Podcast – Monthly Round Up December 2024 – Chest trauma, IO access, AI and more

 Welcome to the St Emlyn’s podcast. I’m Iain Beardsell.

And I’m Simon Carley.

And we are actually for once in the same venue, recording a podcast at the same time, in the same zone, and in the same country. We are in Switzerland, Simon, at the Big Sick in Zermatt, in glorious Swiss sunshine, blue skies, snow capped mountains. It’s a heck of a place to be.

 It’s amazing, isn’t it? I’m just sat here looking up at the mountains, watching people ski down. There’s paragliders in the air. Every so often there’s a, helicopter that goes past from Air Zermatt, amazing group of people who do the mountain rescue here.

And it has been a fabulous week here. We’re very lucky to be here, very kindly hosted by the Big Sick. Simon’s done his talk this morning. This is day one of a three day conference, so there’s plenty more to come.

But we’ve taken the opportunity to just get together on the first afternoon. Most people, it must be said, have taken to the mountains in the planned afternoon break for some more skiing, and we may well do that on days two and three. But for now, we are here with you and Simon with plenty to talk to for December.

And this will be our series ending, our season ending podcast, as is traditional, our discussion of the December blog post from 2024, ending our season 11. And let’s start off by talking about some, evidence based medicine. Can we talk first about the early exercise in blunt chest wall trauma, a randomized control trial?

Yeah, we can. So I thought it was really interesting study, because I have a particular interest in chest wall trauma. I think I’ve said on the podcast before, look after patients on the major trauma ward is one of my many jobs. And a major focus of what we do there is the management of patients who’ve got flail chest, multiple rib fractures or associated spinal and rib fractures.

And they really suffer actually got a lot of pain. It inhibits their recovery. And, occasionally they get things like pneumonias, and that can lead to significant morbidity, increased length of stay, and sometimes even mortality. So it’s quite interesting in this paper, essentially what they did, is there’s a multicenter parallel randomized controlled trial, where they got patients with blunt trauma to the chest and they allocated them to either the standard care, or to an exercise program consisting of four simple thoracic and shoulder girdle exercises. This is for patients who are going home rather than the admitted ones, but it’s all part of the same continuum. Because, Iain, I’m sure you’ve seen people who’ve had a few rib fractures, they’ve gone home and then have come back with pneumonia, in a week’s time or so.

The way in which we manage chest trauma has changed massively, hasn’t it? It used to be, don’t even bother with an x ray, because if you see a fracture, it doesn’t really matter. And this is really where we’re going in the future. And to be able to do something, and I notice this is published by Keri Battle, who you may know the Battle score, so real history of what’s going on with chest trauma, and if we can improve outcomes and stop people coming back, that’s only to be a good thing, right?

Yeah, she’s done incredible work with a team over in Wales.For this one, they recruited 360 patients. mostly,slightly more elderly patients. I think that’s typical of what we see 63, years old and the majority were men as these cases often are, and they followed them up for a period of time and at three months, they looked at things like chronic pain scores and also functionality using the EQ5D5L score, which is one of these sort of global, how are you getting on scores. And I was really hopeful for this because I thought this would be a great trial. It is a great trial. Let’s face it, it is a great trial.

I thought we’d get a really positive result, but actually, interestingly, it didn’t really show much difference actually. And so, the outcomes are pretty much the same whether they got this structured exercise program or not. Bit disappointing. The authors look at this and say,maybe we’re trying to do a one size fits all for this, which is really quite a diverse group of people, and maybe it needs to be a little bit more bespoke. So there’s probably some more work to be done here. Bit disappointing, but great work as well. And we’re learning more and more about the management of chest wall trauma.

Remember there’s all sorts on the website about chest wall trauma, something we’re increasingly interested in to try and prevent all of that morbidity, remember serratus anterior blocks. They were mentioned in Simon’s talk this morning. there’s a blog post about that from some, evidence from the last year or so. So there’s lots we can be doing in the emergency department to optimize the management of these patients, even with what seems like a trivial injury.

And having fallen down on these ski slopes in the last few days, Simon, no injury is trivial. So we need to take them all seriously.

Yeah, there’s a few people here who are known huggers. They’re not hugging anybody at the moment, they’re walking around holding their arms with a few, possibly a few fractured ribs under there.

It should be mentioned actually, don’t tell anyone, there’s a few people in knee braces as well. But luckily, I still have the same number of ligaments I arrived with, so fingers crossed.

Our next paper, Simon, again, you mentioned this morning as part of your talk. This is about intraosseous access and the long term complication. I guess we’re seeing IO as being a really good way of getting quick access to be able to deliver drugs in a timely fashion, particularly in things like cardiac arrest.

And this was trying to say, are we doing harm long term with this? Is this a short term fix for something, but we then cause problems? But it seems that, no, this is a pretty safe thing to be doing.

It does.

 So we’re seeing a lot more patients having intraosseous needles put in, usually in pre hospital care, but also in the emergency department. More humeral needles going in. And I think there’s going to be a bit of a change, not really for primetime yet, but I think we’ll probably be putting more femoral ones, particularly in kids, easier to get to, bigger bone, etc.

What we don’t know, or what I’ve not really seen good data for, is whether or not you get long term complications of things like osteomyelitis. Long term compartment syndromes, infections, or osteonecrosis as a result of these being used. Obviously, there’s a short term conditions where you might get extravasation of fluids and things, but what about the long term?

So, this is a nice study. It’s from Denmark, and they’ve got really good data follow up of these patients. they’ve got really good registry data, and they followed up really a huge number of patients, 5, 387 patients. they lost 375 to follow up. That’s pretty awesome, to be honest. 237 kids, the rest are adults and of the patients who survived, they really found extremely low rates of any concern whatsoever.

Just to put some numbers on that, there were fewer than five cases, which is less than 0. 1 percent of osteomyelitis in all of those cases, nothing else of any major significance.

So yeah. Probably safer than a Venflon. It doesn’t appear to cause any long term conditions, and we should continue to use it.

So if you want to read that paper, it’s in Resuscitation, published in 2024. And as we always say, we talk about these papers, but please do go back and have a read for yourself.

Don’t just believe it because you heard it on a podcast.

 And so IOs, safe to use, may or may not increase our time to drug delivery, but it’s something you can think about if you can’t get easy IV access, and in your service, think about using them if you’re not.

And try not to worry too much if they’re put in the right place and in the right way. They shouldn’t be causing you too many complications.

Matthew Gray did a guest post for us in December about imaging decisions in paediatric trauma. We get these regular Royal College of Radiology updates.

 But this had all sorts of bits and pieces in it. Simon, can you pick out the bits you think are most important?

Yeah, largely it hasn’t changed that much. It’s still following what we call the ALARP principle for imaging in children, which is low as reasonably practical and is still like that.

But in the past, that did lead to us perhaps not imaging some children with higher radiological investigations, such as CT, when they perhaps should. So there’s a couple of updated algorithms in here. One is around looking at CT of the chest, which previously was something which pretty much never, I remember having conversations with people saying there’s never an indication to a CT of the chest in a child, but actually now rapid deceleration impact, very high impact motor vehicle crashes.

And some other indications such as, reduced GCS with distracting injuries. Now it can be considered. So that’s a really positive move forward. I think that’s good. One of the other things that’s come in is a better algorithm for the management of penetrating trauma. Something which was not terribly well described in the previous ones, but unfortunately we’re seeing a lot more of, back in Verchester, we’re seeing more children with suffering, pediatric penetrating trauma.

It now looks very much more like the adults’ protocols. And I think most people will be familiar with those. And then there’s a really interesting section where it really did come out of the experience that we had in Manchester around the Ariana Grande concert bombings is about the management of pediatric blast injury.

And again, that’s now closer to the adult algorithm with early use of CT in these patients, early use of pan CT, and also screening CTs to look for the shrapnel that you see all over these injuries, often with very small entry wounds. So some really good advice there. And the sort of thing that I would be putting into my major incident plans, because paediatric blast injuries are not common in the UK, unfortunately they are more common in other parts of the world, but it’s the sort of thing you’d want as a ready aide memoir should anything absolutely dreadful happen like the concert bombing in Manchester.

And these are those things that it’s worth talking about with your radiologists now, rather than waiting to the moment when you need to use them on a Saturday night at 11 o’clock in the evening, when perhaps there aren’t the right decision makers there when you’re trying to do these new things. And I’d encourage you to have a look at these guidelines.

Take them to your radiology colleagues, they should have seen them, but maybe have a conversation about how it’s going to change your management.

 And I’d go back to the Ariana Grande bombing. Some of the CTs that we did back then, the whole body CTs, there was a mistake, not mistake, but the practice at that time was to do limited CTs.

And what we found is patients would go for one CT of a body part, which is where you thought an injury was, they’d come back and then they have to go back again to have other areas imaged, which is not timely, causes problems. It ends up with even more radiation. So they’re very much a push here to do the right thing first time, get a good decision and make a plan.

Artificial intelligence is playing an ever bigger part in all our lives and it’s a really great tool to be able to use. And there are questions these days about how it’s going to affect healthcare. What will change for us? You’ll have heard the blog post and the podcast we did with Steve Smith back in July in 24 about the use of the PM cardio app and how that can analyze ECGs. And I think that’s a really promising way forward, but there’s all sorts that we may see over the next few years. Just today, we were chatting with Rob McSweeney from Critical Care Reviews about how the world of analyzing data and analyzing papers may be absolutely revolutionized by the use of AI.

And Rick Body’s done an article here reflecting his experience from presenting at EUSEM last year about the promise and perils of artificial intelligence. There are many things that we can be grateful for with AI, but there are also some things we should perhaps be cautious about too.

The positives, we’re already seeing it now.

We’re actually using radiology reporting with an AI base, and to get reports on our chest x rays is actually, my experience so far has been extremely helpful and very good. It is better than me already. But it is still checked by a human. Looking at staffing models, potential there, and then even ambient clinical intelligence, where you can have the AI listening in the background and give you prompts and suggestions.

Those technologies are already here and they’re being used in some emergency departments around the world, but there are problems. Sometimes we, it’s a bit like a black box, isn’t it? We don’t exactly know why it’s making the decisions that it is. And then how do we carry on in the future to keep educating it?

Regulation and monitoring, gosh, a whole minefield there. And then also from a bias point of view, where do these data sets that the AI is making its decisions on come from? So are we trying to apply data which has been learned from a database from the, say the North America, and then we’re trying to apply that in somewhere like South Africa, Is it going to be accurate?

Is it going to be able to learn? Is it going to be able to contextualize the sort of information that we’ve got? And then there’s Rick points out, and Rick’s very good at this sort of thing, actually, hugely wonderful technical mind, but he’s got humanity and runs right through Rick as a, as a core principle.

And he says, actually, if I’m a doctor, I still think there’s a role for all of us, even with the brilliant decision support that AI can produce. Medicine is still a human interaction. And having humans who understand, who can textualize, who can help people make good decisions. I, we’re not going to be out of a job anytime soon, but our jobs will change.

This is one of those things where you’ve got to get on the bus and ride with it, I think. This is the future, whether we feel a little bit intimidated by it and scared by it, whatever it may be. The idea is to be as good as you can be to use the tools at your disposal and AI, Chat GPT, whichever one you’re using, it’s only as good as the prompts you put in it and rubbish in, rubbish out is the same as you get with these sorts of AI engines as you do with anything else when you’re analysing trials or whatever it might be.

So really, this is about learning to use the tool.

 And I’m really looking forward to the International Conference of Emergency Medicine over in Montreal, where I’ve got to talk entitled “Educating Generation AI”, because I think that’s the other challenge for people like you and me is to how do we blend education into our systems where our trainees and our colleagues will have access to this information.

And how do we teach them and help them understand how to use it themselves in practice? And how do we teach with it? And I don’t know, it’s a really interesting, exciting area.

As educators, it is something to really think about. When will people turn to us for education if they can just get everything they need from a Chat GPT search?

And not only could they get a Chat GPT search, Simon, they could put it in and then make that into a podcast and choose the voices they want to speak back to them. And you and I become very redundant. This is something that we’re all going to be looking at in the future. It’s about finding a way to use it and definitely not being scared of it and making the most of this technology early, cause I think early adopters are going to be the power here. They’re going to be the ones who are going to be able to lead and we need leaders in emergency medicine to do it in all of medicine and education, just as we have before.

Greg Yates has continued his series about toxicology and poisoning. I have to admit, something that’s probably neglected slightly in my CPD, so I’m very grateful to Greg because he’s gone over some topics that I would be very rusty about, and he did a post for us in December about toxic alcohol poisoning, and I do have, from my very junior doctor days, a memory of writing somebody up for shots of whiskey or vodka, I think it was, to try and get them to metabolize their methanol.

And I do remember very clearly a case of a patient with profound metabolic acidosis where it turned out they had ethylene glycol poisoning and it was slightly late to be diagnosed. But Greg’s done a really useful article here as a reminder about how to manage the patient with toxic alcohol poisoning, by which we mean methanol, ethylene glycol, those sorts of things.

 I’ve seen a few over the years and, there’s some recently some absolutely dreadful cases coming out of the Far East, weren’t there, where, some tourists over there had been fed the local moonshine, essentially, and that had contained methanol, if I remember rightly, and unfortunately, several of them had died.

Awful stuff. And these are interesting substances. Essentially, you ingest them and the actual substance itself isn’t the toxic agent, it’s the stuff it gets turned into. So methanol actually gets turned into formic acid, which is an antvenom, believe it or not, causes acidosis, but also causes retinal injury or moonshine blindness, and effectively can kill you.

And all of these conversions around the enzyme alcohol dehydrogenase. So the old system of basically, if you had methanol in your system, we used to flood it with alcohol so that the rate of formation of things like formic acid from methanol was so low, it never reached toxic levels. You’re trying to compete against that enzyme.

But there are now drugs. so there is a specific, alcohol dehydrogenase inhibitor, fomipazole, which is really interesting bit. So essentially does the same thing. It reduces the rate of conversion. Therefore you don’t get a high toxic levels. and in this study that’s been reviewed by Greg, again, another great toxicology study.

Toxicology studies aren’t particularly great evidence levels. You don’t get a lot of RCTs. It’s mostly observational data, but what this shows that in 147 patients in Japan, extremely well tolerated and the patients did pretty well, actually. certainly a drug which should be in your cupboard, because it’s part of the RCEM guidelines.

Now, and if you’re not in the UK, we’ll just think about getting it anyway, if you can, if it’s available and you can afford it.

And one of those things again, where you will see it infrequently and hopefully a blog post and a mention on a podcast may trigger your interest to remind you of it. Should that happen to you where you’ve just got those cases, perhaps it’s profound metabolic acidosis or raised anion gap acidosis, and you’ve gone through your mud piles and all of a sudden it turns out the M is the one you’re dealing with.

All too often we skip past the M don’t we to zoom straight the way past it diabetic ketoacidosis or lactic acidosis, but here the M of MUDPILES is for methanol and of the E is ethylene glycol. and you might think, how am I going to manage this for the raised anion gap acidosis? And this is one of those things you need to be thinking about.

And so it’s worth a read. And as ever, thanks again to Greg for making the effort to do these toxicological posts for us, because it’s one of those areas of emergency medicine, which is really key. And we have to be the best at, because these patients, if they’re going to do badly, they do badly pretty quickly.

Absolutely. We had a post from Natalie about the difficult airway society meeting in 2024, neither Simon or I were there. So rather hard for us to relate that particularly, but there’s a load of information there. And it was great to have Natalie across in London, to chat to, and hopefully you’ve heard the podcast by us from the London Trauma Conference.

And if you are subscribing to the podcast, as indeed I hope you are, there are many podcasts on their way from London Trauma Conference with myself and Natalie talking to some fascinating people. So please do remember to subscribe on whichever podcast provider you prefer. I hope we appear on almost all of them.

And as always, there’s always a blog post to accompany the podcast. So the information is there. Should you need it.

 Just on the difficult airway society. There’s some interesting stuff in there. I often think that they don’t necessarily understand emergency medicine, and the pre hospital elements, it tends to have a bit more of an anaesthetic focus, but there are some real good pearls in there and some really good stuff about stridor management, about whether or not we need to be quite as aggressive as we normally are. I think that’s quite interesting.

There’s another great reference back to Dr. John Hines talk on cricoid pressure. I think people like DAS are now getting the idea that maybe it should be used in a very discretionary way. And there’s also, definitely worth having a look, the five commandments of stridor, which is a little bit of dogmalysis changing the way the world looks.

And our last post to just mention, which is worth a read, is from David Purkarthofer, who reviewed EUSEM 2024. It was in Copenhagen this year. Almost 4,000 people attended, some really good stuff. like all of these things, I do believe Simon, as we sit here in glorious Zermatt, that the medical conference is on its way back.

There are plenty of things to attend and there’s so much to learn. And David’s written an excellent article there. There’s some, absolute pearls in there.

It’s a fantastic, definitely worth the read and, a real good look forward to Vienna where he’ll be heavily involved in the creation of that particular conference.

If you’ve ever been to a conference in Vienna, you’ll know what an excellent experience it is. We went there a few years back, didn’t we?

We did. Yeah, for a EUSEM conference back in the day, I remember visiting Mozart’s flat. It was. It was a particular highlight. Absolutely excellent. very much looking forward to that.

While we’re talking about conferences, perhaps just worth a last mention of Incrementum 2025, which will be taking place in Murcia in just a few short weeks. There are still some tickets available. If you have some study leave remaining or perhaps some annual leave, and you just got a bit of spare cash after Christmas that you could put towards some spring sunshine in glorious Spain, it’s very much worth it.

Speaking to the organizers, they’ve got some really exciting plans. There will be English translations for the one or two Spanish speakers. And for all of the English talks, there will be a Spanish translation also. So no one will miss anything, and there’ll be such a good opportunity and also to celebrate Spain, taking emergency medicine as a specialty and watching that growth and really great time to connect. It’ll be a bit warmer than we are today in Zermatt, I hope Simon, but we’ll be still able to connect with people and meet people just as we have here.

And I’m looking forward to doing over the next couple of days.

I’m really looking forward to Spain. Wonderful country, wonderful people, and such a huge degree of enthusiasm from their fledgling emergency medicine community.

Simon, that is our end of Season 11. It’s been a heck of a season. We’ve had, I think, 26 or 27 episodes in this season and that draws that season to a close.

We’ll be very excited to bring you Season 12 and we will keep bringing you quality content, I hope, on a weekly basis from the different conferences we’ve attended the regular monthly updates, some special episodes. We’re hoping to plan some related to some papers that have been out recently. So keep an eye out for those.

Please do, as we always say, like and subscribe and tell your friends if they’re not already listening to St Emlyn’s and you find it useful, entertaining perhaps, and just a nice thing to jog along your enthusiasm in emergency medicine, then please ask them to listen as well. We’d also be really grateful to hear from you if there’s things you’d like us to cover, or if you’d like to get involved and write a blog post for us, in any way, shape or form, we’re always looking to make our team larger and have more voices on both the written and spoken word.

But for now, from Zermatt, we’re going to go off and have a little coffee in a little bar I would hope, and gaze up at the snow capped Matterhorn, and for now we’ll say, we’ll chat to you next month. Have a great time.