinical scenarios may require different approaches. For instance, patients with pyloric stenosis or certain nephrological conditions may benefit from tailored fluid compositions. Monitor and Adjust: Fluid therapy should always be closely monitored and adjusted based on the patient's ongoing needs and responses. This includes considering electrolyte levels, acid-base balance, and overall clinical status. Educate and Advocate: Part of the challenge in shifting to balanced solutions is overcoming established practices and resistance to change. Educate colleagues and advocate for evidence-based practices within your institution. Conclusion The evolution of IV fluid therapy in pediatrics mirrors broader trends in medical practice: the quest for safer, more effective treatments, and the need to challenge established norms with new evidence. While much remains to be learned, current evidence strongly supports the use of balanced solutions over traditional saline in most pediatric scenarios. As clinicians, it's our responsibility to stay informed and adapt practices based on the best available evidence. By doing so, we can improve patient outcomes and advance the field of pediatric medicine. For those interested in further reading, many of the studies discussed are blogged about on our site. Explore these resources for more detailed discussions and links to original research. Stay informed, stay curious, and continue striving for excellence in your practice. Thank you for joining us on this deep dive into IV fluid therapy. We hope this discussion has provided valuable insights and practical recommendations for your clinical practice. As always, we welcome your thoughts and feedback on this important topic.

Exploring the World of Emergency Medicine: Highlights from BadiM and Resuscitology Conferences Welcome to the St Emlyn's podcast! Today, we're diving into the exciting and insightful experiences from recent conferences in the world of emergency medicine. Join us as we explore the key takeaways and reflections from the BadiM Conference in South Africa and the Resuscitology Conference in Australia. These events not only highlighted innovative approaches to emergency care but also fostered a sense of community and collaboration among healthcare professionals. Setting the Scene: Weather and Warm Welcomes As is customary, let's start with a quick weather update. It was a pleasant 16 degrees in Verchester, and similarly, New South Wales enjoyed beautiful blue skies at 16 degrees. The crisp air and clear skies set a perfect backdrop for our discussions on the latest developments in emergency medicine. BadiM Conference: A Unique Experience in South Africa The BadiM Conference in Greaten, South Africa, was a truly remarkable event. Located about two hours east of Cape Town, the conference was set in the picturesque hills, creating a beautiful and serene environment for learning and networking. This residential conference was a blend of a festival and a professional gathering, fostering a sense of community among attendees. Building a Festival of Ideas One of the standout aspects of the BadiM Conference was its emphasis on community and co-creation. Attendees camped in tents, shared meals, and engaged in discussions in large TP-style tents. This setting broke down traditional power hierarchies and encouraged open and honest conversations. The conference aimed to build a festival atmosphere where learning extended beyond formal sessions to informal interactions over coffee or drinks. Addressing African EMS Challenges The conference kicked off with a focus on African EMS and the unique challenges faced in delivering emergency care in resource-limited settings. Haikert's talk on African solutions for African problems was particularly enlightening. She emphasized the importance of developing context-specific solutions rather than applying models from high-income countries directly to African contexts. This approach highlighted the need for mutual learning and collaboration, ensuring that solutions are relevant and sustainable. The Concept of Relief Porn A thought-provoking concept discussed was "relief porn," which refers to the well-intentioned but often misguided efforts of delivering aid without considering long-term sustainability. The idea is to avoid short-term fixes that may not integrate well into existing systems. Dave Drew's discussion on teaching BLS underscored the importance of building comprehensive systems rather than isolated interventions. Advocacy and Clinician Responsibility Nat Fertil's talk on the role of clinicians as advocates resonated deeply. Drawing parallels between working in a war zone and addressing complex health needs in urban settings, she emphasized the importance of standing by patients who cannot advocate for themselves. This advocacy extends beyond clinical care to addressing social determinants of health. The Gender Unicorn: Caring for LGBTQIA Patients Caleb Lachnitz's talk on the Gender Unicorn and caring for LGBTQIA patients was a highlight. He stressed the need for healthcare providers to understand and respect diverse gender identities and expressions. The Gender Unicorn graphic, which differentiates between gender identity, gender expression, sex assignment at birth, and attraction, was a valuable tool in fostering better understanding and care for LGBTQIA patients. Day Two: Workshops and Practical Learning The second day of the BadiM Conference was workshop-focused, providing hands-on learning opportunities. Feedback in Tricky Circumstances We conducted a workshop on giving feedback in challenging situations. This session aimed to equip participants with skills to provide constructive feedback, even in difficult scenarios. We discussed techniques for addressing behavioral issues and ensuring feedback is productive and empowering. Treating Pregnant Patients and Pediatric Emergencies Penny Wilson's talk on treating pregnant patients was reassuring, emphasizing that treating the mother is often in the best interest of the baby. Ross Fisher's engaging session on pediatric emergencies, specifically addressing foreskin issues, provided practical insights for managing these conditions in the emergency department. Tracheostomy Emergencies in Children A session on tracheostomy emergencies in children, led by James Booth and his team, highlighted the importance of patient education and family collaboration. In settings where community services may be limited, working closely with families is crucial to managing chronic health problems effectively. Ophthalmology and Trauma Care Ophthalmology in remote settings and trauma care were also significant topics. Innovative Ophthalmology Solutions William Mapperman's presentation on using the Vula app for managing eye problems in remote areas showcased the power of electronic media in enhancing healthcare delivery. This app has significantly improved the quality of eye care across South Africa and other African nations. Chest Trauma and Autotransfusion Tim Hardcastle's discussion on chest trauma and the use of drains for autotransfusion was enlightening. This technique, which involves collecting and retransfusing blood from a hemothorax, is a practical solution in resource-limited settings with high rates of penetrating trauma. Managing Coagulopathy and Intubation in Shocked Patients Debates on managing coagulopathy and intubating profoundly shocked patients provided valuable insights. Emphasizing the importance of doing the basics well, such as using TXA and maintaining temperature, was a key takeaway. For intubation, using low doses of ketamine and high doses of rocuronium, along with preparing for cardiovascular collapse, were highlighted as best practices. Human Factors and Emotional Resilience Human factors and emotional resilience were recurring themes throughout the conference. The Impact of Violence and Trauma Dom Pinnick's talk on gangs and domestic violence in South Africa shed light on the broader societal impact of violence. The discussion underscored the need for emergency departments to be prepared for the complex emotional and physical needs of these patients. Sleep Hygiene and Self-Care Natalie May's session on sleep hygiene was a timely reminder of the importance of self-care. Sharing personal experiences and practical tips, she highlighted the universal challenges of sleep deprivation in the medical profession and offered strategies to improve sleep quality. Super Bosses: Leading with Compassion Sardlery's talk on being a "super boss" resonated with many. Emphasizing the importance of amplifying the talents of team members and creating a positive environment, he highlighted the role of compassionate leadership in emergency medicine. Final Day and Closing Reflections The final day of the BadiM Conference was a half-day, focusing on simulation workshops and additional learning opportunities. Simulation Workshops and Major Incident Management Simulation workshops, including a major incident workshop, provided hands-on learning experiences. Discussions on managing major incidents, such as the Manchester bombing and a fuel tanker explosion in Mozambique, highlighted the importance of having a common language and system for emergency management. Venomous Plants and Animals A workshop on venomous plants and animals featuring actual snakes and spiders added a unique and context-specific element to the conference. Understanding local environmental hazards is crucial for providing effective emergency care in different regions. Organ Donation and Cruise Ship Medicine Dave Thompson's session on organ donation in South Africa and Caroline Lewis's talk on working on cruise ships provided diverse perspectives on emergency medicine. These sessions emphasized the need for specialized skills and adaptability in various medical settings. Personal Stories and Patient Safety Kirsten Kingma's personal story of crashing a paraglider and subsequent injuries provided a poignant reminder of the vulnerability of healthcare providers as patients. Her insights into the patient experience underscored the importance of empathy and effective communication in healthcare. Resuscitology Conference: Reflective Learning in Australia The Resuscitology Conference, organized by Cliff Reed, was another standout event. Held in the Blue Mountains of Australia, this residential course focused on case-based reflective learning. Case-Based Learning and Human Factors Participants brought challenging resuscitation cases, which were discussed in detail using the STEPS approach (Self, Team, Environment, Patient, System). This method facilitated deep learning and practical problem-solving. Fresh Air Life and Wellness The concept of "Friluftsliv" (fresh air life) was integrated into the conference, encouraging outdoor activities and wellness. This holistic approach to learning and self-care was well-received by participants. Breaking Bad News and Debriefing One significant takeaway was the idea that breaking bad news does not always have to be the responsibility of the treating clinician. This team-based approach allows for emotional support and cognitive load sharing. The importance of debriefing and support for team leaders was also emphasized. Looking Ahead: Future Conferences and Learning Opportunities As we reflect on these enriching experiences, we're excited about upcoming events. The St Emlyn's Live Conference on October 9th promises to be another exceptional gathering, featuring keynote speakers Natalie May and Claire Richmond from Sydney HEMS. Additionally, the Teaching Co-op Course will offer a masterclass in medical education, focusing on practical skills for bedside teaching and departmental learning. For those interested in Resuscitology, the next event is scheduled for November 15th and 16th. This innovative course will continue to build on the success of its inaugural session, providing a platform for reflective learning and collaboration. The Value of Conferences in Emergency Medicine While conferences can sometimes be seen as mere gatherings, the evolving quality and focus on interactive, participant-driven content have transformed them into valuable learning experiences. Events like BadiM and Resuscitology highlight the importance of community, collaboration, and continuous improvement in emergency medicine. Thank you for joining us on this journey through the world of emergency medicine conferences. We hope to see you at future events, whether in Manchester or Sydney and continue to learn and grow together. Until then, enjoy your practice, stay curious, and keep pushing the boundaries of emergency care.

The Importance of Acute Psychiatric Emergencies Training: Insights from the St Emlyn's Podcast Introduction Welcome to the St Emlyn's blog, where we delve into the latest topics and developments in emergency medicine. Today, we explore a crucial yet often overlooked aspect of our field: acute psychiatric emergencies. This post summarizes a recent conversation between Simon Carley and Kevin McRey Jones, highlighting the significance of addressing psychiatric emergencies within emergency departments. We will shed light on the Apex course, its methodologies, and the vital need for integrating psychiatric care into emergency medicine. Addressing the Gap in Psychiatric Emergency Care Kevin McRey Jones, a key figure in emergency medicine, recently joined the St Emlyn's podcast to discuss the Apex course, an initiative designed to fill a significant gap in emergency medicine training. Despite considerable advancements in managing various medical emergencies, psychiatric emergencies often remain underemphasized. The Apex course addresses this gap by focusing specifically on acute psychiatric emergencies. Kevin explained that while many advancements have been made in managing cardiac, trauma, and obstetric emergencies, psychiatry has not received the same systematic approach. This has led to a fragmented care model where physical and psychological components are often treated separately. The Origins and Purpose of the Apex Course The Apex course, originating in 1992 with the Advanced Life Support Group, was created to systematize the training for managing acute psychiatric emergencies. Kevin, who has a long history of organizing and delivering courses in emergency medicine, emphasized the need for a unified approach to patient care. The course aims to bridge the gap between emergency physicians and psychiatrists, promoting a co-ownership model of patient management. Why Psychiatric Emergencies are Often Overlooked One major reason psychiatric emergencies have not received the same attention as other medical emergencies is the perception that these are problems best handled by psychiatrists or liaison nurses. This mindset leads to a tendency to pass psychiatric cases off to specialists rather than integrating psychiatric care into the emergency department's responsibilities. Kevin highlighted a common issue where patients with both physical and psychological illnesses are often divided into two separate cases: the physical bit managed by emergency physicians and the psychological bit by psychiatrists. This division can lead to suboptimal care and poor outcomes, as the interconnected nature of these issues is overlooked. The Consequences of Ignoring Psychiatric Components Ignoring the psychiatric component of patient care can have severe consequences. Kevin pointed out that patients with psychiatric diseases often have poor outcomes regarding their physical health. This is largely because their physical ailments can be neglected due to the focus on their psychological issues. Simon added that the outcomes for patients with psychiatric diseases, in terms of their physical health, are often terrible. This emphasizes the need for a more integrated approach to patient care, where both physical and psychological aspects are managed simultaneously. The Need for Integrated Care Kevin stressed the importance of co-owning the problem rather than treating psychiatric emergencies as the sole responsibility of psychiatrists. By doing so, emergency departments can provide more comprehensive care, addressing both physical and psychological needs. This integrated approach is essential for improving patient outcomes and ensuring that all aspects of a patient's health are considered. Common Practices and Their Pitfalls Simon discussed a common practice in emergency departments where patients presenting with apparent psychiatric problems are often assessed solely for physical issues before being referred to psychiatric specialists. This "clear them medically" approach can lead to delays in psychiatric care and inadequate management of the patient's overall condition. Kevin acknowledged this issue and emphasized the need for emergency physicians to be involved in the psychiatric assessment and management of these patients. This approach ensures that all aspects of the patient's health are addressed, leading to better outcomes. Rethinking Emergency Care for Psychiatric Patients Simon reflected on the current practices and highlighted the need for change. The idea of dividing patient care into physical and psychological components, with little overlap, is increasingly seen as problematic. Kevin agreed, noting that sometimes organic problems can be overlooked when patients are quickly referred to psychiatric care without a thorough assessment. The Apex Approach: AIOU Methodology The Apex course introduces the AIOU methodology, designed to integrate psychiatric and medical care seamlessly. This structured approach includes: A: Assessment of aggression and agitation. E: Environment in which the patient is assessed. I: Intent of the patient, including suicidal ideation or harm to others. O: Objects the patient may use to carry out their intent. U: Unified assessment, combining both physical and psychological evaluations. Implementing the AIOU Methodology Kevin explained that the AIOU methodology is a co-created approach by psychiatrists and emergency physicians. This collaboration ensures that both physical and psychological aspects of patient care are addressed. The methodology aligns with the primary assessment, resuscitation, and definitive care phases familiar to emergency physicians. Addressing Challenges in Psychiatric Emergency Care Rapid tranquilization is a common concern in managing psychiatric emergencies. Kevin emphasized that the goal is to use the minimum level of intervention required, whether that involves oral medication or, if necessary, safe rapid tranquilization. The course teaches a balanced approach to ensure patient safety and effective management. The Role of Risk Assessment Psychiatry is a risk-driven specialty, focusing on assessing risks of violence, flight, and harm to self and others. Kevin highlighted the importance of minimizing these risks through a structured, systematic approach. This methodology allows for a comprehensive evaluation and management plan that addresses both immediate and long-term risks. Structured Approach to Both Psychiatric and Physical Assessment The Apex course emphasizes a structured approach to both psychiatric and physical assessments. This dual-focus ensures that all aspects of a patient's health are considered, leading to more comprehensive and effective care. Collaboration Between Psychiatrists and Emergency Physicians The course promotes collaboration between psychiatrists and emergency physicians, encouraging them to learn from each other and develop joint solutions to patient care challenges. This partnership is essential for providing holistic care and improving patient outcomes. Co-Assessment and Risk Management The course highlights the importance of co-assessment and risk management. By working together, psychiatrists and emergency physicians can provide a more unified approach to patient care, addressing both physical and psychological needs simultaneously. Substance Abuse and Psychiatric Symptoms Substance abuse often complicates psychiatric emergencies. The Apex course takes a symptom-based approach, focusing on the specific challenges presented by patients with delirium, confusion, aggression, and self-harm. This approach allows for a more tailored and effective management plan. Prevalence and Importance of Addressing Psychiatric Emergencies Psychiatric emergencies are more common than many realize. Kevin noted that about 5% of patients in emergency departments present with direct psychological or psychiatric symptoms. Including substance abuse and alcohol-related cases, this number can rise significantly. Addressing these emergencies systematically is crucial for improving patient care and outcomes. Conclusion The Apex course represents a significant advancement in the training and management of acute psychiatric emergencies. By promoting a unified approach to patient care, it addresses a critical gap in emergency medicine. Collaboration between psychiatrists and emergency physicians is essential for providing comprehensive care and improving patient outcomes. For more information on the Apex course and upcoming training sessions, visit the Advanced Life Support Group's website. Final Thoughts Reflecting on the discussion, Simon emphasized the importance of integrating psychiatric care into emergency medicine. The dichotomy approach, where physical and psychological issues are treated separately, is increasingly seen as inadequate. The Apex course offers a pathway to more comprehensive, patient-focused care, ensuring that all aspects of a patient's health are addressed. How to Learn More For those interested in learning more about the Apex course and upcoming training sessions, visit the Advanced Life Support Group's website at www.alsg.org. The course is offered in various locations, providing opportunities for emergency physicians and psychiatrists to enhance their skills and knowledge in managing acute psychiatric emergencies. By embracing this integrated approach, we can ensure that patients receive the comprehensive care they need, improving outcomes and advancing the field of emergency medicine.