In this episode of the St. Emlyn's podcast, hosts Iain Beardsell and Simon Carley share their insights from recent conferences, including Gateshead's RCEM scientific conference, Tactical Trauma 24 in Sweden, and the Premier Conference.

They explore 'Goldilocks moments' for executing life-saving procedures in critical care, emphasizing optimal timing for interventions like thoracotomies. The episode also discusses innovative training methods like shadowboxing to enhance decision-making in high-stress medical scenarios. In addition, they review a significant trial on smoking cessation in emergency departments, highlighting its potential role in broader public health initiatives, including sexual health and HIV screening.

Discussions also cover various pain management strategies, such as the use of intranasal vs. intravenous Ketorolac for renal colic. The hosts critique the traditional peer review process in medical research and advocate for open peer review to support equitable and accessible scientific publishing.

00:00 Introduction and Catching Up

02:07 The Goldilocks Moment in Critical Care

05:25 Training and Decision-Making in Emergency Procedures

07:23 Smoking Cessation in Emergency Departments

10:07 Challenges in Implementing Preventive Health Strategies

10:38 Successful Public Health Projects in Emergency Medicine

11:19 Exploring Alternative Interventions in Emergency Departments

11:52 Highlights from the Premier Conference

12:54 Intranasal Ketorolac for Pain Management

15:46 The Future of Peer Review in Medical Research

20:09 Concluding Thoughts and Upcoming Content

In this episode, recorded at Tactical Trauma 2024, Andrew Petrosoniak discusses real-world experiences in trauma care, and the innovative use of simulation to resolve systematic issues in blood delivery and overall trauma resuscitation protocols.

Key takeaways include the concept of intelligent failure, reducing cognitive overload for medical staff, and the creation of efficient medical environments. Moreover, the episode delves into the significant improvements achieved through simulation, such as a 50% reduction in blood delivery times, and the integration of performance data to enhance CPR and clinical space design. Emphasizing the importance of using data to drive improvements, the conversation explores the implementation of roles like a CPR coach and the scalable application of these practices across individual, team, and systemic levels.

Listeners are encouraged to view failures constructively and leverage simulations and data for better patient outcomes and team performance.

00:00 Introduction to Simulation in Emergency Medicine

01:05 A Real-Life Trauma Case

02:18 Identifying Systemic Issues

02:46 Implementing and Testing Solutions

05:45 The Concept of Intelligent Failure

09:41 Scaling and Impact of Simulation

10:22 The Power of Simulation in Experimentation

10:56 Data Integration in Healthcare and Sports

11:29 Evaluating CPR Quality Through Simulation

12:14 Using Data to Improve Clinical Performance

13:47 Designing Clinical Spaces with Simulation Data

15:28 Scaling Impact with Simulation

18:02 Efficient Team Communication in Trauma Bays

19:04 Broadcasting and Recording Simulations for Education

19:39 Conclusion and Future Directions

Dr. Andrew Petrosoniak is an emergency physician and trauma team leader at St. Michael’s Hospital and an Assistant Professor in the Department of Medicine at the University of Toronto. He has completed a Master of Science in medical education where he focused on the use of in situ simulation (practice in the actual workplace) in procedural skill acquisition.

Andrew’s field of research includes in situ simulation and simulation-based technical skill acquisition. His work focuses on usability testing and the identification of personnel- and systems-based safety threats within acute care medicine. He is the principal investigator of the TRUST study (Trauma Resuscitation Using in Situ simulation for Team Training) that includes a partnership with human factors experts to evaluate systems and processes during high-stakes trauma simulations.

In this episode of the St Emlyn's podcast, Iain Beardsell is joined by Dan Horner, a consultant in Emergency Medicine and Neurocritical Care, and Tom Roberts, an Emergency Medicine Registrar and clinical lecturer, to discuss their recently published SHED study on subarachnoid haemorrhage in the Emergency Department (ED). This landmark study, published in the Emergency Medicine Journal, explores the safety of CT scans in diagnosing subarachnoid haemorrhage up to 24 hours after headache onset and evaluates the role of further investigations like a lumbar puncture.

The study examines acute severe headache presentations in the ED and the diagnostic approach to ruling out subarachnoid haemorrhage, a critical and often feared diagnosis among emergency physicians. Conducted through the Trainee Emergency Research Network (TURN), the study included over 3,600 patients from 88 UK EDs with acute severe headaches reaching maximum intensity within one hour and no focal neurology. Data collection included CT scans, lumbar puncture results, and 28-day follow-up to identify missed cases of subarachnoid hemorrhage.

Key findings from the study revealed a 6.5% prevalence of subarachnoid haemorrhage, with a significant number presenting within six hours of headache onset. The sensitivity of CT scans remained high beyond the traditional six-hour window, suggesting that CT alone could safely rule out subarachnoid haemorrhage up to 18 hours in many cases, potentially reducing the need for lumbar puncture. The risk of missing an aneurysmal subarachnoid haemorrhage after a negative CT was found to be extremely low, around 1 in 1,000.

These findings challenge the routine use of lumbar puncture in patients presenting beyond six hours if the CT scan is negative, potentially changing ED practice and reducing unnecessary invasive procedures. The discussion also emphasized the importance of shared decision-making and recognizing that diagnostic testing is about managing probabilities, not certainties. For clinicians, the episode highlights the need to expedite CT scans for patients with acute severe headaches, especially those presenting within 10 minutes of onset, as they are more likely to have significant pathology. Emergency physicians are encouraged to own the decision-making process for ruling out serious causes of headaches and not defer solely to 'specialists'.

The SHED study supports extending the diagnostic window for CT scans in ruling out subarachnoid hemorrhage up to 18 hours, reducing the need for lumbar puncture in many cases. This data empowers emergency clinicians to make informed decisions, manage patient expectations, and streamline ED processes.

For more information, listeners are encouraged to read the SHED Study in the Emergency Medicine Journal and explore the related blog post on the St Emlyn’s website. Emergency clinicians are also invited to connect with TERN to get involved in future research opportunities.

This episode provides valuable insights for clinicians in managing acute severe headaches, emphasizing a more nuanced approach to subarachnoid hemorrhage diagnosis and the importance of clinical decision-making in the ED.

In this episode, we delve into the critical role of neuroprotection in pre-hospital care, particularly in pediatric head injuries. Through a real-life case study of a 13-year-old boy who suffered a traumatic brain injury after being hit by a car, we explore the steps taken by paramedics and critical care teams to stabilize him and prevent further neurological damage. From airway management to advanced interventions, this episode highlights the challenges of pre-hospital neuroprotection and the incredible teamwork that led to the patient’s remarkable recovery.

There is more detail on the full blogpost here.

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

Ed is a Speciality Trainee in Emergency Medicine in Wessex and a trainee Critical Care Practitioner with Dorset and Somerset Air Ambulance. Ed is also the co-founder and Managing Director of Enhanced Care Services, a Southampton-based company delivering enhanced and critical care to the event medical sector, providing frontline ambulance services across Hampshire and clinical education at all levels, employing over 200 clinicians. Ed holds the Diploma in Immediate Medical Care (RCSEd) and, having promised to not take on any more work, is currently undertaking a Masters in Resuscitation, Pre-hospital and Emergency Medicine at QMUL.

Enhanced Care Services' mission is to provide and influence excellent patient care, irrespective of injury, illness or location, through the delivery of high-quality clinical operations and education. Founded in 2015, ECS now provide frontline ambulance operations across the South, delivers extensive medical cover to some of the most prestigious events across the UK and provides education from its bespoke education centre in Southampton and beyond.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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