Podcast – Monthly Round Up February 2025 – Skills Fade, Resuscitation Targets and more

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

And I’m Simon Carley.

Simon, last time we spoke on the podcast, both of us were actually in Switzerland together and we recorded it live in glorious Zermatt at The Big Sick Conference. And this is the first time we’ve spoken again for a podcast, but we have seen each other recently in person at the fabulous IncrEMentuM 2025.

And before we get into the meat of February’s blog posts and other content, I thought we could just mention a little bit about IncrEMentuM. ‘Cause I think it deserves a bit of a mention on the podcast.

Absolutely. I think this is the first time I felt quite the same way at a conference, from the very early SMACC conferences. And by that, I mean, amazing content, but just the enthusiasm, the sort of a positivity which, isn’t always around in emergency medicine or in, in healthcare at the moment.

And just a wonderful group of people who are all there for a common purpose of, getting better at what they do, having good time and learning as much as they possibly could in a really concentrated, fantastic place with quite frankly, some of the best food I’ve had in a very long time.

There was a lot of positives about IncrEMentuM, and I have heard on the grapevine that there will be an IncrEMentuM 2026, which I’m sure we’ll hopefully be working with Paco and Carmen and the rest of the team to help them promote as it comes up, but do keep an eye out for that for next year. But I think it’s worth just saying what was so good, because it’s easy to get enthusiastic about these things, then we’re going, oh, okay. You’ve jumped on a bandwagon of a thing. But for me it was the quality of the talks was so good that even I, who at a conference quite happily will go and sit on my own and have a coffee during the bits I’m not having to be involved with, I was watching every talk, and that almost never happens at a conference for me because there was such good stuff.

The quality of the talks, I tell you what, the live simulations. I’ve never seen anything like it. So, jess Mason, who people may know from EMRAP, Taran and others and you involved too, doing live emergency hysterotomy with the best mannequins I’ve seen was something else at a conference.

Yeah. So that was a session. we did together myself, Taran, and Jessie. I’m glad you enjoyed it, Iain, because the preparation that went into that was insane. The amount of rehearsal, the theatrical elements, but also the clinical bits to make sure that everything was right to the second of timing, that level of detail and preparation. I think you don’t get on a conference where it’s, here’s an hour session, there’s three 15 minutes talks, and then 10 minutes for questions. It’s a completely different experience, and so it was a real privilege actually to be in that session. Tarlan and Jess. they are such amazing educators and I’ve been in this gig for quite a long period of time, but there’s no way you could not be on the top of your game for working with that kind of faculty.

Amazing.

The way they put the program together were the different ways of delivering the talks there was some chat show elements that you and I were involved in, and that makes it sound corny, but it was just about a way of changing the way that you delivered information and rethinking a bit about what a conference is about.

But we had live simulations. We had. The talks from some, Scott Weingart, Sarah Cragar to name just two

 It was amazing.

The list went on and on and it was all about learning and I cannot bear at work people describing my work colleagues as family. I am very comfortable with describing a community, and it felt like an IncrEMentuM community of people who came together, and 60% of the people there, their primary language was Spanish. But somehow with dual translation and, just we managed to make it work. So, you got to meet people from all over Europe. There was people from across the world, and I could do a whole podcast series about what I enjoyed about IncrEMentuM, but just to say thank you again to Paco and Carmen, the whole team, over in Murcia, keep an eye out for next year because I think they can only build on it and it was special and not too expensive. The fees for going were not that expensive, Murcia itself was not that expensive, so all those things that normally stop you going to these things just weren’t there. So fabulous time and thank you again to them.

 And final word for me, quite frankly, tomatoes. Quite insanely the best tomatoes I’ve ever had in my entire life. And that sounds ridiculous, but if you go, you’ll know exactly what I mean.

The food was something else. the meals were, yeah, you’d have seven things of tapas, and then at 11 o’clock at night, they brought out the paella. And you wondered what on earth is happening. I have had to restart my omeprazole since coming home.

 Let’s get into some emergency medicine and think about some blog posts. Now, a lot of the content from February was a bit about The Big Sick and the amazing talk you gave with others about top research from the last year. We’re gonna do that as a separate podcast, so we will come back to talk about the top papers from 2025, because having looked at what people enjoy, that’s the sort of thing that I know you get a lot of value from, but there’s other things to talk about. As ever, we’ve had publication of the podcast that we’ve been recording at Tactical Trauma, and I would like to pause and just talk about the podcast we did about skills fade with Natalie. recorded back, as I say, in Sweden with, again, fabulous conference, Tactical Trauma.

This is the idea about how do we keep up to date. Natalie is an amazing individual. She’s an emergency physician, in Belgium, she works with Tier One operators. She’s done, I think two Masters and I think two PhDs. That actually does happen. And this was about how to maintain competency. And this for me really struck at the heart of what’s important for us when we need to be great.

Those HALO procedures we talked about in Spain. How do we keep up to date with those when we might do them once in our life? If that, how are we ready to go? Cliff Reid talked about it again in Spain. These things of practice and mental rehearsal. It’s a real question for us, isn’t it? When we’re in the dredge of referring people to medicine with collapsed query cause and chest infections, and then we’re asked to do a lateral canthotomy, how do we keep up to date with that?

So, it’s a real challenge. I think I quite like the concept of currency, as opposed to competence so that you actually, you may have been competent at one period in time, but then actually maintaining that for a period of time so that at any point when you are required to do something, you’re actually current in your abilities.

So, I think there’s something about learning the skill initially. But then there’s also that thing about how often are you preparing for it and to what degree. We talked about this in the HALO posts in the past I can prepare to do a lateral canthotomy sat here right in this chair right now, because I can fire up the mental simulator and I can think about the circumstances when I would be doing it. I can even talk through and think through the practical procedures of going through it. And that’s okay. I could do that all the time. I can then do part task simulation type things, and I can do full cadaver courses.

And so, it’s getting an idea about how often do I need to do that, but not just me, the team around me as well. I think it is complex, but underlying all of which I’ve just said, and I think the same that you heard on the podcast, is that this is a deliberate act. It’s not something that you just, oh, I’m, I’ve done a course in the past, I’m probably competent. It’s about maintaining that ability to feel that you are current in all of these quite rare events that you need to prepare for.

And like many of the things we talk about in emergency medicine, this takes time, and it takes planning and in amongst, it’s not getting any easier, is it? I don’t know about around the world. Talking to the guys in Spain, Emergency Medicine is the same across the world in many ways but trying to get through all of the patients who need our attention, and all the ones who don’t, having time to do this and whether it’s cost effective.

Simon, you deal a lot with high up people in government and others about what they get for value for money. And do they think that training to do lateral canthotomies on a however long we need to do it basis is value for money? I’m not sure, but it has to be, doesn’t it? 

It does, and I think, it’s a really interesting question, I don’t think I’ve had those direct talks, but, I’ve no doubt that the reason why things like Royal Colleges exist and people like I exist within the Royal Colleges is to make sure that the curriculum and the scope of practice, which we define for the people who work in emergency medicine, is of the standard which is satisfactory for the job.

 And if I was an economist, which I think is where you’re going with this, and I said, what do I need? actually, I’ve been all that Halo procedure stuff because. It’s so rare and the people who get it, many of them aren’t gonna survive. So, what’s the point in spending lots of time and energy training for that small actually will do more on the bread and butter, and that is a word I have had thrown in my face a number of times at very high level, why aren’t you focusing on the bread and butter of emergency medicine as opposed to training people for this high-end stuff, which they may never do or may only do once in a career. And, I don’t agree, so we don’t agree because that’s why we’re here. And actually, rare things are rare, but lots of people have rare events, and lots of people have rare diseases. And that’s where actually, that’s why we are there. That’s as, as highly trained clinicians to spot and to be able to deal with them. There is a different school of thought I don’t subscribe to obviously, but it is actually, to plug the royal colleges, that’s what we do in a lot of these arguments and discussions with people to say, actually, we need a properly trained workforce who can do the full scope of what is required, not just which is very common or very easy.

And we’ve got to remember that we need to encourage people to want to do this specialty. And although 95% of it is the stuff we’re not talking about, the 5% is sometimes the bit that keeps people coming back. And in Spain, IncrEMentuM, we didn’t spend a long time, maybe we should have spent longer talking about how to manage the patient with shortness of breath.

We were talking about other things and that’s the stuff that excites us. And being excited when you go to work is really important. And so, I think this does talk to how we make sure as leaders and followers, both of which are important, we keep these things as at the forefront of what we do and we don’t allow for us to be distracted by the fact that, yeah, but you may never use it. Cliff Reid is a great advocate for this. He’s such an inspiration when he talks about what he does to practice, how he keeps up to date, and also as an educator, what he does to help educate the people around him. It’s that energy that we need to keep and maintain, I think. 

If you read, Chris Hadfield’s book, which is the first one which he wrote, which I think is The Astronaut’s Guide to Earth, he talks about, astronauts, and I know we’re not astronauts, we’re not that sort of amazing type level of person, but as an astronaut, you may spend your entire career training for something which you never do.

The vast majority of astronauts who are recruited to NASA never go into space. What they do is they have a life where they practice, they prepare, they train, they develop, they help other people achieve their goals. They achieve goals for their organization. They move science forward. They make the world a better place.

And I’m not suggesting that you’re an astronaut, but a lot of what we do is I read that book and thought, yeah, I can find a lot of inspiration from people like Chris Hadfield about some of the things we do. Around tasks, responsibilities, and training for stuff, which we may never do.

It’s a good book actually. It’s well worth read.

And ironically, of course Natalie did work in space medicine. Cause that’s, of course she did, and aviation and how that’s managed. So, do have a listen to that podcast, but it’s worth giving some thought to what do we do to maintain our skills when, in that day-to-day stuff, perhaps, we still need to maintain those skills.

I’m not, you know, we need to be good at ECGs, we need to be good at looking at chest x-rays, all of that stuff until AI takes over. But you know, there is the other bit too. One of the things that I think is a real thing about us doing things better is the management of cardiac arrest, and diastolic blood pressure as a new resuscitation target has been something we’ve talked about before on the podcast in cardiac arrest particularly.

And so, you did a blog post Simon, actually based on an editorial by two other St Emlyn’s contributors, Dan Horner and Rich Cardin about the use of diastolic blood pressure as our resuscitation target. And this is something that’s becoming more and more into my daily practice, I think. And also, the accurate measure of blood pressure, perhaps we can mention that too, but this is something where we can make a difference by doing something a little bit different.

 So, in summary, there’s plenty of evidence now, there’s no evidence. we’ve known it forever. we did an undergraduate, medical school or even perhaps even before that, that the coronary arteries are perfused during diastole. So, your coronary perfusion is a function of your diastolic blood pressure. That’s the first thing. If that’s the case, then you clearly need to have a decent diastolic, blood pressure in order to perfuse your heart, and if you don’t peruse your heart, you don’t survive. Now in cardiac arrest, what we’ve seen is that unless you can get the diastolic blood pressure above 35 millimetres of mercury, your chance of getting a ROSC is really small.

So, you can do things like tailor your drugs and tailor your CPR, in order to achieve that, to try and get ROSC. But what we’re also seeing in this, article, which is more about trauma. Is that maintaining that coronary perfusion is a really important thing for our trauma patients, who you may be able to get through that initial phase of profound shock and get ’em through the lifesaving surgery, but then they subsequently die of cardiac failure on the ICU.

And so, maintaining that or managing it, should I say, is perhaps our next sort of resuscitation target. And in order to do that, as you quite rightly alluded to, your oscillometric blood pressure, your non-invasive blood pressures are rubbish. So, basically, once you get to very high blood pressures or very low blood pressures in the critically ill, you don’t know what you’re measuring. And I see this pretty much pre-hospital all the time where, I’ll have a really sick patient, I’ll put the BP machine on and it’ll gimme a blood pressure of 170 over 140, and I go, great. Except, I don’t believe it. And what we found quite clearly is that by putting in a lot more arterial lines in any shock, sick, unwell, big trauma patient or cardiac arrest patient, if you want to manage this, you can need better data. And you’re only really gonna get data from invasive monitoring.

So, paradigm shift for me has been for these big sick patients, be it medical, cardiac arrest or trauma is early arterial access is really important. If it can be achieved in a timely manner, and I’m titrating and managing the patient according to all of the blood pressure parameters, but I’m taking much more notice of the diastolic than I ever used to, cause three years ago I’d be talking about systolics and MAPs. I probably wouldn’t even talk about the diastolics. And whereas now I think it’s actually a key, it’s a key resuscitation goal for me. So yeah, I’ve had a real shift in my practice.

And it follows on from skills fade or skills acquisition. Perhaps one of the top five skills we need is the ability to put in an arterial line and do it well and do it first time and also be able to do it in people who don’t have much of a palpable pulse. And that brings us back to ultrasound guided arterial access, and making the first attempt the best attempt cause rogering arteries and making them less accessible for other clinicians is not a great idea.

So, if I was gonna say to somebody who’s wanting to be a resuscitationist and do emergency medicine, one of the key skills is to be able to put in an arterial line, make it happen first time, and also the stuff around it. It’s a team event, an arterial line, it’s not an individual thing. You’ve got to get that pressure bag, you’ve got to get the fluid going through, you’ve got to have the transducer set up, you’ve got to know how to zero it. That’s perhaps one of the key things we can do that makes a difference. And more and more, I think this is tailoring cardiac arrest management, tailoring trauma management, all of that is really important. And if you’re fumbling around at a wrist or in a groin, not knowing quite what you’re doing, you’re probably then into the realms of harm versus benefit.

And I think that’s, that’s one of those where we can practice to really tilt the scales towards benefit.

 Just as an example, three times in the last week, I can think of times where arterial access has made a profound difference, stroke change, stroke difference to the management of critically unwell patients. So, it’s definitely happening on the ground.

Another topic, talking a little about those HALO procedures, the things that, high acuity, low occurrence, the things that we don’t do that often but need to know about. One of the ones that probably does keep us awake at night a little is the resuscitative hysterotomy. Which is also known as the perm mortem caesarean section.

A mother with a foetus that is at least at survivability of term, who is in cardiac arrest or about to be in cardiac arrest, how do we manage those? And what do we do? And this is a time critical intervention, it can’t necessarily, depending on where you work, depend on a call to an obstetrician to be there and a paediatrician who’s then going to resuscitate a very poorly baby. and this is something we need to do.

Caroline Leach and others, Caroline of course, friend of the podcast and was part of a podcast we did from Tactical Trauma, has written a guidance about this and how we might get better at doing it. And kudos to the Resus Room team. They’ve done an interview with Caroline, do have a listen to what they’ve talked about, but this is one of those things, Simon, I’ve been part of one of these I’ve not had to do. It just shows that in a 20-year career, it’s not gonna happen often, but it could happen tomorrow. And it’s worth knowing about. So, this was a systematic review, worth probably going into in a bit more detail.

 I think this is an absolute game changer actually for me. Again, I love papers that come along and really shake up the world. A bit of dogmalysis if you like. So, the general teaching is that you do a resuscitative hysterotomy, a patient who is a maternal cardiac arrest and you have to do it within four minutes of the cardiac arrest. And that’s what I’ve been taught and that’s what you’ll find in most of the textbooks.

I’ve always thought it was a bit odd cause the chances of me being there at the, within four minutes of the patient actually having a cardiac arrest is quite low unless they rest in front of me. Then I’ve always felt that this timing was just unachievable.

And I remember Cliff Reid talking years back at a SMACC conference, I think, where they were saying that there had been survivors up to about 16 minutes. And I thought, wow, that’s, that opens a window a bit more. Maybe I’m gonna be a bit more liberal in my timing, but this paper really changes that.

This is a paper, which is a review of 42 publications and there’s lots of great information here, but I’ll keep give you the headline stuff. The other thing that was always taught, wasn’t it, is that it’s, this is about saving the mother. You save the mother by taking the baby out.

And again, I never really figured that one out. Anyway, so you save the mother by doing a massive intrabdominal, surgical procedure. Yeah. Okay. That makes sense, let’s think about that a bit more. Anyway, so it was all about the mother and you had to do it within four minutes. So, the data shows in these papers that the maternal survival from this procedure is low is 4.5%, so about one in 20. Still worth doing. Go for it.

The amazing thing is that the neonatal survival 45%. And in terms of timings, they have positive, neurological outcomes for women up to 29 minutes after the onset of arrest, and for the children up to 47 minutes after the time of the arrest. And that’s a game changer.

So what that now means is that this is now a procedure which is entirely possible that you will be required to do in the emergency department and definitely in pre-hospital care, because you will definitely be meeting these women, at a time period where we know you can have a positive neurological outcome for either mother or baby.

And that’s also, related to the fact that the positive outcomes are more common if this is done pre-hospital, which is a timing type event, I’m sure. But yeah, I think this paper opens a time window for this procedure to be done more often. Lots of caveats because it’s a review of papers, it’s not a review of cases.

Therefore, people may have only published when they’re being more positive than not. But even so, basically, let’s put this four minute to bed and let’s put this, it’s only for the mother to bed. It’s not, it isn’t. Get on with it.

So, the message for me is it’s worth doing. You’ve got to be able to do it, and you’ve got to be the competent person at the end of the bed who’s willing to do it. There is still a Goldilocks moment for me in some of these things about, when is the time? Do you have to lose a pulse? Do you have to have a, do you have your arterial line in?

At which point when the blood pressure goes low, you do it? and I’m not sure that I have the answer for that yet. For me, for a lot of these things sooner rather than later. I think. same with things like PEs and thrombolysing PEs and stuff. Why wait until you can’t feel a pulse to do something? Feels a bit late to me.

Same with stab wounds to hearts and stuff like that. So, there is still a question of when to do it, but the bottom line is, you need to have the ability to say, this is what I’m doing. And often it’s the emergency physician who’s leading the case who has to give the confidence to the people around them to say, we’re doing this now, and if you want to do it, great. And if you don’t, I’m ready to go.

Have a read of the paper. as I say, Caroline’s a top person and there is plenty of other stuff on St. Emlyn’s that Caroline’s been part of. Hoping to have a chat with her about this as well in the near future, and make sure that you and the people around you are ready.

Where is the kit in your recess room? Would you know how to call an obstetrician if you needed them? Is there a fast bleep that they will get them to the resus room quickly if they come? Are you on the same page to know what to do together. In your pre-hospital environment, are you and a paramedic at one as to who’s gonna do what?

And although it may never happen to you, as we’ve just said, you’ve still got to know. Have a read and have a think, all good stuff. Simon, perhaps it seems a bit of a non-sequitur or maybe it isn’t. but Loz Evans has also done a post for us about death and what death is. And this is one of those things that I think sometimes we struggle with a bit about so when are you dead? and what does that mean? And neurological criteria for death, and where they came from. This is some new guidance and great of them to do a post for us about it. Make it a little bit easier to understand, I think.

 It is quite interesting actually, and it’s definitely worth the read this post because you’ll pick stuff up which may appear in an exam sometime soon. The Academy of Medical Royal Colleges have come together to talk about the criteria of a diagnosis of death and concepts around it for medicine, it’s quite important. Most of this will be most relevant, on the intensive care unit, but not entirely. Certainly, in the emergency department and prehospital it can be as well.

So, death. There’s three processes by which you can die. So, they’re called about somatic death, we don’t see so much in the hospital, these days, but it’s, when people can diagnose death based on the fact that, resuscitation will be, clearly be futile. So, things like decapitation or where the patient is completely disrupted and those traumatic criteria, overwhelming physical trauma. And, associated with the time base and we’re just not gonna continue. And that’s fine. You understand that.

Then you’ve got the circulatory criteria, which most of us will be familiar in the medical world from when we used to go to the wards and diagnose death on the wards, which is an observation that the patient has apparently died. And then observing them for a period of at least five minutes. And then checking for, any, presence of. circulatory functions. So, heart sounds, breath sounds, pupillary responses, et cetera. And that’s another way, and that’s the one we’re most familiar with. And those are actually, the first two are actually fairly easy because we understand what those are.

But then the neurological criteria, the brain death criteria are the ones which cause quite a lot of problems and of caused sort of anxiety. And in my time then brainstem death testing was fairly clear. You, had to, get a patient who was usually on the ICU would be on a ventilator, and there was a whole set of criteria, some of which were physiological, some of which were, biochemical about rises in CO2, putting cold water in their ears, checking for pill responses, checking for cough reflex, those kind of things, which are fairly standardized. And they’ve been done for a long period of time, and they were fine. understood all of those. And then unfortunately, over a period of time people got a bit more complicated.

So, things like they put ’em on ECMO. So, if you’re on ECMO, how do you actually die? It’s quite complex really. So, there was supplementary guidance put out in 2018, I think for that. About how you can do it. There was also a case in 2021 where somebody had a diagnosis of brain death and then for some reason, they did a decompressive craniectomy or they’d done it and then the patient woke up and had a good neurological survival.

So, there was more data put into that. And then there’s the concept of ancillary testing. So, things like doing things like, CT angiography to find out whether people have got, blood flow into the brain. And people have used things like, EEGs, which is more common in different places. So, actually the concept of death is actually really complex, particularly when you hit the intensive care unit.

And this does sometimes happen in the emergency department as well. So, there have been some changes. They, the latest ones I think you do have to read, particularly if this is your area of practice, and I would like to say it’s a really good area where you can write exam questions on this sort of thing.

I don’t write the exam, so genuinely that isn’t a hint. But if I was writing exams, then this would be the sort of thing I might go and look at because it’s easily tested. So, it’s all ages now and they’ve made a change to the carbon dioxide rise criteria. So, you have to have a higher rise in carbon dioxide levels, which might cause a problem with whether they may then become hypoxic, and the time of death is now on the time of the second set of observations, not the first one. The patient has to be of a decent temperature and the testing for things like eyes and ears, you have to do it in both eyes and both ears if they’re available.

And it’s all the usual stuff about the patient has to have a diagnosable, reason why they are potentially brain dead. So, there could be a reason for it. No aetiology GTS three and an absence of all the obvious confounding things like, make sure there’s no drugs in the system, make sure the decent temperature, all of those kinds of things remain largely unchanged.

But yeah, it’s a really interesting area actually. And Loz who’s a trainee, dual trainee in emergency medicine, intensive care medicine, known her for ages. She’s absolutely fantastic, great to see her writing on the blog with Dan Horner.

So quite a lot to think about this month as far as our blog posts go. As I say, there will be a different episode about all the papers that Simon discussed in Zermatt at The Big Sick, but really I think the message is quite coherent across what we’ve talked about, which is from life and death, it visits us in the emergency department.

We are the people who can make a difference, and it may not happen to us every day. In amongst what’s going on in emergency medicine around the world, to be highly trained, highly motivated, and to try and learn as much as we can and practice as much as we can as we were able to observe and do when we’re in Spain.

This is where emergency medicine’s at.

Simon, I think that’s it for February. Lots to talk about. It’d be worth us just saying. a quick thank you to both Galen Pharmaceuticals and PM Cardio who are very kindly supporting the activity on St. Emlyn’s, and we’ve got lots of other exciting stuff coming.

Please do have a look on the website to see what’s going on. Keep up to date. We are trying to up our social media game a little bit as well, although moving away from certain platforms and onto other ones, but I’m sure those of you listening will be aware of that. And we haven’t talked about all of the other podcasts we’ve released over the last couple of months and in February, but please have a listen.

There’s some really good stuff in there. And as ever, dare I say like, and subscribe. Simon, that is February. We’ll be back on the St. Emlyn’s podcast very soon. It’s great to talk to you all.