Podcast – April 2024 Monthly Round Up – Bougies, cardiac arrest, trauma, sepsis, race and medicine, and choosing with intention

We’re going to go straight into some evidence-based medicine. And let’s talk about bougies, or the gum elastic bougie, as I was taught when I did anesthetics many, many years ago. And do bougies increase first-pass success? So this is a paper, Simon, that you reviewed, and it’s taken from the Annals of Emergency Medicine, published just in February this year. The full title is “Effective Bougie Use on First Attempt Success in Tracheal Intubation: A Systematic Review and Meta-Analysis.”

Pretty much everybody on the podcast is familiar with what a bougie is when you’re doing an intubation. You get a laryngoscope, and then you can see the cords, you pass a bougie through the cords, and you railroad the tube over the top. And it’s something we’ve been saying we’ve been advocating for a long period of time because we want to improve our ability to get the tube in the first time. The issue about first-pass success is it’s widely regarded as a measure of good quality, good process in intubation. So if it helps, you get it in first time, then that’s probably a good thing to do.

We’ve lots of little studies knocking around about this, but they’ve got a lot of variability. So what this study did is a systematic review, so they’ve gone out, they’ve tried to find as many papers as possible that might be relevant, and they’ve done a meta-analysis, so they pulled the information together to find out whether or not, if you add all of these different papers together, do you actually find out whether there’s a benefit, yes or no? So they actually looked at a whole bunch of papers, of which only 18 were relevant to the question, actually, in some detail. And that’s over 9,000 patients, so quite a lot of patients. And 13 of those studies were randomized control trials. The other five were sort of mixed observational type of studies. And to put it in broad terms, what they found is that if you plan on using a bougie first time, you’re more likely to get the tube in first time. And I think that’s probably fairly obvious, to be honest. The difference is they’ve got a ratio of 1.1, it is statistically significant. And if you go back to their figures and you do, what’s a bit naughty really, which is just basically bastardized their figures, take the overall event rates for how successful people were with the bougie versus the overall success rate about how successful they were without a bougie, it’s 84% versus 71%, which is 13%, which is about 1 in 9 patients. You’ve got a benefit from that.

A couple of caveats. One is you shouldn’t really do what I’ve just done there, which is take those raw data in a meta-analysis. They’ve done much better analysis and still found a difference. The second thing is those rates are really quite low. If your first-pass success rate in your service is 84% or 71%, it’s actually quite low. And it makes me wonder whether or not the studies were done in the kind of services where I work and I think where you work, Ian, where our first-pass success rates are actually in the 90s. So there’s a few interesting things to take for this, aren’t there? Then this is the concept of first-pass success. And I think in previous papers we’ve discussed, there are definitely different ways of defining what first-pass success is. And I know for some, that’s you look at the cords, you go down through the cords, you are successfully put a tube into those cords and that’s that. For others, I think they’re a little bit stricter about what they may include. And so perhaps across these different trials, it wasn’t necessarily the same for what our first-pass success was. And Simon, do you really think that first-pass success is a marker of quality care and outcome? Or is it just the surrogate we use to look at our services?

Well, that’s a really interesting question. I mean, it’s widely used in intubation studies as a measure of success. But we’ve got another paper coming up which will discuss, or next month, which is going to directly address that question. Because I’m increasingly skeptical about whether first-pass success is, in fact, the most important marker of this particular skill.

So there we have it. Generally, this meta-analysis suggests that if you use a bougie, you are more likely to have first-pass success. There’s a few questions around that. And I think the main thing for me is using a bougie is not a marker of failure. I think sometimes it has certainly, when I was, and I go back again to when I did anesthetics, which was in 2000, it was always seen that if you were really good at airways, you wouldn’t need one. But perhaps we’ve developed our thinking a little bit, so we’re not quite so binary about our thinking with that.

Yeah, and the other question out there is there are people who are wedded to the use of a stylet. And that’s not covered here as well. And that may well have similar effects, so we just don’t know that.

So lots to think about. Simon, you have also been on travels, as we’ve talked about on previous podcasts. And you’ve done a blog post here about your travels to Gratz in Austria. I was lucky enough to go to Gratz a few years ago. It’s a heck of a conference, a very new area of emergency medicine across Europe really. But enthusiasts, they’re very warm hosts, and it looks like you had a great time, but learnt a lot as well.

Oh, a huge amount, it was really good fun. And a big shout out to Simon Orlob, who’s a big friend of the podcast, who helped me navigate Gratz and really looked after us. It was really fantastic. And this is a conference about emergency medicine in a country where emergency medicine is not a primary specialty. And yet, most of the people coming along with fantastic atmosphere, really incredibly enthusiastic people. And it, you know, go out there and visit. There’s always one stream in English, if your German is not that good, fabulous.

Quick mention before we go on to talk about some of the things I learned. One of the things I saw out there, and you will have seen out there as well, is the, I’m going to try, I’m going to terribly pronounce this. But the Medizine Corps of Gratz, which is basically an ambulance service, which supports the local, sort of, National ambulance service, is just in Gratz. It’s 120 years old. It’s staffed by medical students, but supported by emergency physicians, as sort of senior clinicians within the service. It’s absolutely incredible. Great kit, fantastic training, huge amounts of enthusiasm. It’s just wonderful to spend some time with young people who are fantastically excited about emergency medicine and doing great things. They’ve got a website out there, go and have a look at that, it’s absolutely fantastic.

And in terms of the content, there was loads, I’ll just put, could put a couple of highlights out if that’s okay. Quite, there’s quite a theme around cardiac arrest. So, a couple of things came in like that. One was, there was really interesting stuff about cardiac arrest management in hospital, pediatric cardiac arrest management. And they were going to say, well, what on earth is that going to do with what we do? Because, you know, it’s not right, it’s not the right areas, mostly pediatric intensive care units. The Chapel Robert Berg, Professor Robert Berg, amazing speaker, really good. And what essentially showed was that if you take pediatric arrest, instead of just going through the motions of APS type algorithms, but if you have central access, if you have an arterial line in, and you can titrate your resuscitation against the physiological parameters, your success rates go up enormously. And this has been seen across the US, North America, and it’s been really remarkable. And it was really important to me to listen to you, because that’s kind of where I think we’re potentially going with cardiac arrest management over here as well. And we’re looking at, instead of just going through the motions, still just going around the algorithm, it’s actually looking physiologically, what is it we’re trying to achieve? How do we get good, good, good, perfusion pressures? How do we maintain that we know that we’re confusing the brain? All of those kinds of things, I thought, it was really, really exciting, really, really interesting. Lots more on the blog about that, to go and read, but also great speaker for everyone who invokes him anywhere.

Speaking of great speakers, Sheldon Cheskes, who did the dose of the DOSE VF trial, which we’ve covered on the blog a number of times, actually, it’s one of our favorite papers over the last few years. You’ll remember this, this is the RCT of dual sequence defibrillation or vector change defibrillation or standard defibrillation, done in Canada, and showed a massive difference, so like a 30% success rate, with the dual sequence compared to, gosh, off the top of my head, around about 10% if you just stayed doing what you were doing. So really fabulous paper, a whole game changer of kind of a crash management for me. But a couple of other things that he mentioned in his talk, which are fantastic, interesting. One was that just the understanding for me, or the confirmation, that the reason why defibrillation has failed is because you’ve just not defibrillated the whole heart. So you might defibrillate some of the heart, you might even see that some things have changed on ECG, but unless you get complete defibrillation, the patient will stay in VF, because that small area of VF, which you’ve not managed to get, will catch the rest of the heart, you go back into it. That’s why you can’t get people out of it. So if you think of that, you’ve got the anterolateral pads on, which we normally do, and you’ve defibrillated them three times, and it hasn’t worked. What’s not going to work again, is it? I mean, just doing the same thing, it’s just not going to work. Changing makes a lot of sense. And the second really interesting thing was that, in the trial, if you remember, what you were supposed to do with the dual sequences, do them a second apart. So you do one, then wait a second, two, but these are humans. And so they were using two defibrillators, and what they found is that people weren’t always consistent at one second, sometimes it was a bit longer, sometimes it was a bit shorter. But in those patients who had the two shocks delivered within 75 milliseconds of each other, there was a much higher rate of return of ROSC. So the future is possibly not one second apart, or two seconds apart, three seconds apart. The future is probably getting closer to that simultaneous defibrillation, which is where the original research started some years ago.

So that was really interesting on the cardiac arrest front. I’m sure that there are people right now in mechanical laboratories, working at how to make this machine. And in five or 10 years, we’ll look back on this podcast, while we’re using our special DSD defibrillator extraordinary machines that does this automatically. They will be there, wouldn’t they? And it does seem to make a difference. And I more and more believe that cardiac arrest is about those cardiac arrhythmias that we can do something about rather than the patient who’s deteriorated over a long period of time and is now dying. These are about that patient where you can make a real difference. And as soon you make the difference, as soon you keep that oxygen going to the myocardium, the more chance you have of defibrillating. So the better we do at the beginning, even better. And if that’s not working, you’ve got to change pretty fast. I think somebody once said that the definition of stupidity is to keep doing the same thing over and over and expecting a different result, isn’t it? And this is the degree of that in cardiac arrest management.

Oh, I couldn’t agree more. And on that, defib thing, so we think defibs are good for cardiac arrest. They clearly are. And there’s quite a really great presentation on drone use. So getting AEDs around by drones. And of course, summarize that in probably in two sentences. One, what a fantastic idea we should definitely be doing that, too. The regulation around the management of airspace is so complex, particularly in built-up areas, or where I am, which is with the airport just down the road, is so complicated that we’re not there yet. And certainly from a healthcare perspective, it almost looks if it’s impossible in a lot of countries around the world. Caviar being that when someone like Google or Amazon decide that they want to do it, they’ll probably just push it through and we’ll just follow there whatever happens. So when you can get pizza delivered by Amazon, you might be getting a defib, but not just yet.

So there was also some stuff about trauma? Yeah, so Zayn Perkins from London Hems, brilliant, just a fantastic talk. I think we’ve probably talked about Zayn’s work before. It’s been really bringing us up to speed about how well-functioning, well-trained, well-audited service, and it’s the whole service, the service from point of injury all the way through, so we have managed traumatic cardiac arrest. So a couple of things that took away from this one is there’s a big difference between you having cardiac tamponade and exsanguination. If you’ve exsanguinated, they’re in cardiac arrest. You have pretty much no survival after five minutes, and you really want to capture that group of patients while they’ve still got a narrow complex tachycardia and you can do something about it. If you don’t catch them really quickly and refill them, they die. That’s really sad, which is just the reality. If you’ve got cardiac tamponade, however, that’s a completely different kind of fish. So again, survival falls off a cliff that longer you go from the time of injury, but overall in London, they’ve got 25% survivors from their thoracotomy rates for cardiac tamponade. It’s amazing. 50% survival if you do it within one minute of arrest. So both of these things are utterly time-critical and seconds count in these group of patients. So they think of their thoracotomy as in four ways. One, open the chest, two, open the pericardium, three, close the wound, four, restart, refill. And so that kind of approach. And I think that’s important because a lot of people I speak to when they talk to them about thoracotomy. It’s all about getting into the chest. And that’s just not enough. You need to get into the chest and then do something about it.

Another great learning point is that asystole in cardiac tamponade is not a complete disaster. There got lots of survivors who are asystolic with their cardiac tamponade. Lots of reasons why that might be. But asystole in itself, the patient’s just arrested in front of you and they’re asystolic. That is not a reason not to carry on. So really interesting stuff on that. I know thoracotomy is not everywhere, but we get a lot in Manchester. Depending where you are in the world, it might be a very relevant thing for you. Sadly, it seems like every day in the UK, there’s more news about a person being stabbed. And of course, penetrating trauma is one of those areas where you can make a real difference with these interventions not long ago. Near me, down the road at Bournemouth, there was a couple who were stabbed, one of whom sadly died. And so this isn’t just in the inner cities. Knife crime sadly is going up across the UK. And we’ll be seeing this more and more, I fear, as this goes on.

So theme two, that was trauma. And all of it, we should say, many of these talks are available and all of the links are on the blog site. So if you’re not actually watching detail what these talks are about and they’re clearly worth a few minutes of your time, then please do go back and have a look.

And then theme three, another biggie for all of us, sepsis. So yeah, there’s a really interesting talk from Judith Martini on the management of micro-circulation sepsis. And again, read the blog post and have a think about this. But it was taking me right back to original physiology and that model about oncotic pressure and how fluids move around the capillary walls. But this was taking it to a whole new level, looking at the viscosity of fluids and how that affects the interaction with the glycocalyx and the capillary walls and how that can potentially lead to changes in sepsis, increase leak and sort of edema and things like that. So really quite complicated. One of the big problems with God is that micro-circulation is clearly hugely important in sepsis and that’s where a lot of the problems arise. But we’re still struggling to find really good ways of measuring it and monitoring it. And I think there are ideas out there. I’ve seen people with sort of sensors under the tongues and stuff but it’s quite a way to go yet for that.

But last one from me, as a special mention to a chap called Frank Chego who’s a nurse who works with the London Air Ambulance, he gave us super talk actually. Oh, he got his word, he called it the fluffy stuff. So in this big bad world of thoracotomies and people believing today for all sorts of stuff, he is a nurse who’s been working with them for years. He does so much work with follow-up the families. And what was really, really interesting was to hear about what the patient’s experience was for those who survived of being in these terrible situations and the family’s experience about what goes on and just the importance of language. Something you’ve mentioned so many times on these blogs. You know, the importance of what language you use, how you mention it, how you talk to people can have such long-lasting effects on people. And he’s really, you know, like all the people I mentioned so far, inviting them to conferences, they’re brilliant speakers, really, really great stuff. So lots to read and lots to think about.

And this is something that we’re doing more and more at St. Emlyn’s, is being very happy to go along to conferences, to try and put these blog posts together. And also, in some cases, do podcasts from where we can get some content to you to see some of the things that you might not be able to get the chance to go to. We’re lucky enough to be invited to certain conferences. I’ll be going to the Premier Conference for Pediatric Medicine and Trauma, which is happening in Winchester next week. Tickets are still available. And we’re going off to Sweden in October to go to Tactical Trauma 24. And there’s more coming up after that also. So lots of times where hopefully St. Emlyn’s team can get there. We can get the messages out. So if you’re not lucky enough to be there yourself and as ever, we’re very grateful for the invitations and hope that it helps spread the word about all this amazing work that’s going on.

Simon, the next thing that’s probably worth covering is the R-K-M CPD conference. Again, talking about a conference that you’ve been at. And again, talking about a blog post where there’s a lot to talk about. One particular session, obviously, meant a lot, which was the RACE or race session. And that seems like there was a lot going on there and a lot to think about.

I mean, it was really, really interesting. And it sort of dodged us a lot of the other work that I get involved in through education and as dean and looking at things like differential attainment, employment, progression, all of those kinds of things. Very interesting. We’ve got a very active and very, very, very helpful EDI committee, R-K-M. And this was their session at the R-K-M CPD conference. I thought, there was so much in it. I thought I’d do as a separate blog post. I was planning to three sections, three great speakers.

So number one was Rita Das. And she gave us a history of race and how that’s been related to medicine. And it’s kind of one of those ones where you think, oh, I’ve got a bit of an idea about this sort of thing. But it was really quite upsetting and uncomfortable at times listening to it. And that’s a positive thing, I’ve got to say, about this. And she took us through how race has been dealt with the medicine, how a lot of the things that we might actually even be using today or have knowledge of have actually got quite significant concerns in the past. So you’d be familiar with things like the Tuskegee syphilis experiments where they took a load of black men and then didn’t treat their syphilis patients there. They didn’t treat their syphilis to see what would happen. And that was done on racial grounds. The Sims speculum is quite controversial about how that was developed and using potentially exploitative techniques. And then the Hottentot Venus, Sarah Bartman, being used almost as like a living cadaver during medical education. And then there were also all sorts of horrible things going on in other aspects. It was a real eye-opener, actually. And eugenics, we think as medicine, we’ve got this and we understand and everything’s fine. But our history is pretty poor. There was a journal of eugenics. It was something which was a medical profession. It would have been a training program back then if training programs did exist. And some of the stark facts that she came out with, race is pretty much an independent predictor of all health outcomes. The South Asian population, we know, has worse cardiovascular outcomes. We know that our black patients are much more likely to be restrained in a mental health crisis. We don’t give analgesia to women or to black patients as much as we do to white men. You know, there’s so much going on there. And it’s right in front of us, and it’s in our departments every day. And we need to think about how we can make that better.

David Chung talks about differential attainments. Well, that means mostly for me, it’s around education. It’s about how do we get people through exams and how do we get them through their LCPs and progression. There’s clearly differences when you look at the data. It’s not an easy and well-to-do. And I think David speaks really well. All the things he talks about is just not a lab-playing field. So if you’re a UK graduate with a UK professional medical qualification and you’re not an international medical graduate, you remember how hard it was passing your exams. But try and do that in a foreign country in a different language, where your parents are a different way apart. Your partner may not be able to work because they’re not going to visa. You don’t understand the system. You’re not living near the hospital. You can’t get accommodation. All of these other things, all these other barriers that are in the way to make it more difficult for people to get on. You know, psychologically, that’s incredibly challenging. If you try and put yourself in those shoes. And again, there’s more in the book.

And then, and Severin Derajah, and who I’ve known for many years. She gave what I think is really important to her because I’ve been to loads and loads of talks about EDI. And they often end with that look, there’s a problem. And that’s where they stop. And what Sev did, you know, you said, “Okay, well, you know there’s a problem. We told you there’s a problem. The data’s there. What the hell are you going to do about it?” And this is really important. And there’s no point collecting more data. Well, there is, but the data’s there. So what do you do? Well, the first thing is, look at this wheel of power thing, the diagrams on the blog site. Where do you sit? Where are your influences? Where have you got authority? And also look at intersectionality because a lot of the issues that we talk about is not just about race. It’s race plus ethnicity, race plus gender or sexual orientation or other things or body size or language. All those things coming together. And who’s advantageous, who’s disadvantageous, quite complex?

So she uses, I’ll finish off with this, the assess pneumonic. So these are the things that she says we should do and I agree with them. And we should ask couple questions. That’s the aim. Second, first assess is we should seek self-awareness. So we think about these sort of things as we’re doing. Second, assess is suspend judgment. Then we’ve got E, express kindness and compassion, which I think we all agree with. And next, assess is support, a safe and welcoming experience for all of those people who come and work with us. And I think the last one’s the most important one, actually, is start where the other person is. I think when I’ve seen people try and do interventions or try and support, there’s all too often a tendency to say, well, look, if you just a bit like me or if you just do what I do, then you’ll be fine. But of course that doesn’t work. That’s not starting where the other person is. That’s starting where you are. So that needs to change.

And lastly, on that one, it’s okay to make mistakes. So it’s quite clear on that. If you cock it up and you make a mistake, apologize, but don’t disengage. Keep working on it. There’s a really good session. Really good. And you’ve added a long reading list at the end there for people who aren’t. Did, and frankly, we should all be interested in me. I’ve been discussing different attainment quite a lot at an undergraduate level and how undergraduate differential attainment then leads into postgraduate achievement later on. And it is a complicated, multifactorial issue that is very hard to kind of put your finger on one thing. Oh, if you did that differently, that would help. Or if we could just change this, that would be better. But there is certainly something about the core of it. It’s how we all behave. And as I’m often reminded and taught to my boys about, the only person you have control over is yourself. And so the only way you can really influence other people is first by influencing yourself. And whatever we all say, there are definitely things we can all do that make a difference. And we can all look at our own practice and our own behaviors. Actually also just recognizing just how lucky many of us are to be in the position we are. And to then use that with positivity.

And actually talking about choosing, and Paul’s told us a good time to talk about Liz Crowe’s post choosing with intention, because Liz also goes on to talk a little bit about how we choose what we’re going to do and who we’re going to be and how we can choose to say, well, instead of saying yes to everything, we learn to say no. And actually every time you say yes to something, you’ll only have to say no to something else. And those choices are probably very valid. But I think Liz makes some good points. And I think Simon talking to you offline, this has made quite an impact on you, I think.

Oh yeah, and there’s a quote that she’s got at the beginning of it. It says, “What you don’t do determines what you can do.” And we do, through life, tend to acquire stuff, which we’re not prepared to get rid of, we’re not prepared to hand on to other people perhaps. This has got some legacy or some value to it. But actually, there’s an awful lot to be said for. If you want to go and do something positive and do something different, then yeah, get rid of it or hand it over or support somebody else or mentor or coach and sponsor somebody else to get their opportunities that you’ve had and leave it to them. And I think that’s really important. There’s some great quotes in here actually. Liz always writes beautifully, doesn’t she? And she talks about what an intention is. And the intention is a choice, yes, plus a commitment. So too many times, I think, it’s easy to go into the choice element, yeah, I’ll do that, whatever, but not actually commit to it. But if you are going to commit to it, then you’ve got to be able to make sure that you’ve got the time to do it.

Just talks about how you say no to things, which I’ve always found quite difficult. I’ve definitely used this next one. So what she talks about is, feel quite guilty when somebody says, can you do this and go, wow, sorry, I can’t do that. And actually rephrasing it into, I don’t do that. I’ve had it recently where somebody asked me to talk at a conference at a weekend, which, you know, look like a positive thing to do. It would have been something I would have maybe liked to do. But I was just overly committed at the weekends for several weeks. And I change it to, I just don’t do conferences on Saturdays for this type of event. And just changing from I can’t or I don’t was actually really powerful. Again, a bit like, you know, we were saying before, a little bit of a checklist about deciding what you want to do about a decision is, you know, does it meet with your values? Does it meet with your family’s needs and those around you? Does it reach current goals? Does it meet the demands of your work? What about your well-being in relation to this? What about the finances? Are you rested enough? And will you be able to prepare for the next week? You know, wise people like Scott Weingart have talked about very similar things in the past about, you know, are you prepared to go and do this? Well, okay, do I really want to do it? Is it really good? Because I’m going to enjoy it. Is it really, really good for me from an education, from a, you know, a development point of view? Or is it financially good for me? And you’ve got to have two out of three of those to make it worthwhile. And that’s one thing that might actually be worthwhile doing in the world. And it means that you’re not going to get suddenly laden down with loads and loads of commitments. Of stuff that you said yes to ages ago and aren’t actually giving you value. And if not giving you value, you’re probably not doing them to the best of your ability. And maybe there’s somebody else out there who could do better.

This is one of those things I think a lot of medics struggle with, isn’t it? That ability to say no, particularly when you feel, and I find this more and more actually with our annualized contracts and shift working. It’s hard sometimes to define what a day off is. When you were doing Monday to Friday and Saturday and Sunday was your weekend, they were your days off. Now I’ve done works that a day, it’s annual Sundays and they know I’ll keep working during the week and I do quite a bit of education and other stuff. And you find out if you don’t take it out, I just had it just before we started recording. There’s something that I’ve been asked to do, which would probably be a day off. It’s a week day after I’ve been working another weekend. And it clashes with doing something with my middle boy, where he needs me to take him to something and drop him off. And that’s important to him. If I don’t say no to the other thing, I won’t be able to help him. And it’s on my day off. And so I did have to think before I sent the email saying, “I’m really sorry I can’t do it.” It feels really difficult sometimes. But you’ve got to think, and as I say before, that the only person you can really affect is yourself. You know that actually just making that decision for you and your family, and what are your values is probably the most important thing.

Yeah, and his take was advice more often. I think I had two great days off, well, I had two days off the other week where I did absolutely no work. I also had COVID at the time. Those two things may have been coincidental, but there you go. Yes, often the enforcement of illness is one of those things that we think is lucky. Oh, I had a few days off because I was spending every five minutes in the loo. Just to remind you people, that’s not a day off. That’s called being ill.

There was one or two other posts from April, including one from Anisa about the ARC, H. Principal, this is about global health and we’re always really grateful to Anisa. And to Stefan, for all the posts they do about our global health, we’ve got a really strong global health section on St Emlyn’s. And this is very much worth a read just about how we can interact with global health a bit more positively. And some of the links that you can get involved with if you are interested in this. I think it’s one of those things, Simon, that if you’re not on the inside, it feels very hard to do, but actually once you get involved, there are lots of people who want to help.

Yeah, the ARC-H. Principal, is quite good. So it’s something we’ve talked about with Anisa and Stefan for a long period of time. Is that there’s a general idea that what’s happened a lot in the past is a sort of a colonial approach to this, is that the high-income nations go and tell the low-income nations what to do. And this is kind of about the ARC-H. Principal is about changing that dynamic because just wandering in for a few months, telling people to buy an ECMO machine when you haven’t got basic health care, is just bonkers. I’m being extreme, but these sort of things vaguely happen. So ARC, H. is access resources, context, and then the context of the limited health care scenario. And basically it’s about rebalancing where the expertise lies. The expertise for working global health is almost always the true expertise is in the people who are working there. We can potentially, other places and other people can go in and help, but the true expertise should be there and that’s about empowering local people when these projects develop and when they get implemented. Anisa and her colleagues are really passionate about that particular aspect. So yeah, it’s a good read.

And so when that really wraps up, or we’ve got for April, although April does seem a long time ago, we do have to get better at keeping up with our months, don’t we? Life keeps, we keep choosing, don’t we? That’s the thing, we keep choosing other things. That’s why we keep getting delayed. So forgive us because we’re choosing with intention. But that is it for April 2024. We will discuss more about the Royal College Conference when we come to talk about the May posts. And there’s lots more in that as well. So please do join us again next month. Well, we’re talking more about emergency medicine. Keep an eye on the website. There are some changes afoot. We’re looking at trying to make it easier for you to find different articles and content. So that of all the over what it is, a thousand blog posts we’ve done over the last ten years or so, there’s lots of good stuff in there. And there is lots to find. So you may see some changes on the website over the coming weeks, which we hope will be useful and look forward to your feedback on. And also you may see it as a conference near you. And if you do any of the team, please come up and say hi and as ever. If you’d like to get involved with St. Emlyn’s, please just contact us through the website. We’d be delighted to have new contributors. And it’s always great to have new voices. So please, if you would like to write something or just learn more about the work we’re doing, then get in touch and as ever. As all podcasts, to say, please like and subscribe. And it helps get the message out that we’re here and might be just something that would help people along with their emergency medicine and other parts of their work life. Simon, thanks as ever. We’ll talk again soon.