The St.Emlyn’s Podcast

Making decisions with incomplete information is part of everyday emergency and trauma care. But when the stakes are particularly high, how do you know when you have enough information to act? Waiting too long may cost lives. Acting too soon may put patients, colleagues or yourself at unnecessary risk.

For our 300th St Emlyn’s podcast, Iain Beardsell revisits conversations he and Liz Crowe recorded at Tactical Trauma in Sweden. Drawing on interviews with Claire Park, Sean Brayford-Harris, Alice Hutin and Chris Bishop, he explores how clinicians and first responders make difficult decisions under pressure, from major incidents and mass casualty triage to prehospital eCPR and ECMO in trauma.

In this podcast:

• How Claire Park uses the 40–70 rule to explore when we have enough information to act, while recognising the risks of entering potentially dangerous scenes.
• Lessons from the London Bridge terrorist attack about delayed treatment, casualty evacuation and the difficult balance between responder safety and patient survival.
• Why the Ten Second Triage tool was designed without physiological measurements, allowing non-clinical responders to prioritise casualties and deliver immediate lifesaving interventions.
• How simple, familiar frameworks can reduce cognitive load when responders are frightened, overwhelmed or working outside their usual clinical role.
• Why the availability of prehospital extracorporeal CPR (eCPR) does not mean every patient should receive it, and the challenges of explaining decisions not to proceed.
• The value of discussing decisions aloud, seeking colleagues' views and debriefing after difficult cases.
• Why veno-arterial ECMO remains controversial after major trauma, particularly because of anticoagulation and bleeding risks, and how multidisciplinary decision-making can help identify potential candidates.

About the contributors

Claire Park is a consultant in prehospital emergency medicine with extensive experience of high-threat incident response. Sean Brayford-Harris is a London Ambulance Service paramedic who helped develop Ten Second Triage. Alice Hutin is an emergency physician working with the prehospital eCPR service in Paris. Chris Bishop is a clinical perfusionist and research fellow investigating VA-ECMO for cardiogenic shock following major trauma.

Links and resources

You can explore the original conversations and their accompanying St Emlyn’s articles:

• Care in the Hot Zone with Claire Park
• Ten Second Triage with Sean Brayford-Harris
• Prehospital eCPR with Alice Hutin
• ECMO in Trauma with Chris Bishop
• NHS England: Ten Second Triage tool and major incident guidance
• Tactical Trauma Conference 2026 – Sundsvall, Sweden, 2–4 November 2026.

More from St Emlyn’s

St Emlyn’s provides free, evidence-based education for the emergency and acute care community. Explore our blogs, podcasts and other resources.

If you have an idea you would like to share, would like to write with us, or want to get involved with St Emlyn’s, we’d love to hear from you.

Learning from podcasts?

If podcasts form part of your CPD, MedPod Learn helps you turn listening into documented learning. You can use it across all your podcasts — not just St Emlyn’s — to record your listening, make notes, answer questions, reflect on what you have learned and create a record of your CPD.

Subscribe to the St Emlyn’s Podcast wherever you get your podcasts.

Tactical Trauma is an international conference held in Sundsvall, Sweden, bringing together doctors, paramedics, police officers, military medics and rescue services to share experiences of delivering care in challenging and sometimes hostile environments. The programme covers prehospital trauma care, resuscitation, major incidents, tactical medicine and human performance, with a particular emphasis on learning from real-world experience. The next conference takes place on 2–4 November 2026, and these conversations were recorded at the last Tactical Trauma meeting.

Chest pain that sounds like indigestion, feels mild or seems “atypical” can still be myocardial infarction. The difficult question is not whether troponin is useful, but which patients actually need testing — and how much weight we should give symptoms, cardiovascular risk factors and clinical judgement.

Professor Rick Body looks at the evidence behind those decisions, drawing on his own research and other studies of patients with suspected acute coronary syndromes. He explores which clinical features genuinely change the probability of myocardial infarction, which are less useful than we might think, and how to balance the risks of missing MI against unnecessary investigation.

In this podcast:

• Why “heavy” or “crushing” chest pain only modestly increased the probability of myocardial infarction in Rick’s study population.
• Why indigestion-like pain should not automatically reassure us, and why apparently “atypical” symptoms cannot safely exclude acute coronary syndrome.
• The diagnostic significance of associated features such as vomiting and, particularly, sweating observed by the clinician.
• Why dividing chest pain into “typical” and “atypical” presentations has limited discriminatory value.
• Why having no recognised hypertension, hyperlipidaemia, diabetes, smoking history or family history does not rule out acute myocardial infarction.
• How clinician gestalt does track with risk, but is not sufficiently reliable on its own to rule myocardial infarction in or out.
• Why none of this means testing everyone: Rick’s practical approach is to seek a convincing alternative explanation and use troponin when MI remains a plausible diagnosis that has not otherwise been adequately explained.

The numerical probabilities discussed come from populations already selected for investigation of suspected myocardial infarction, so they should not simply be transferred to every patient presenting with chest pain.

About Rick Body

Rick Body is Professor of Emergency Medicine at the University of Manchester and an Honorary Consultant in Emergency Medicine at Manchester University NHS Foundation Trust. His research has focused extensively on diagnostics in acute coronary syndromes, including cardiac troponin and strategies for the early rule-out of myocardial infarction.

Timestamps

00:00 – Which patients with chest pain need a troponin?

02:00 – What individual symptoms do to pre-test probability

05:00 – Vomiting and observed sweating

08:00 – The problem with “typical” and “atypical” symptoms

10:00 – Do traditional cardiovascular risk factors help?

13:00 – How reliable is clinical judgement or gestalt?

16:00 – Avoiding both under-investigation and over-investigation

17:00 – Rick’s practical approach to deciding when to test

Links and resources

The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes

Examining the signs and symptoms experienced by individuals with suspected acute coronary syndrome in the Asia-Pacific region

‘Chest pain typicality’ in suspected acute coronary syndromes and the impact of clinical experience

Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the Emergency Department?

Can Emergency Physician Gestalt “Rule In” or “Rule Out” Acute Coronary Syndrome? Multicentre validation study

More from St Emlyn’s

St Emlyn’s provides free, evidence-based education for the emergency and acute care community. Explore our blogs, podcasts and other resources.

If you have an idea you would like to share, would like to write with us, or want to get involved with St Emlyn’s, we’d love to hear from you.

Learning from podcasts?

If podcasts form part of your CPD, MedPod Learn helps you turn listening into documented learning. You can use it across all your podcasts — not just St Emlyn’s — to record your listening, make notes, answer questions, reflect on what you have learned and create a record of your CPD.

Traumatic cardiac arrest demands rapid treatment, but one of the hardest decisions is whether a resuscitative thoracotomy is likely to help. Can the location of a penetrating injury and the rhythm on the monitor give us better information than an uncertain history of when the patient arrested?

Recorded at Trauma 2030 at the Royal College of Surgeons of England, Iain Beardsell speaks with Laura Kocierz about a data-driven approach developed from London’s Air Ambulance experience. They discuss distinguishing cardiac tamponade from exsanguination, using ECG rhythm as a surrogate for arrest duration, and why thoracotomy should target the underlying pathology rather than simply the diagnosis of traumatic cardiac arrest.

In this podcast:

• Why traumatic cardiac arrest is better thought of as a clinical low-output state rather than relying on a simple binary definition.
• How the surface location of a penetrating injury can help estimate whether cardiac tamponade or exsanguination is the more likely cause.
• Why a wound within the cardiac box or epigastrium was associated with more than a 30% chance of isolated tamponade in the London data.
• Why treating presumed exsanguination should not stop the team actively looking for concurrent tamponade, including with ultrasound.
• How the presenting ECG rhythm may provide useful physiological information when the reported duration of traumatic cardiac arrest is uncertain.
• The observed progression from organised sinus rhythm through bradycardia and agonal complexes to asystole as arrest duration increases — and why these are population-derived timings rather than precise clocks for an individual patient.
• Why an organised rhythm in a patient with suspected tamponade may support immediate resuscitative thoracotomy even when the reported arrest time appears prolonged.
• Why resuscitative thoracotomy is not, in itself, a treatment for exsanguination, where haemorrhage control, blood transfusion and rapid movement towards definitive care may need to take priority.

About Laura Kocierz

Laura Kocierz is a consultant in intensive care medicine and anaesthesia in Worcester and a consultant with London’s Air Ambulance. Her work includes research examining how clinical information available at the scene can support decision-making in traumatic cardiac arrest.

Timestamps

00:00 – Defining traumatic cardiac arrest

02:00 – Injury location, tamponade and exsanguination

05:00 – When should resuscitative thoracotomy be considered?

07:00 – Using the ECG as a surrogate for arrest duration

11:00 – Combining likely pathology with presenting rhythm

13:00 – Moving beyond a simple 15-minute rule

14:00 – Why thoracotomy is not the treatment for exsanguination

Links and resources

Read the paper: Improving decision-making for prehospital Resuscitative Thoracotomy in traumatic cardiac arrest

Read the London’s Air Ambulance study of 601 prehospital resuscitative thoracotomies

Find out more about Trauma 2030

More from St Emlyn’s

St Emlyn’s provides free, evidence-based education for the emergency and acute care community. Explore our blogs, podcasts and other resources.

If you have an idea you would like to share, would like to write with us, or want to get involved with St Emlyn’s, we’d love to hear from you.

Learning from podcasts?

If podcasts form part of your CPD, MedPod Learn helps you turn listening into documented learning. You can use it across all your podcasts — not just St Emlyn’s — to record your listening, make notes, answer questions, reflect on what you have learned and create a record of your CPD.

Subscribe to the St Emlyn’s Podcast wherever you get your podcasts.

Trauma 2030

TRAUMA 2030 united experts and innovators to shape the future of trauma care. Over two days, it explored breakthroughs in science, systems, and frontline practice, fostering collaboration across disciplines. The symposium aimed to inspire research, inform policy, and build a bold roadmap for trauma care worldwide.

The Fifth Universal Definition of Myocardial Infarction changes some familiar language around MI and puts new emphasis on how we interpret troponin, myocardial injury and imaging. For emergency clinicians, these changes affect both how we describe what is happening and how confidently we can make the diagnosis.

Iain Beardsell introduces Rick Body, Professor of Emergency Medicine at the University of Manchester, who works through what has changed and what it means in practice.

In this podcast:

• Why the familiar type 1–5 classification has been replaced by primary, secondary and procedure-related myocardial infarction.
• How conditions including plaque rupture, spontaneous coronary artery dissection, coronary vasospasm and embolism now fit within primary MI.
• Why the definition now supports sex-specific 99th percentile high-sensitivity troponin thresholds, and what this may mean for commonly used assays.
• How coronary or cardiac imaging has become more important when moving from a likely MI diagnosis towards confirmation and defining the underlying mechanism.
• Why a raised troponin is not synonymous with myocardial infarction, and how acute myocardial injury may result from inflammation, haemodynamic stress, physiological stress, catecholamine excess, toxicity or trauma.
• The challenge of diagnosing chronic myocardial injury in the emergency department when the definition describes assessment in a stable clinical setting.
• Why interpreting a troponin delta remains nuanced: absolute versus relative change, time from symptom onset and the interval between samples all matter.
• Where occlusive myocardial infarction (OMI) now sits: the terminology has not replaced STEMI/NSTEMI, but recognised occlusion patterns including de Winter T waves, Wellens syndrome, Sgarbossa criteria and posterior MI are explicitly discussed.

About Rick Body

Rick Body is Professor of Emergency Medicine at the University of Manchester and an honorary consultant at Manchester Foundation Trust. He is also Editor-in-Chief of the Emergency Medicine Journal and chairs the NICE Interventional Procedures Advisory Committee.

Timestamps

00:00 – Introduction and why the new definition matters

02:00 – Primary, secondary and procedure-related MI

04:00 – Sex-specific troponin thresholds

05:00 – Imaging and confirmation of myocardial infarction

06:00 – Acute myocardial injury and its causes

09:00 – Chronic myocardial injury in the ED

11:00 – Absolute versus relative troponin deltas

15:00 – OMI, STEMI and NSTEMI terminology

Links and resources

Read the accompanying St Emlyn’s article

Read the Fifth Universal Definition of Myocardial Infarction

View the IFCC high-sensitivity cardiac troponin assay reference tables

More from St Emlyn’s

St Emlyn’s provides free, evidence-based education for the emergency and acute care community. Explore our blogs, podcasts and other resources.

If you have an idea you would like to share, would like to write with us, or want to get involved with St Emlyn’s, we’d love to hear from you.

Learning from podcasts?

If podcasts form part of your CPD, MedPod Learn helps you turn listening into documented learning. You can use it across all your podcasts — not just St Emlyn’s — to record your listening, make notes, answer questions, reflect on what you have learned and create a record of your CPD.

Small decisions in the resus room can save minutes; badly designed systems can waste thousands of hours. In the April 2026 St Emlyn’s round-up, Iain Beardsell and Simon Carley move between both ends of that spectrum, from external haemorrhage control and chest drains before CT to ED crowding, clinician productivity and the reflex to solve safety problems with more mandatory training.

There is also new evidence on smoking cessation in the emergency department and HI-PEITHO, a randomised trial of catheter-directed thrombolysis for higher-risk pulmonary embolism.

In this podcast:

• A practical escalation approach to external haemorrhage control: why accurate direct pressure still matters, when to escalate, and why a tourniquet should not automatically be the first intervention.
• Chest drains before trauma CT: when physiological compromise makes drainage necessary and when inserting one first may simply delay definitive imaging.
• How Stevan Bruijns’ idea of a cognitive bridge can help clinicians explain ED crowding to colleagues who do not experience the problem themselves.
• Why asking how many patients per hour a clinician sees can be misleading if staffing, crowding, IT, physical environment and workflow are ignored.
• Jesse Spurr’s challenge to healthcare’s instinct to respond to errors with another training module, and why systems thinking may identify more useful solutions.
• What a systematic review tells us about smoking cessation interventions in the ED, including the difference between behavioural advice alone and interventions incorporating nicotine replacement therapy.
• The HI-PEITHO trial of ultrasound-facilitated catheter-directed fibrinolysis plus anticoagulation for intermediate-high-risk pulmonary embolism, and why the composite outcome and balance of benefit and harm need careful interpretation.
• Why putting a major trauma patient straight onto a portable monitor, checking transfer oxygen and preparing equipment early can remove avoidable delays on the way to CT or theatre.

Links and resources

Read TTL Tip 8: External Haemorrhage Control

Read TTL Tip 9: Chest Drain Before CT? Think, Decide, Communicate

Read Explaining Emergency Department Crowding Using a Cognitive Bridge

Read Marching Backwards into the Future: Why Healthcare Needs Fewer Modules and More Systems Thinking

Read How Many Patients Should We See Per Hour?

Read Fit to Quit? The Trial Evidence for Smoking Cessation Interventions in ED

Read the Emergency Medicine Journal systematic review of ED smoking cessation interventions

Read the St Emlyn’s review of HI-PEITHO

Read the original HI-PEITHO trial in the New England Journal of Medicine

Read TTL Tip 10: Put the Trauma Patient Straight onto the Portable Monitor

More from St Emlyn’s

St Emlyn’s provides free, evidence-based education for the emergency and acute care community. Explore our blogs, podcasts and other resources.

If you have an idea you would like to share, would like to write with us, or want to get involved with St Emlyn’s, we’d love to hear from you.

Learning from podcasts?

If podcasts form part of your CPD, MedPod Learn helps you turn listening into documented learning. You can use it across all your podcasts — not just St Emlyn’s — to record your listening, make notes, answer questions, reflect on what you have learned and create a record of your CPD.

In this month’s St Emlyn’s podcast, Iain Beardsell and Simon Carley work through some of the most interesting recent posts and papers from the blog.

The conversation ranges from the latest pulmonary embolism guidance to the persistent problem of emergency department crowding, and from pre-hospital whole blood to the uneven availability of enhanced critical care across the UK.

They also look at whether TOE might help us deliver more effective CPR, why arterial pressure may be a more useful resuscitation target than simply watching compressions, and a remarkable report from Gaza that challenges some long-held assumptions about pericardiocentesis in traumatic tamponade.

As ever, the focus is less on simply repeating what the papers say and more on what they mean in practice. Some of the evidence is reassuring, some of it is uncomfortable, and several of the studies raise as many questions as they answer.

It is a discussion about uncertainty, physiology, systems and the importance of being willing to change your mind when the evidence does not fit what feels intuitively right.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.

What separates an expert from someone who simply knows a lot? Sara Crager argues that expertise is less about accumulating facts or hours of experience and more about developing better mental models: structured ways of organising knowledge and approaching difficult problems.

Iain Beardsell speaks with Sara about deliberate practice, how experts can make their thinking visible to learners, and Rapid Sequence, the clinical simulation game she developed with Ryan Ernst to let clinicians practise complex decision-making, cognitive load and critical care physiology without putting real patients at risk.

In this podcast:

• Why the familiar idea that expertise comes from simply accumulating 10,000 hours misses the importance of deliberate practice, feedback and progressively refining how you think.
• How mental models allow experts to organise large amounts of knowledge into practical approaches they can use at the bedside.
• Whether expert ways of thinking should be taught earlier in medical education, rather than expecting learners to develop them through experience alone.
• Why teaching the H's and T's of cardiac arrest may be less useful than showing learners how experienced clinicians structure a differential diagnosis around respiratory, haemodynamic and metabolic problems.
• The challenge for experienced clinicians of recognising and explaining what they actually do, rather than simply teaching medicine in the way they themselves were taught.
• How Rapid Sequence combines simulated clinical cases, interruptions, competing priorities and expert debriefing to create a safe environment for repeated practice and failure.
• Why “multitasking” may be better understood as rapid task switching, including deliberately pausing, bookmarking and returning to clinical problems as interruptions occur.
• Why gamification is not intended to replace clinical experience, podcasts, simulation or teaching, but can add another way to practise applying knowledge under realistic cognitive load.

About Sara Crager

Sara Crager is an emergency physician, intensivist and medical educator with a particular interest in making complex critical care physiology understandable and clinically useful. She created ICUedu and co-developed Rapid Sequence with emergency physician and educator Ryan Ernst.

Links and resources

Explore Rapid Sequence and play a sample case

Visit ICUedu

More from St Emlyn’s

St Emlyn’s provides free, evidence-based education for the emergency and acute care community. Explore our blogs, podcasts and other resources.

If you have an idea you would like to share, would like to write with us, or want to get involved with St Emlyn’s, we’d love to hear from you.

Learning from podcasts?

If podcasts form part of your CPD, MedPod Learn helps you turn listening into documented learning. You can use it across all your podcasts — not just St Emlyn’s — to record your listening, make notes, answer questions, reflect on what you have learned and create a record of your CPD.

In this episode of the St Emlyn’s Podcast, Iain Beardsell and Simon Carley catch up on the February blog posts, recorded in the rather unseasonal context of a UK heatwave. They begin with congratulations to Simon on his reappointment as Dean of the Royal College of Emergency Medicine, before reflecting on recent conferences including IFEM in Hamburg and Don’t Forget The Bubbles in Glasgow.

The clinical focus this month is trauma team leadership, with practical tips on interpreting trauma CT reports, maintaining momentum after the scan, performing safer log rolls, and making feedback more useful for learners and colleagues.

Key learning points

• Look at trauma CT images yourself as part of your own clinical learning and to integrate the scan with your examination findings.
• Treat the first CT report as a primary survey, not necessarily a definitive final report.
• Speak to the radiologist and share clinical concerns or uncertainties.
• Do not lose momentum after CT; this is a vulnerable phase in trauma care.
• Log rolls should have a purpose and should minimise movement, pain and physiological risk.
• Use clearer team communication: “Is anybody not ready to move?” and “ready, steady, move.”
• Feedback sticks when it is specific. Add “because” to positive feedback so the learner knows exactly what to repeat.
• Leadership and followership skills apply everywhere, not just in formal trauma team leader roles.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.

In this episode of the St Emlyn’s Podcast, Iain Beardsell speaks with Anna Dobbie, consultant in emergency medicine and pre-hospital care, and Clinical Lead for London HEMS.

Recorded at Trauma 2030 at the Royal College of Surgeons in London, the conversation explores what it means to lead exceptional teams in one of the most high-pressure areas of emergency medicine. Anna reflects on six years as Clinical Lead for London HEMS, sharing lessons on leadership, culture, psychological safety, difficult conversations, managing strong personalities, and supporting clinicians to do their best work.

The discussion also touches on the unique nature of pre-hospital care, where teams move rapidly between downtime and high-intensity clinical decision-making, and where trust, openness and mutual respect are essential. Anna describes the importance of making sure all voices are heard, not just the loudest, and explains why leaders need to be consistent, approachable and willing to have honest conversations when things do not go as well as they should.

Anna also reflects on learning leadership on the job, the value of formal leadership training, the challenge of maintaining boundaries when you care deeply about a service, and the relationship between London’s Air Ambulance and its supporting charity.

Finally, Iain and Anna look ahead to the future of trauma care and pre-hospital medicine, including research, ECMO, marginal gains, quality improvement, and the continuing ambition to reduce preventable deaths from trauma.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.

Trauma 2030

TRAUMA 2030 united experts and innovators to shape the future of trauma care. Over two days, it explored breakthroughs in science, systems, and frontline practice, fostering collaboration across disciplines. The symposium aimed to inspire research, inform policy, and build a bold roadmap for trauma care worldwide.

In this episode, Iain and Simon catch up on the papers, posts, and conversations that have been sitting with us since the start of the year. Some are familiar. Some are uncomfortable. All of them feel relevant on shift.

We start with the RSI trial — ketamine versus etomidate. A study that generated a lot of noise, and perhaps more certainty than it deserved.

We move through trauma team leadership. Not as a checklist, but as a set of decisions made under pressure — when to call a Code Red, how to structure a handover, and what it means to lead a team that hasn’t worked together before.

There’s a discussion about trauma units. Not the big centres. The places where most patients go. Fewer resources. Different pressures. The same expectations.

We talk about spinal cord injury and blood pressure targets. Numbers are useful. But they’re still just numbers.

And then corridor care. Not a new problem. But one we may have started to accept in ways that should make us uneasy.

We discuss:

• What the RSI trial actually showed — and what it didn’t

• Why secondary outcomes should make you pause, not pivot practice

• How and when to activate a massive haemorrhage protocol

• Why early senior decision-making matters more than perfect diagnosis

• What good trauma handover looks like — and why it often doesn’t happen

• How trauma teams function differently in trauma units

• The limits of blood pressure targets in spinal cord injury

• Why corridor care is not just operational — but ethical

This is not a guideline episode. It’s a conversation about practice. About judgement. About the small decisions that shape outcomes long before the data catches up.

If you’re listening after a shift, you’ll recognise most of it.

If podcasts are part of how you learn, you can log your listening, reflect, and build CPD through MedPod Learn. It works across podcasts, not just this one.

As always, thanks for listening.

these ideas are tested in practice.

Learning from podcasts?

If podcasts form part of your CPD, you can log your listening time across all podcasts on MedPod Learn — not just St Emlyn’s — and generate structured reflection. The app is free to download, includes a one-month free trial, and offers globally adjusted pricing.