The St.Emlyn’s Podcast

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.

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 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.

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.

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.

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.

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.

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 course introduces the AIOU methodology, designed to integrate psychiatric and medical care seamlessly. This structured approach includes:

• A: Assessment of aggression and agitation.

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.

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.

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.

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.

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.

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 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.

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.

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.

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.

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.

Welcome to the St. Emlyn’s podcast, your monthly source for insightful discussions and reviews from the world of emergency medicine. I’m Iain Beardsell, and alongside me is Simon Carley. In this edition, we're diving into the posts we’ve covered on our blog in April. After a grueling winter, we are finally catching up. We’re recording this in May, and it's a significant achievement for us. Let’s delve into the highlights and key takeaways from April.

Firstly, Simon and I are thrilled to be back on track. The sun is shining, signaling the end of winter here in the UK, and we’re embracing the spring warmth. Before we dive into the specifics, Simon, you’ve been traveling quite a bit recently. Can you share some of your experiences?

Simon: Indeed, Iain. Recently, I had the privilege of visiting Graz, Austria, a beautiful city where I was invited by the NordDoc and the Austrian Society of Emergency Medicine. We attended the ninth Congress, or as they say in German, "Abit's Goermanneshaft for Notfallmedizin." It was an enlightening experience, despite my initial challenges with the language.

The hospitality in Graz was exceptional, and the city itself is stunning. Emergency medicine in Austria is still in its nascent stages, but the enthusiasm and energy among the young physicians were palpable. The simultaneous translation during presentations was a unique experience. I also conducted sessions on feedback and ultrasound teaching, which were well-received.

Iain: That sounds incredible, Simon. It’s always inspiring to see how different countries are integrating emergency medicine into their healthcare systems. Let’s move on to the main topics we covered in April.

Iain: One of the key discussions in April was about feedback and coaching, a topic Simon presented in Austria. Feedback is crucial for continuous improvement in emergency medicine. Simon, can you elaborate on your main messages from the talk?

Simon: Absolutely, Iain. Feedback is essential for growth, and there are three main types: appreciation, coaching, and evaluation. One common issue is when these types are confused. For instance, after a challenging night shift, if a consultant gives a detailed coaching session instead of simple appreciation, it can be demoralizing. It’s crucial to match the feedback to the context and needs of the receiver. This ensures the feedback is purposeful and effective.

Rick's post from April 10th delved into the nuances of diagnostic tests, emphasizing that results are not merely positive or negative but often fall into a gray area. Simon, can you shed more light on this?

Simon: Diagnostic tests in emergency medicine are indeed complex. Take troponin levels, for instance. A troponin of 2000 is vastly different from a troponin of 15, although both might be labeled positive. Understanding the probabilistic nature of diagnostics is crucial. Rick's post does a fantastic job explaining this with examples, especially around acute coronary syndrome. We use a T-max calculator in Manchester to determine the likelihood of ACS based on various factors, including troponin levels. This probabilistic approach is vital for accurate diagnostics.

Another powerful post in April was Ashley Liebig's discussion with Noah Galway about their experiences during the Iraq war. Their insights provide a stark contrast to typical emergency department scenarios. Iain, what stood out to you in this post?

Iain: The personal bond formed between Ashley and Noah through shared traumatic experiences is profound. Unlike the typical patient-doctor dynamic in emergency departments, battlefield medicine creates a deep, enduring connection. This post reminded me that the emotional and psychological impacts of medicine are just as significant as the physical treatments. Noah’s journey, from experiencing trauma to achieving remarkable feats like participating in the US version of Strictly Ballroom, is truly inspiring.

We also discussed the use of whole-body CT in pediatric trauma patients. Simon, can you summarize the findings from this journal club article?

Simon: Certainly. Whole-body CT is a common practice in adult trauma but its utility in pediatric trauma is questionable. A multi-center cohort study from the National Trauma Data Bank in the US found that focused CT is often more appropriate for children. In Manchester, we rarely perform whole-body CTs on pediatric patients unless there's a significant mechanism of injury. The radiation risks and the lower incidence of severe injuries in children make focused CT a safer and more effective choice.

Dan Horner's professorial lecture on the complications of anticoagulation and how to manage them was another highlight. Simon, what were the key takeaways from Dan's talk?

Simon: The sheer number of patients on anticoagulants in the UK, approximately 660,000, underscores the importance of this topic. Bleeding is a significant risk, and managing it, especially with the newer DOACs, is challenging. Dan provided practical advice on handling bleeding complications, including when specific antidotes are unavailable. Understanding these risks and management strategies is crucial for emergency physicians.

In another significant event, I presented the top 10 trauma papers at the Trauma UK conference. This talk was later featured on the Resusary podcast with Simon Lang. It's always a pleasure to delve into the latest research and innovations in trauma care.

Iain: That sounds fantastic, Simon. For those interested, the blog post contains all the details and links to the podcast. If you have any suggestions or think we've missed some crucial papers, do let us know.

Zak Stein, who trained with us in Manchester and now works in Philadelphia, shared insights on penetrating trauma. Interestingly, patients arriving by police or private vehicle have higher survival rates compared to those transported by ambulance. Simon, what are your thoughts on this practice?

Simon: The practice in Philadelphia highlights the time-critical nature of penetrating trauma. Quick transport to the ED, even by police or private vehicle, can significantly improve survival rates. In the UK, scene times can be prolonged, especially if the scene is unsafe. This practice makes us reconsider our approach to time-critical conditions. It's a balance between ensuring safety and providing timely care.

Our final post in April was the launch of "The Resuscitationist’s Guide to Health and Wellbeing," a comprehensive resource compiled from our blog posts. Simon, this has been a significant project for you. Can you tell us more about it?

Simon: This book is part of our ongoing effort to promote wellbeing among emergency medicine professionals. It includes practical tips on managing night shifts, reflective pieces on coping with difficult situations, and much more. Wellbeing is one of the four pillars of St. Emlyn’s, along with the philosophy of emergency medicine, evidence-based medicine, and clinical excellence. We hope this book will be a valuable resource for our community. It’s available for free, so please read and share it widely.

April was a busy month for us at St. Emlyn’s, filled with travel, conferences, and insightful blog posts. We’re excited about what’s coming up in the future. We have a busy summer ahead, including the emergency surgical skills course with Caroline Leach in Manchester and our St. Emlyn’s live and teaching co-op course in October. Tickets are selling fast, so grab yours soon.

Before we sign off, a quick mention of the Bad E.M. Fest, which was a spectacular event. We’ll discuss it in more detail in future posts and podcasts. For now, you can read the four blog posts we’ve published about it so far.

Iain: It’s always fun to chat with you all. We hope everyone is enjoying the spring sunshine and looking forward to the summer. Simon, any final thoughts?

Simon: Just one, Iain. Are we the only emergency medicine podcast that talks about the weather at the beginning and end of every episode? It seems like the most British thing ever.

Iain: It's hugely important, Simon. Maybe next time, we’ll focus entirely on the weather! Until then, enjoy the sunshine and take care, everyone.

Thank you for joining us for this edition of the St. Emlyn’s podcast. Stay tuned for more insights and discussions, and don’t forget to check out our blog for the latest posts and updates.

Simon and Iain talk through what the team has been up to in April. All the blogs should be on the website and of course you can subscribe to the podcast via iTunes or via PodBean.

Key publications in April.

1. Our e-book on health and wellbeing for the resuscitationist. http://stemlynsblog.org/the-resuscitationists-guide-to-health-and-wellbeing-a-st-emlyns-e-book/

2. Police drop offs for penetrating trauma in the US. http://stemlynsblog.org/to-protect-and-serveand-drop-off-st-emlyns/

3. The latest blogs on the amazing #badEMfest18 conference in South Africa http://stemlynsblog.org/bademfest18-day-3-st-emlyns/

4. The top 10 trauma papers of the year http://stemlynsblog.org/top-10-trauma-papers-2017-2018-for-traumacareuk-conference-st-emlyns/

5. Complications of anticoagulation http://stemlynsblog.org/complications-of-anticoagulation-and-how-to-manage-them-st-emlyns/

6. Trauma CT in kids http://stemlynsblog.org/jc-trauma-paediatric-wbct/

7. The folly of dichotomous diagnosis http://stemlynsblog.org/50-shades-black-white-folly-dichotomy/

8. Bonded in Blood with Ashley Liebig and Noah Gallagher http://stemlynsblog.org/bonded-in-blood/

9. How to coach your team and the Austrian EM conference http://stemlynsblog.org/how-to-coach-feedback-team-st-emlyns/

Gosh, when you write it down and think about all the work the rest of the team puts in to teach and learn it makes me kind of proud. Don't forget to join us later this year for the live version at #stemlyneLIVE in Manchester.

S

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Welcome to the Centeminine's podcast monthly roundup for March 2018! This post delves into key highlights from our blog, discussing critical topics in evidence-based medicine and sharing exciting upcoming events. Let's dive in!

As the harsh winter fades, we’re catching up with several important topics from March. Despite the seasonal lag, there's a lot happening in the world of evidence-based medicine. Our blog has been buzzing with insightful posts, and we encourage you to explore the rich content we have curated for you.

Before diving into March's blog posts, let's highlight some exciting events on the horizon. We are thrilled to announce St Emlyn's Live and the Teaching Course in Manchester. If you're planning your study leave for the next 12 months, these are opportunities you won't want to miss.

St Emlyn's Live is shaping up to be an unmissable event. Scheduled for October in Manchester, this event promises a blend of learning and fun, with the added bonus of Manchester's unique charm—where the sun always shines (psychologically and philosophically, if not literally). Check our website for more details and secure your spot. We’re putting immense effort into making this event exceptional, ensuring it’s worth both your time and money.

Alongside St Emlyn's Live, we have our renowned Teaching Course in Manchester. As you consider your professional development for the year, keep in mind the benefits of attending a well-structured, impactful course like ours. We're confident you'll find it a valuable investment in your career.

One of the standout topics in March has been the ongoing debate over IV fluids in critically ill patients. This subject stirs significant anxiety and diverse opinions across departments and even within the same hospital.

The crux of the debate revolves around whether to use normal saline or balanced fluids such as Hartmann's or Plasmalyte. The evidence to date has been mixed, leading to differing practices. Our colleagues down under published the SPLIT trial a few years ago, finding no significant difference, but the sample size at the time limited the conclusions.

Recently, two significant trials published in the New England Journal of Medicine have shed more light on this issue. These trials investigated the effects of balanced crystalloid versus saline in critically ill patients and emergency department patients admitted to the wards.

The trials used a cluster randomized design, where units were randomized to administer either balanced crystalloid (lactated Ringer's or Plasmalyte) or saline for a period before crossing over. With over 15,000 participants in each study, the findings are quite robust.

The trials revealed a small but significant difference in major kidney events in the critical care group (14.3% vs. 15.4%), suggesting a potential benefit of balanced fluids. While the mortality difference was not as pronounced, these results could have important implications for global intensive care practices.

As emergency physicians, how do these findings influence our practice? Over the past few years, there's been a shift towards more frequent use of balanced solutions, driven by a sound physiological rationale. Although the exact clinical significance of hyperchloremic acidosis from saline remains debated, the pathophysiological argument for balanced fluids is compelling.

In our practice, preferences vary. For instance, our neurointensive care unit favors saline for patients with specific neurological issues, as explained in a podcast with Dr. John Hell from Southampton. For general use, Hartmann's is often the go-to solution.

We emphasize the importance of fluids in emergency medicine to our new doctors. With only four main treatments—oxygen, analgesia, antibiotics, and fluids—it’s crucial to administer fluids effectively. While the choice of fluid might not be critical initially, ensuring the right volume is given can make a significant difference.

Another highlight from March was the successful teaching course in Cape Town. This course will be replicated later this year in Manchester, offering an excellent opportunity for hands-on learning and professional growth.

The Cape Town course was a resounding success, providing valuable insights and skills to all participants. The feedback was overwhelmingly positive, highlighting the course's effectiveness and the enriching experience it provided.

Chris Weymouth, a UK-trained physician, shared his experience working in a rural South African hospital. His story underscores the importance of structured and well-supported international placements. Such experiences not only enhance clinical skills but also foster personal growth and resilience.

Our final major topic for March revolves around predicting outcomes in cardiac arrest, specifically through pupil responses. This topic, close to our hearts, is critical for making informed decisions during resuscitations.

A recent study from France, analyzing over 11,000 cardiac arrests, examined whether early pupil responses could predict outcomes. The findings were intriguing but not definitive.

The study found that the absence of a pupillary light reflex is a poor prognostic sign, but with only 72% sensitivity and 68.8% specificity, it’s not conclusive enough to base critical decisions on.

Deciding when to stop resuscitation remains one of the most challenging aspects of emergency medicine. While some cases are clear-cut, many fall into a gray area, making it difficult to determine the right course of action.

With emerging technologies like ECPR (Extracorporeal Cardiopulmonary Resuscitation) and reports of remarkable recoveries from prolonged arrests, the decision to stop becomes even more complex. In young patients with no prior morbidity, the stakes are even higher, and the decision requires careful consideration and often consultation with colleagues.

As we wrap up our March roundup, we look forward to several upcoming events and ongoing discussions. The St Emlyn's team will be speaking at the Retrieval Conference in Scotland in April, and we have a variety of summer events lined up.

Don't forget to join us at St Emlyn's Live in October. This event promises to be a highlight of the year, offering a blend of cutting-edge medical insights and networking opportunities. Check our website for all the details and secure your spot today.

We'll be back in May with updates on April's posts and more engaging content. Until then, keep enjoying your emergency medicine practice, take care of yourselves and your patients, and stay connected with the St Emlyn's community.

March has been a month filled with significant developments in evidence-based medicine, exciting course announcements, and thought-provoking discussions. As always, our goal is to provide you with the best possible insights to enhance your practice and support your professional growth. Thank you for being part of the St Emlyn's community. We look forward to engaging with you through our blog, podcasts, and upcoming events.

Iain and Simon catch up on what happend on the St Emlyn's blog and podcast in March 2018.

Visit http://www.stemlynsblog.org for more info and links to the articles mentioned in the podcast.

This month we cover IV fluids and the never-ending debate around balanced crystalloids vs. saline, we look at working in Africa on secondment or as a placement and we round off with a discussion of the utility of pupillary signs in the prognosis of patients post cardiac arrest.

S

The Physician Response Unit (PRU) is an innovative service in East London that takes the emergency department to the patient. The PRU is led by Tony Joy, consultant in emergency medicine and prehospital care and is a fairly unique service to the UK.

In this podcast our very own Richard Carden interviews Tony for an in depth understanding of how the service is supporting the entire emergency care system in London.

You can read more about the PRU here https://londonsairambulance.co.uk/our-service/news/2017/10/remodelled-pru-to-be-a-seven-day-service-for-the-first-time and look out for a blog post on the St Emlyn's blog site very soon.

The Physician Response Unit (PRU) is an innovative service in East London that takes the emergency department to the patient. The PRU is led by Tony Joy, consultant in emergency medicine and prehospital care and is a fairly unique service to the UK.

In this podcast our very own Richard Carden interviews Tony for an in depth understanding of how the service is supporting the entire emergency care system in London.

You can read more about the PRU here https://londonsairambulance.co.uk/our-service/news/2017/10/remodelled-pru-to-be-a-seven-day-service-for-the-first-time and look out for a blog post on the St Emlyn's blog site very soon.

Welcome to the St. Emlyn’s podcast blog! I’m Ian Beardsell, and alongside Simon Cully, we're here to bring you our monthly update. This post will delve into February's content, upcoming events, and the latest discussions in emergency medicine.

Winter has been relentless this year, and we're still feeling its impact. The influx of patients hasn't slowed down, and our departments are buzzing with activity. Up in Manchester, we continue to see a high volume of patients, while down south, the weather has been kinder, though no less busy. As a Yorkshireman, I can empathize with the challenges faced in the North. Hang in there, and let's get through these cold evenings together!

Before diving into February's posts, let's talk about the exciting events we have lined up. This October, we're hosting the St. Emlyn’s Live conference and the Teaching Course in Manchester.

The St. Emlyn’s Live conference is a one-day event focused on our philosophy's four pillars: clinical work, evidence-based medicine, wellbeing, and the philosophy of emergency medicine. With international speakers, this event promises to be an enriching experience for all attendees. Spaces are limited, so make sure to book your spot early via our website.

Following the conference, we have a three-day Teaching Course designed to develop you as an expert teacher in emergency medicine. This comprehensive course covers all aspects of teaching and is an excellent opportunity to enhance your skills. All bookings can be made through the St. Emlyn’s website.

February was a month rich with valuable insights and studies. Let's delve into some of the highlights:

One of the standout studies we reviewed in February focused on the use of intranasal ketamine and fentanyl for managing pain in children. Pain management in pediatric patients is always challenging, especially when IV access is difficult. Traditionally, we've used intranasal diamorphine, but there's been a shift towards using intranasal ketamine and fentanyl, particularly in the US.

This randomized controlled trial compared 1 mg/kg of intranasal ketamine against 1.5 mcg/kg of intranasal fentanyl in children aged 4 to 17 with suspected isolated extremity fractures. The primary outcome was pain reduction, and both drugs performed similarly in this regard.

The key takeaway was the difference in side effect profiles. Ketamine is known to cause dysphoria, vomiting, and dizziness, while fentanyl has fewer unpleasant side effects. Therefore, fentanyl emerged as the preferred choice not because of superior pain relief but due to its more favourable side effect profile.

The study underscores the importance of having a streamlined protocol for intranasal medications in emergency departments. While some departments might still use syringes, investing in mucosal atomizer devices can simplify administration and improve patient care.

We had a guest blog from Claire Bromley, a medical student working with us in Manchester. Claire shared her experiences and insights into why she chose emergency medicine as a career, despite the occasional negativity she faced from other specialties.

Claire's blog is an inspiring read for medical students considering a career in emergency medicine. She highlights the importance of engaging students in the department and ensuring they see the undifferentiated, unwell patients that characterize our specialty. Her experiences as a SMACC volunteer and her early involvement in FOAMed (Free Open Access Medical Education) are testaments to the value of early engagement and online education.

One of the significant challenges we face is balancing the educational needs of students with the operational demands of the department. However, investing time in student education is crucial. These students are our future colleagues, and their early exposure to emergency medicine can shape their career choices and prepare them for the challenges ahead.

A fascinating study we reviewed involved the use of isopropyl alcohol for nausea relief. The concept of sniffing alcohol swabs to alleviate nausea isn't new, but this study provided robust evidence supporting its effectiveness.

The randomized controlled trial compared the effects of isopropyl alcohol sniffing to oral ondansetron in adult patients presenting with nausea in the emergency department. The results were surprising: patients who sniffed isopropyl alcohol swabs reported greater relief from nausea than those who took ondansetron.

While the study's findings are promising, implementing this practice consistently in emergency departments can be challenging. Ensuring that alcohol swabs are readily available and that staff are trained to use them effectively is key. Additionally, clarifying whether a Patient Group Directive (PGD) is required for this intervention could streamline its adoption.

One of the lighter yet insightful pieces this month was a video from the 1970s showcasing a casualty department in Liverpool. Watching historical medical practices can be both amusing and educational, offering a perspective on how far we've come and what future generations might think of our current practices.

While humorous at times, the video also highlights the core principles of emergency medicine that remain unchanged. It reminds us of the importance of continuous learning and adaptation in our field.

As we look forward to the year ahead, we’re excited about the upcoming SMACC conference in Australia in 2019. Planning for study leave and participation in such international conferences is essential for continuous professional development. These events provide unparalleled opportunities for learning, networking, and sharing best practices.

February has been a month filled with valuable insights, studies, and preparations for future events. The emphasis on pain management in children, engaging medical students, and innovative approaches to nausea relief reflects our ongoing commitment to improving patient care and education in emergency medicine.

Iain and Simon review the best of the blog from February 2018.

Simon Carley

Welcome to the St. Emlyn's podcast. I'm Iain Beardsell, and I'm Simon Carley. We are delighted to be back with you after what can only be described as a rather tricky winter. The winter season has always been challenging for emergency departments across the UK, but this year felt especially relentless. In this blog post, we will reflect on the past few months, share key insights, and look forward to exciting events on the horizon, including the St. Emlyn's Live conference.

Down south in our emergency department, we have faced significant challenges. Iain shared his experiences: "We have been having a heck of a time. It has been a real struggle. I'm utterly exhausted, and it has only been in the last couple of weeks that it felt like we could breathe again." The situation has been similarly difficult up north. Simon echoed these sentiments: "It's been a bit grim up north, to be honest. This winter felt different, harder. The emergency departments in the UK have always had problems over winter, but it has felt more relentless this year."

We didn't have much of a summer to recuperate, and the winter was relentless day in and day out. Our department saw unprecedented pressure, with patient numbers pushing us to our limits. Interesting statistics from our department showed consecutive days of being over capacity, creating concerns about patient care and safety. Despite the exhaustion, we managed to maintain a high standard of care, with complaints remaining at normal levels and even receiving more compliments than usual.

Maintaining patient care while looking after ourselves has been a challenge. We have implemented various strategies to keep on track, from educational events to incredible clinical work. Reflecting on our achievements, Simon highlighted the importance of continuing education and maintaining healthcare standards even under pressure. "We have done some amazing things over the winter, and it is something we can be really proud of," he said.

The public's understanding of the pressures in the healthcare system has increased, although tolerance for the challenges faced remains limited. Political activity over the winter saw clinical leads writing to the Prime Minister, and emergency medicine frequently made the front pages of newspapers. However, recent events, such as the nerve agent attack in Salisbury, have shifted the focus away from A&E crowded corridors, providing some relief.

We have many exciting events coming up this year, including the highly anticipated St. Emlyn's Live conference. Scheduled for Tuesday, the 9th of October in Manchester, this one-day conference will bring us out from behind our microphones and keyboards to present live. The event promises to be hugely cost-effective, with an incredible lineup of speakers from around the world, including Claire Richmond from Sydney Hems, Natalie May, Salim Rezy from the US, and Kat Evans from South Africa.

We have designed St. Emlyn's Live to be an interactive conference, reflecting everything we aim for in our podcasts and blogs. The conference is priced at £150 for consultants, with discounts available for trainees, registrars, doctors in training, allied health professionals, nurses, and medical students. Given the limited venue size, we expect tickets to sell out quickly, so we encourage early booking.

For those looking for more in-depth learning, we are hosting a teaching course on the 10th and 11th of October, directly after the conference. This course focuses on practical education techniques, helping clinician educators improve their teaching skills. It has been highly acclaimed by previous participants, offering a transformative learning experience.

At St. Emlyn's, we value reflection and evidence-based practice. In January, we covered several important topics on our blog, including devastating brain injuries, dizzy patients, and the adrenal trial. Let's delve into these discussions and see what we can learn.

One of the critical topics we discussed was devastating brain injuries. Historically, decisions about the prognosis of patients with severe traumatic injuries or subarachnoid bleeds were often made too quickly, based on initial CT scans. However, recent guidance suggests that we should not make precipitous decisions about patient outcomes solely based on early imaging.

In summary, it's essential to give these patients at least 24 to 72 hours before making a prognosis. This allows time for clinical outcomes to become more apparent. In our hospital, we transfer these patients to neuro-intensive care and have a proactive organ donation program, ensuring patients and their families receive the care they deserve.

Another challenging area in emergency medicine is dealing with patients presenting with dizziness or vertigo. Differentiating between central causes, such as posterior circulation strokes, and peripheral causes can be difficult but crucial. We highlighted the importance of understanding the difference and utilizing tests like the HINTS exam to aid diagnosis.

As emergency physicians, we must continue to educate ourselves on these diagnostic tools. Utilizing resources like the St. Emlyn's blog, YouTube, and FOAMed can help us stay updated and improve patient care. It's essential to be comfortable revisiting and revising our knowledge to ensure accurate diagnoses and appropriate treatment plans.

Reflection is a powerful tool for lifelong learning and self-improvement. Despite recent controversies, such as the case involving a junior doctor in Leicester, we must not abandon reflection. It helps us increase self-awareness, think critically about our practices, and improve our clinical skills.

Natalie May's blog post on reflection emphasizes that it's not just about ticking boxes but about purposeful and structured thinking. Her insights from Sydney Hems highlight the importance of integrating reflection into our daily practice to enhance our growth as clinicians.

The adrenal trial, reviewed by Dan Horner, examined the use of steroids in septic shock. Published in the New England Journal of Medicine, this trial aimed to determine whether steroids improve outcomes in these patients. The results showed no significant difference in mortality, although some secondary outcomes, such as vasopressor use and ICU days, showed variations.

The trial highlights the complexity of medical treatment and the need for continuous learning and evaluation. It reminds us that while some treatments may show promise, their benefits might not always be clear-cut. This underscores the importance of evidence-based practice and staying informed about the latest research.

Emergency medicine is a dynamic and ever-evolving field. At St. Emlyn's, we are committed to continuous learning, sharing knowledge, and improving patient care. The challenges of winter have tested our resilience, but they have also shown the importance of collaboration, education, and maintaining high standards of care.

We encourage our readers and listeners to stay engaged with our content, participate in upcoming events, and continue striving for excellence in their practice. The St. Emlyn's Live conference and the teaching course are excellent opportunities for professional development and networking with peers from around the world.

As we move forward into the spring and summer, let's take a moment to reflect on the lessons learned and the progress made. The past winter was tough, but it also demonstrated our ability to adapt, innovate, and support one another. With exciting events like St. Emlyn's Live on the horizon, we have much to look forward to.

Thank you for being part of the St. Emlyn's community. Stay connected, stay curious, and let's continue to learn and grow together. Here's to a bright and hopeful future in emergency medicine.