2018 thoughts and reflections

As 2018 comes to an end we asked the St Emlyn’s team to reflect on the highs and lows of a fascinating year. The brief was pretty vague as we wanted the team to think fairly broadly and to give a broad range of answers.

You can read more about the authors here.

What’s the most important change to your practice this year?

Dan Horner: Consideration of steroids in severe pneumonia, based on the recent Cochrane review.

Simon Carley: Putting the zero point survey into practice. It’s something we’ve sort of done for years, but by giving it a name a structure I can see real benefits in the resus room for our sickest patients. I am biased but I think it’s as equally important as the primary survey in resuscitation skills.

Rick: The biggest change has probably been with regard to my appreciation of the need to look after our wellbeing. Laura Howard’s paper (which I was privileged to work on with her) was a real wake-up call for me. Laura interviewed our colleagues to ask about how events at work had affected them personally. I was shocked by the responses. I knew that we were all affected by events at work, but I simply hadn’t realised how much. Taken in the context of the growing body of literature in this area including what we know about the incidence of burnout and compassion fatigue among emergency physicians, this really emphasises how important it is for us to look after ourselves and our colleagues. Our work is great, but it is also tough at times. If we want to look after our patients well, we have to be in good shape ourselves – so initiatives like the ED Spa, which Laura has pioneered, are so important. Every day, we need to be looking out for each other.

Ross Fisher:Don’t give any fluid to trauma patients unless it’s blood!

Stevan Bruijns: Working less

Gareth Roberts: I’m using a bit more ultrasound now I’m back doing more adult EM. Need to crack on and learn more though

Chris Gray: Thanks to a lot of discussion on Twitter and at conferences, particularly from people like Linda Dykes and Alex Psirides, I’ve tried to be better at talking about dying. Establishing what my patient wants, and what their expectations are. We need to be better at having that conversation.

Ashley Liebig: The 3 second wait time in learning conversations that I learned from Natalie May has changed my practice. In teaching this means, allowing the learner a wait time to think without prompting, then allowing another wait period after they have answered before you respond. What I have found, just as Natalie taught, and the research suggests, that learners benefit massively from these uninterrupted periods and both process and articulate responses differently. It’s pretty game changing! You should learn more about it and try it!

Laura Howard: I have really been making a conscious effort to be more compassionate at the times i find it most challenging, especially when hungry, tired and overwhelmed. I was really inspired by the idea of small is all by Mary Freer, in her talk at the DFTB conference.

Liz Crowe: Wiser delegation. I think it’s human nature that we all want to be involved in the more ‘exciting’ cases, the bigger traumas etc. It is our responsibility as educators and leaders to grow the next generation of clinicians to be far more skilled and compassionate than we could ever hope to be. This year I have tried to be mindful of this and step back and support my team to do fantastic work. It’s also a timely reminder that when we are doing the ‘smaller’ clinical tasks that they remain life changing events for those families.

Natalie May: Nighttime airway handover (NAWHL). Not a concept you have heard of, but more on this in the next few months.

Rusty Carroll: Moving from prehospital to unscheduled primary care.

Zaf Qasim: Focusing much more on human factors, and taking lessons from my #FOAMed colleagues to finally implement in-situ sim into the ED

Best blog you read?

Ross: Rudeness and team performance with Ken Milne on the SGEM.

Simon: Likewise about Ken Milne and the SGEM. The team he has put together and the consistent quality they create is really rather remarkable. Ken is also one of the nicest people you could ever meet. I’d also mention LITFL and EMCRIT in the same vein. Consistently blogging with style, panache, wisdom and beauty.

Chris: Rusty Carroll’s blogs on his journey with PTSD has really made me think a lot more about how I maintain a good life/work balance, whilst becoming more vigilant on how others around me are doing too.

Dan: First 10 EM take on the parachutes RCT published in the BMJ

Rick Body: I really like the RCEM Learning new section on research. It’s amazing, and has been pioneered by some of my great friends and colleagues, some of whom I’ve had the privilege of supervising during their academic placements – Govind Oliver and Charlotte Kennedy have done an amazing job.

Nick Smith: I have stated educating learners in how people really learn, not how people think they learn; the use of retrieval practice though mind maps and flash cards; the ability to sift through their feedback to pick out the useful bits by realising the difference between what we intended to happen when we do something vs the impact it had when we did it.

Rusty: I preparation for the most excellent week spent at St Emlyn’s Live and Coop Manchester, this blog helped me both prepare and consolidate some of the core learning: https://www.stemlynsblog.org/better-learning/educational-theories-you-must-know-st-emlyns/

Ash: You mean after St. Emlyn’s correct?! I’ve really enjoyed watching the growth of the foamfrat.com blog and podcast. This team is really contributing something special to the prehospital community. Easy to read and navigate, very clever vodcasts and outstanding content make it my fav this year. Tyler Christifulli, Sam Ireland and Cynthia Griffin should be very proud of their work on this site.

Nat: Keisha Ray on the inherent privilege in using patient stories

Gareth: Simon’s 5 strategies to improve your Resus Room

Nick: REALLY difficult choice because there have been SO many – Without blogs and Twitter to lead me to these blogs I wouldn’t have achieved what I have. Pretty much anything by Nat makes me think but I am going to go with a non-medical blog from The Effortful Educator: Are Our Teaching Methods Hindering Our Learners? https://theeffortfuleducator.com/2017/01/12/are-our-teaching-methods-hindering-our-learners/

Stevan: Simon is not a doctor. He is an NHS suit who understands systems. I believe his work will change the way we look at flow across the NHS

Best podcast you heard this year?

Dan: RCEM learning. They have struck a great balance between education and entertainment and really found a groove of late.

Stevan: I really like the RCEMlearning podcasts. We are hoping to build a micro curriculum around these for our junior doctors in 2019

Ross: Blood on the tracks from the BBC. Colin Murray gathers together four music obsessives to debate and argue their favourite tracks.

Rusty: This podcast is in a series by the very robust US military veteran Jocko. Often searching for meaning in the darkest of human experiences, this podcast is a lesson in positivity, humanity and humility.

Zaf: I’ve enjoyed watching the Resus Room podcast (www.theresusroom.co.uk) develop over the years, and it’s always got great content every month.

Nick: Again there have been lots but I am going to go outside of MedEd again and say Why We Choke Under Pressure (and How Not To) from Freakonomics http://freakonomics.com/podcast/choking/ as it has a use for my students when it comes to assessments

Rick: The St Emlyn’s podcast on moral injury with Simon and Esther Murray was really interesting, especially because it covered something outside our usual area.

Nat: Nick Gorton at Fix18

Ash: Another paramedic driven FOAM contribution wins for me here as well. The Medic Mindset with Ginger Locke is outstanding! She has a talent for the interview and getting to the core of a person. She ranges from clinical topics to mental health and it’s all fantastic. I had the pleasure of sitting down with her at a conference this year and it was the most fun I’ve ever had doing a podcast! Take a listen here

Laura: Having spent 9 months of this year non clinical on maternity leave I have really loved listening to the serial podcast.

Liz: Berne Brown has a great animation on Empathy and why it’s so different from sympathy. https:www.youtube.com/watch?v=1Evwgu369Jw

Janos: Emcrit Weingart about how SoMe algorithms try influence our daily life

Gareth: Mark Knight Toolroom Radio. Tech house music so not for everyone but I can highly recommend it.

Simon: There are many, too many to choose from in fact so I’m going to ask you to listen to Robert Lloyd on the ponderMed podcast. It’s different and more interview based, and a bit long at times, but there is some great stuff in there and some great guests. I’m hoping to make an appearance in 2019 (fingers crossed for invite). My regular listens are EMCRIT, the SGEM & the resus room.

What book would you recommend others read?

Simon: Jeremy Faust got me into audio books and it’s been an inspiration. I’ve read/listened loads this year and so it’s tricky to choose. As an educator and clinician I think ‘Why we sleep‘ is an absolute must. It’s changed my life, body and mind. I would strongly recommend it. If you’re in the UK then I’d read ‘The Secret Barrister‘ to understand the law, and also because I think criminal barristers are the legal equivalent of ED consultants. For fun I have really enjoyed Rincewind and other adventurers on the Discworld.

Gareth: I also choose The Secret Barrister.

Rich: Too many to choose from, I’m going to be naughty and offer a top 3. Sapiens, Prisoners of Geography, and Oxygen: The Molecule That Made the World

Dan: Diary of a wimpy kid – the meltdown. It’s funny. Wellbeing and all that…

Nick: Two that immediately spring to mind, both recommended by Simon to me, are ‘Thanks for the Feedback’ & ‘Why We Sleep’ but I am guessing that others will also recommend those so instead I shall say ‘Understanding How We Learn; A Visual Guide’ from the people that run learningscientists.org . There’s not a lot new here apart from some stuff on attention but it’s brilliantly written and a serious rival for Make it Stick

Stevan: Melody Beattie’s Codependent no more

Ross: Make it Stick – Brown, Roediger and McDaniel

Rusty: This year I have had the pleasure of re-discovering the Harry Potter books whilst reading them to my son. I would recommend anyone to re-read a book you have previously enjoyed.

Rick: Leading by Sir Alex Ferguson

Janos: Game of thrones (obviously)

Ash: The Culture Code.

Zaf: Many people have read it already, but I only just got round to it – Black Box Thinking – well worth it!

Chris: The Invisible Library by Genevieve Cogman. If you like fantasy novels then give this series a try! No medical related books here – you need an outlet from work as well!

Liz: Leading the Unleadable by Alan Willett. It’s hard to be a leader particularly when there is conflict or challenging personalities or dynamics. This nook is very easy to read and conversational in nature and offers tangible tips. It is not specific to health though completely transferable.

Your personal highlight of 2018?

Rich: Buying a house – despite how much work it needs!

Gareth: Being appointed a consultant. It’s finally done!! (Ed – oh no it’s not 😉 )

Nick: Writing my first public blog for St. Emlyns (as opposed to ones behind firewalls for my University) and realising that nothing bad happens (yet)

Ross: Completing the Knighthood of Sufferlandria (12 hour, cycle turbo trainer challenge).

Stevan: Picking up my (immigrant) family at Heathrow after being apart for nearly six months. I’m so grateful for what this country has offered us.

Dan: Starting the publication trail from our last big research project. One paper in JTH, one in BJH, one under review and the whole thing accepted for the HTA monograph series. It’s always really nice to see clear outputs from a research project.

Rick: Being appointed as Director of the Diagnostics and Technology Accelerator in Manchester. This is an initiative to work with industry to generate research evidence for new in vitro diagnostics and medical technologies. It’s really exciting because it has such great potential to change our practice in new and innovative ways.

Chris: A fantastic holiday to Vietnam with my long suffering partner Lauren and our friend Shaun, including a challenging hike up Fansipan mountain. The feeling of making it to the summit (3,143m) was exhilarating, and the views incredible!

Simon: Completing my PhD in less than a year. OK, it was by publication and the ‘work’ had largely been done already, but constructing the PhD around online learning and technology in emergency medicine brought together a journey that started with BestBets and which led through to #FOAMed and St Emlyn’s.

Zaf: Finding more balance between home and work

Ash: So many wonderful things this year but a major highlight was taking my 12 year old daughter to Manchester to meet my St. Emlyn’s family. The welcome and love shown to her was beautiful.

Laura: Becoming a family of 3 with the birth of my daughter

Liz: Facilitating a 90 minute panel on ‘Leadership in the Paediatric Intensive Care’ at the PICU World Congress in Singapore. It was an exceptional panel of individuals and a great experience for me personally… even though it was a little terrifying

Nat: EMSA18 – integration of three layered keynotes with Jesse S & Ian S at a multiprofessional conference. Risky but it seemed to work

Best paper of 2018

Rich: Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock.

Dan: Neurofilament light chain for prediction of good outcome after ROSC. In JAMA neurology. The best work I have seen on biomarkers for this indication.

Ross: Disparities in the management of paediatric splenic injury A. M. Warwick T. Jenks R. Fisher R. Garrett‐Cox F. Lecky D. Yates

Rusty” Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial.

Stevan: Mmm, tricky. I would probably say the origami paper I used to fold tulips with with my kids

Zaf: So many great papers out there – from a trauma perspective, certainly both PAMPer and COMBAT showed the that one-size does not fit all for prehospital blood product use – you really need to examine your system. I also congratulate the AIRWAYS-2 and PARAMEDIC2 trial researchers on pulling it off so well and giving us all more discussion points about what is the best practice for our cardiac arrest patients.

Simon: Best is a tricky category. AIRWAYS – 2 and PARAMEDIC – 2 were incredible pieces of work. In addition I’d highlight the POLAR trial as another excellent pragmatic RCT on hypothermia in brain injury.

Rick: I know I’m a co-author on this, but I’m naming it because I felt so inspired by Laura’s work: How events in emergency medicine impact doctors’ psychological well-being. Emergency Medicine Journal 2018

Gareth: Gotta be PARAMEDIC 2. Left us in a difficult ethical situation one that I don’t think doctors should be solving.

Laura: The moral injury paper, this is such an important addition to the wellbeing conversation

Liz: Rotenstein et al 2018 Prevalence of Burnout Among Physicians. A Systematic Review JAMA,320 (11) Van Mol et al The Prevalence of Compassion Fatigue and Burnout among Health Professionals in ICU:A Systematic Review, PLOS One, 10 (8) Burnout is a very real phenomenon however not well researched or as prevalent as many would tell us.

Nick: I am not a big reader of education papers if I am honest for the simple reason that it seems that if you study it then it works. Instead I am going to suggest the best/most useful academic BOOK I read this year is Cognitive Load Theory by Sweller, Ayres & Kalyuga

Janos: Injury Prevention : surgical rates in game of thrones (an unusually funny but well designed and written paper)

Nat: PARAMEDIC-2 (not for having all the answers but for making us all think)

Best experience of 2018?

Dan: EMTA 2018. A great conference put together by hard working and diligent trainees. Also lovely to watch TERN grow alongside, gather more interest and develop into a funded entity with clear projects and engagement from every deanery.

Nick: On a professional level I have to say being involved with #stemlynsLIVE and #TTCManchester and meeting such an amazing group of likeminded educators

Rick: Taking part in the largest ever industry sponsored symposium at the American Association of Clinical Chemistry (AACC) Conference in Chicago. Six major diagnostic companies got together to sponsor this large symposium, putting aside commercial interests purely in to advance medical education and science. It was great to be part of and I hope we’ll see more like this in 2019.

Gareth: Started speaking at conferences this year which has been quite cool

Zaf: Medical – finally attended the ATACC course as guest faculty (thanks to Mark Forrest for the invitation!) After hearing so much about it, I was expecting great things and I was not disappointed! What struck me more than the excellent simulations the group put on was the incredible cross-discipline camaraderie and continual learning between both faculty and candidates. On a more personal note: on the same trip I went back up to Manchester – it was great catching up with my good friend Janos, but it was also very important for me to personally see the city again after the tragic events of 2017. It was heart-warming to see my previous home so strong.

Ross: Learning after making my registrar cry during surgery. Sitting down for a difficult feedback discussion, listening and seeing the benefit that change in my behaviour made.

Laura: At work watching the EDSPA flourish and be of benefit to staff. This project is such a privilige. Outside of work it has to be the ups and downs of being a first time mum.

Janos: Purchasing and moving into my fort house : never been so stressed 😫

Liz: I had 9 weeks long service leave to wrote up some of my PhD. Being home full time with my boys was the highlight. Being able to cook them breakfast and talk to them when they got home from school…. I loved it. It coincided (deliberately) with my eldest sons final 9 weeks of school . He is now off to University next year! The days are very long with children and the Years way too fast! For those of you who are parents lots of opportunities in your career will always be there, your children won’t … enjoy them.

Rusty: Summiting with my son on his first mountain.

Stevan: A short break in the New Forest with my family. Thed have Llamas, a heated pool and we went geo caching.

Simon: BADEMFest18 was an amazing conference filled with the most amazing people, in a stunning setting, and with great content. I had an epiphany on a run through the hills and have not looked back since. A real turning point in the year for me. I’d love to go back in 2019.

Nat: Also BADEMfest18 🙂

One to watch in 2019?

Rich: I’m biased but there is a lot of exciting activity in the world of trauma research. The national trauma network is not only delivering outstanding care, but is being used to co-ordinate some important research, such as Cryostat-2.

Dan: The TERN project. Although I have a vested interest, the trainees engaged in this have already achieved more than I would have thought possible in the time. They are motivated, ambitious, intelligent and collaborative. It is a pleasure working with them and I am excited about what they can do in 2019

Rusty: A child. Any child, learn as they learn, grow as they grow.

Simon: I am frequently amazed at the talent, energy and inspiration of our junior colleagues. our junior colleagues on St Emlyn’s are great examples, but there are many others out there who are working in the #FOAMed world with maturity and talent. Aidan Baron is my one to watch in 2019, he’s a great educator and ultrasound researcher and I’m sure we will be hearing a lot more from him over the next few years. We also have SMACC Sydney in 2019 and although I will be sad that this is the last SMACC conference I am so excited to be travelling back to Australia to meet friends old and new at what I’m pretty certain will be a legendary conference.

Chris: If you don’t already follow Tony Breu, you need to. His Twitter threads answering questions you probably know the vague answer to, but not the “why?” are fantastic. One recent thread covered why we need to correct hypomagnesaemia to correct hypokalaemia – , and he has many more listed under a pinned tweet. A great educational resource more should know about.

Rick: The NIHR Incubator for Emergency Care. This will coordinate academic careers in emergency care (Emergency Medicine, Pre-hospital Care, Emergency Nursing, Allied Health Professionals and methodologists) on a national basis. It’s got huge potential to provide the resources that will encourage and inspire people to do more meaningful research in emergency care and to take up academic careers. For those who do take up academic careers, the Incubator will hopefully provide the resources to maximise the chance of them and their research succeeding.

Ross: Jesse Spurr https://www.ededucate.co.uk DFTB19

Zaf: My friend Rick Pescatore (@Rick_Pescatore) is going from strength to strength – he covers great topics on the bread and butter of emergency medicine, with some awesome myth-busting along the way, and I’m sure he’ll continue to do great things in 2019.

Laura: I can’t wait to see Charlie Raynards PhD evolve and Ricks HEMAX study taking chest pain research into prehospital care is exciting!

Liz: I’m really looking forward to be part of the opening plenary of the Pediatric and Congenital Cardiovascular Disease Conference in February in Los Angeles. I’m also a keynote at the International Clinical Skills Conference in Tuscany this year.

Gareth: Im really looking forward to EUSEM in 2019 and defending our Sim crown

Janos: Smacc Sydney of course

Nick: Person: Kirsten Walthall – Brilliant and passionate / http://www.learningscientists.org – go to website for education / EMEC 2019 – Amazed how good it was last year and looking forwards to this year (would also add stemlynsLIVE2019 if we can convince Simon that it’s worth all the stress again!)

Stevan: Simon Sethi beyond a doubt @SethiSimon

Nat: I’m looking forward to a third visit to FIX19. A fabulous conference for everyone in NYC.

Final thoughts.

We had a great time in 2018 and we hope to build on the successes (and failures) into 2019. We still love to blog and podcast, we love to hear from you and we love to share the learning from St Emlyn’s and other #FOAMed sites as widely as possible.

We hope you have a great 2019 and if you want to share your thoughts and ideas in the comments or online through the usual social media channels.



Cite this article as: Simon Carley, "2018 thoughts and reflections," in St.Emlyn's, January 1, 2019, https://www.stemlynsblog.org/2018-thoughts-and-reflections/.

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