Podcast – January 2024 Monthly Round Up – New Year resolutions, incubating poisoned patients and wellbeing the Emergency Department

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

 And this is season 11 episode one, Simon. A new dawn, a new season. We’re going to be talking about January 2024. How are things with you?   

I’m pretty good actually. I’m busy as anything. I’ve just come back from Switzerland and the Big Sick conference. Absolutely incredible conference. We’re going to tell you more about that in our next podcast. But oh my god, if you get a chance to go there, it’s fantastic. Really small, bespoke, and had a bit of the vibe of the really early Smacc conferences. It was excellent. And then today, I’m off to Canada to see our great friend David Carr at the CBD conference over there. Again, we’ll tell you more about that in February’s edition of the podcast. But yeah, I’m busy as hell, but I’m really having a great time meeting some wonderful people.

 This is where I like to remind people that the podcast is a two-person venture because the invites do tend to go to the professor rather than the other dude. I need to work harder obviously to try and get invites and the other irony to all this is you don’t ski. Do you know that happening?   

So you’ve been in Zermatt and you’re about to go to Whistler and the skis will stay completely away from your legs. It’s all work. There’s no problem. That’s what I hear. It’s all work, work, work.

 And how are things at the college? Again, we must send our best wishes to Adrian. It’s good to see him recovering, our president of the Royal College.   

I see he’s doing what all emergency physicians do, and I’ve got a couple at my place at the moment where you have operations and then you don’t stop working anyway. And you keep working from home, onto which I saw that he’d arranged a meeting with somebody from the Royal College of Radiology and they visited him at home. So he’s now sort of having home visits, but our best wishes must go to him.

 And then anyone else who’s recovering, and I’ve got a couple of colleagues at Southampton who are currently getting over some pretty big operations. And we’re at that time of life, aren’t we, where people seem to need operations, seem to get poorly, and yes, it’s middle-life crisis the right word. I’m not sure.   

Oh, I don’t know, but you’re right. College is, again, lots and lots of work going on there. Obviously, people will be aware of the pressure in emergency departments all over the place, still working very hard on that and crowding particularly. There’s also the issue of physician associates, which is really politically tricky at the moment and there’s more coming out. By the time you probably listen to this podcast, you’ll have heard some more information coming out from the college about that as well. And we’ll be talking a bit more about the working conditions and retention and what it’s like to be in emergency medicine in a paper a little bit later on.

 But Simon, let’s start with chatting through some of the blog posts from January 2024. And this started as sort of a tradition these days with a New Year’s Eve, I want a New Year’s Day Resolutions post from Liz Crow. But this was a bit of a different flavor rather than us just saying, oh, what we’d like to achieve in the new year. This was a really thoughtful post from Liz about what we can do to change and keep that change for a longer period of time.   

I mean, although this was a New Year’s post, it could be applicable to absolutely anything at any time when you’re trying to make a change about your personal life, you’re trying to make a change about how you work, take about making a change about how things function in your life and the people you influence around you. I thought it was really good actually because she’s taken a relatively evidence-based approach, as Liz does. So she speaks so beautifully about these sorts of things, but she’s always backing it up with some science. She was talking essentially about if you want to make a change, then you have to create habits. So it’s not about the change, it’s about creating a habit. They’re two different things. They probably are. But it’s focusing on the end goal because we do things because they become habits.

 So how do you do that? And the first thing to say is it takes ages, 59 to 91 days to actually create a bit and then for it to stick. And creating habits, three things you’ve got to get a cue, have the behavior and then you have a reward.   

And the problem we have a lot with our jobs is that often the cue and the behavior in the ward on habits, but they’re not good ones. So the cue is, I’ve had a bad day. The behavior is, I have a beer or a slice of chocolate cake and the reward is, I feel good after having beer and chocolate cake and that becomes a habit. And so we have to kind of build different ones. So we still have the same cues because we still have our same experiences in life. But then how do we then get a different behavior, which still has a reward? So that becomes the alternative habit.

 And she talks about some really sort of interesting forcing type things in there. That’s great. I mean, it’s a really good quote in there as well. 90% of fame that comes from people who have a habit of making excuses. I think that’s probably true.   

Well, the thing I’ve always learned from Liz is that emergency physicians tend to be slightly go-getting, don’t we? So we don’t just do things little by little. We just hit it hard and we hit it hard for a few weeks and then we stop. But I think one of Liz’s important messages is to start small. So, you know, give yourself a little bit of a cue and then a reward, behavior, and reward, but don’t go straight for it.

 Simon, this is a bit of a humble brag, but the other day I went to the gym and for some reason I decided, I don’t go to the gym that often, but I was watching Mission Impossible: Dead Reckoning, a film which by the way, I don’t think is as bad as people say, I quite enjoyed it. But it’s two and a half hours long. Anyway, me being me, I decided if Tom Cruise can run for two hours, so can I. Anyway, I ran 15 miles and now I can’t walk. And now I don’t really want to go to the gym again.   

And that’s the sort of nonsense thing that people like you and I and people listening to this do. I would be much better if I ran a little way many days of the week, rather than just running one big run once in my lifetime. And these are the things I have to learn. And Liz has always tried to bang on to me about just starting small, setting yourself small goals, particularly when work is so tricky at the moment. It feels like too much, doesn’t it? And you’re right. Sometimes the reward, it feels like we deserve chocolate cake or we deserve beer because we’ve had such a bad day. And somehow naughty rewards feel more rewarding.

 The other thing that she talks about in here, she talks about many things, but the other thing I quite liked was, and one of the ways to get around that is to do forced behavior, forced cues. So one, I think she talks about, you know, if you’ve got a habit of coming out and opening a beer, then put all the alcoholic beer in a cupboard and put the cold beers, which are the non-alcoholic beers in the fridge. So when you arrive home, do you want a cold, nice, fresh, non-alcoholic beer or do you want to warm your kebab out of the cupboard? You know, that’s a forced cue. Or you can make your own lunch, or you can have your gym kit next to your bed when you wake up in the morning. So you’ve got to walk past your gym kit to not use it, sort of thing. So little things that you can do to sort of get yourself into the habit, and then once the habit is established after that, whatever it is, 59 to 91 days, then you’ve got the opportunity and the hope that it will continue for some time.   

The first thing I’ve always found is to not have the beer in the house at all. That’s the best forced behavior. But even then, I go to the supermarket and somehow they make me buy things I shouldn’t be buying, crisps and chocolate. But yeah, the time I’ve listened to the sort of diet people who advise you about these things, and I’m a big fan of the van Token and Twins, and the way they approach things with diet, they say, just don’t have it in the house. But these are the ways of thinking about it. There are things we can do, and we feel overwhelmed at the moment. It feels like our cup is full, and people like me and you telling people that they shouldn’t be doing the nice stuff and having the rewards, people would tell us to get stuffed, but little things and actually, you know, getting enough sleep, making sure you’re eating well, those are the things that can make life a bit better so that when you’re at work, you don’t feel quite so awful.

 But highly recommended. Liz is always great to read. She’s a great writer, and a little shout-out to Chris Hicks, who’s one of the authors on the bibliography, who I know you’re going to be seeing over the next couple of days when you’re over in Vancouver and Whistler, and that great team over in Canada, who I miss a lot. And I would love to see again. Onto our next one, Simon. This is about a journal club post, and this is an

 intubation for the patient with low GCS, particularly related to poisoning. And now we’ve always been taught, haven’t we, that GCS less than eight equals intubate, and other such things. Is that still true?   

Yeah, I think that went out some time ago, and yours and my mind, I think we’ve been exercising a lot more discretion over the years, but I still hear it, and it’s still in the books. But clearly, it doesn’t really make a lot of sense because the GCS 9 and 8 intubate and things about all you lose, all your airway reflexes at that level, and there’s pretty good evidence now, and there’s not pretty good evidence, that that’s just not true. And I’m quite happy to aspirate with a higher GCS, as we’ve all seen, and you can have pretty good airway reflexes below that as well. So it could be a little bit more bespoke. Certainly in toxicology land, there has been a trend, I think, that if they’ve got a low GCS when they come in, then getting intubated, going to ICU, often for what is essentially just bed and breakfast and a ventilator is perhaps not always in the best interest. But in my clinical practice, I think over the years what I do now is I use the word trajectory a lot with these patients. So we see them as they arrive, they’ve got a GCS which is low, or about this kind of level. And I often go, well, we can monitor them in the emergency department now, have a look at them and see how they go. And I’ll come back and see them in half an hour, or be in the recess room, see them in half an hour, see them in an hour. And if their trajectory is getting better, then we’re probably not going to intubate them. But if they’re getting worse, or the same, our hand is forced and we’ll go with it. I don’t think we’ve been doing the strict rule for quite a period of time. I don’t know what your practice is in Southampton. Probably similar actually, but a lot of this is often related to the pressure on intensive care beds, isn’t it?

 We sort of give the decision-making or we make the decision-making alongside our intensive care colleagues. And by the time we’ve procrastinated a little bit and thought about whether or not they need a CT scan and all those other things, the patient starts to improve. And that’s often the case, isn’t it? These are the patients who could really do with that short-term intensive care environment that really is recess plus, isn’t it? It’s beyond the four hours, but it’s not the 24 hours of admission to ICU. And it’s kind of what I imagine Scott Weingart does in America. I’ve never really asked him about it, but that sort of EDICU interface whereby there is a group of patients who need a short period of time of critical care. But almost by the time you get them to ICU, they’re better. And that includes this group. It includes patients with diabetic ketoacidosis, you know, the ones who just need physiologically quite a lot of support, but you know should get better.   

And I think for this group, it’s exactly the same. And we do struggle sometimes with having the intensive care capacity for our emergency patients, particularly when we’re trying to keep going with elective patients who can’t have their operations unless intensive care capacity exists. It’s a real tension. And so I’m not surprised when intensive care colleagues come down and say, “Could you just keep an eye on them and see how they go?” Let’s just, you know, do our best. I really sympathise with that because there’s a lot of pressures. And it’s not just that one patient who’s in front of me that they’re having to deal with.

 I completely agree. And often these patients present in the latter part of the day. So when you do admit them to ICU, people generally relax and wake them up at three o’clock in the morning, which again is a decision I would agree with. So they do tend to use that bed right through to the morning. So this is all conjecture between you and me, isn’t it? So let’s have a look at the evidence, I suppose. So, a French paper. There’s a lot of really good stuff coming out of France of late. Whether that’s because I’m just seeing it in English language journals when it’s always been brilliant in other journals, I don’t know. But we are definitely seeing some really good quality studies coming out of France and French-speaking nations.   

But this was a multi-centre randomised control trial, 20 emergency departments and one of their intensive care units, looking at comatose patients who came in with suspected acute poisoning and GCS less than eight. What they did with them is they randomised them to either, okay, we’re going to intervene, we’ll intubate these patients as we normally would, or we will withhold intubation and we’ll watch and we’ll see what happens. So 225 patients, 116 were in the “just let’s watch and wait,” 109 in the “normal practice.” And essentially what they found is that there was no massive difference. What they found was that there was no major difference in the primary outcome, which is interesting. Because their primary outcome is a little bit complicated. So there’s a hierarchical composite endpoint of in-hospital death, length of ICU stay, and length of hospital stay. And essentially what they did is this analysis, we’ve got a win ratio. So each patient is paired with everybody else in the opposite group. And then they sort of like almost like a betting type thing. So the first one to sort of blink, the first one to fail, or the first one to get intubated or not intubated, is where they sort of sense that person and then move on to the next one. So it’s an interesting way of looking at it, but it kind of, it’s kind of like doing a bet where you take the odds of winning. So your decision was the right one versus the opposite decision. And 16% of the patients in the watch group got intubated, 88% in the normal practice got intubated because some didn’t really at the end. Adverse events, no real difference. And of course, complications slightly higher in the intubated patients because some of the complications are related to being intubated. So things like hypertension, hypoxia, and difficulty in intubation, which you don’t get if you don’t intubate the patient. It’s interesting and it probably backs up my practice. It is small numbers, 225 is not really that much to be absolutely sure that we’re not going to kill somebody by this approach on a fairly rare basis. But yeah, I think it backs up what we’re doing at the moment.

 I say, when I was preparing for today’s recording, I was particularly looking forward to your explanation of the Finkelstein-Schneurnefeld method, which I think is what you just did. But something I’d never heard of, a different statistical analysis, and I do this is where I look to you as our professor and personally knows about this sort of stuff. But it was quite complicated in how they did it, I think, and pairing these patients up. But for us emergency physicians, bottom line is there was no huge difference between the two groups, a watch-and-wait strategy versus an early intubation strategy. It feels that both get a similar outcome, and so probably almost whatever you’re doing, you’re probably doing okay. We haven’t taken this on particularly much further than we knew beforehand, but it does back up the way that we’re currently practicing. And if you want to read this paper, it’s in JAMA. So please, as always, don’t just believe what we say, please do go and look up the actual paper and on the blog site you can find the links to both that paper and other things related to it. So it is worth going and having a look and then having a look at the paper yourself.   

Do you want me to go more into the Finkelstein-Schneinfeld method? It’s really interesting. I mean, I go on, why not? Yeah, I suppose the interesting thing about it is we see a lot of papers where you have a composite endpoint. And it’s very common in things like VTE papers, very common in our acute coronary syndrome type papers where we look at these composite outcomes. And it’s always tricky, isn’t it? Because in something like a cardiac paper you might say composite outcome is death or revascularisation or another MI. And you think, well, they’re not equal. Are they? You know, death is generally thought to be worse. So in this method, what they do is essentially they rank those three things in the composite outcome. And they look at the first one first. And if it happened, then if the first worst event happened, then that’s censored. That goes off. So in this case, it was death. So if anybody died, there was a win ratio between two things. That person goes out of the equation. But if the first event didn’t happen, they then look at all the second ones. And then they look and see if any of those happens, win ratio is done again, then they censor those ones, and then they go to the third. And so they move through these composite outcomes, which gives it a bit of hierarchy. And so I just thought it was a really interesting method. And if you are looking at any papers with composite outcomes, I think this is one that you might just want to go and have a little bit more information about. And there’s a link on the blog site where you can go and get all nerdy about it.

 And this is a reminder that critical appraisal is a really important skill. Whatever stage you’re at in your career, the ability to read a paper and read all these little bits that you might miss

 otherwise. The idea of death is not the same as revascularization, but somehow that might get linked together and that might be the end whereby you get a p-value. And you just pay attention to the p-value and do you know what, you’re so excited about the p-value you tweet it out because you want everybody to know about it. But actually, it’s and then somebody reads it and they then tell all their colleagues and then before you know it, everyone thinks that’s true. But this is why it’s really important to properly critically appraise papers, have a real look at them and have those experiences and those skills yourself. So that’s a bit about intubation in toxicology.   

Simon, a bit more of a post related to what working life is like. And this is about retention and working conditions and what it’s like to work in emergency medicine. And this is very much your wheelhouse to do with your Royal College work. I know that we should mention that you are the dean of the Royal College of Emergency Medicine. And so your focus is very much education, training and development as opposed to the, dare I call it, the political side of emergency medicine. But I know you’re heavily involved with this sort of stuff and it’s worth spending some time on this, particularly in this month of the year where, well, winter is 12 months of the year now, but this is what we call deep winter, I believe.

 Winter is always coming in the emergency department. But yeah, interesting paper. It’s a qualitative paper published in the EMJ, essentially looking at retention, working conditions and potential opportunities to make it better because we do know that we have a few issues with staff.   

And staff is really interesting in emergency medicine because, you know, I don’t know what it’s like where you are, but the common theme I find is that people actually like people in working in emergency medicine just want to do emergency medicine. And they quite like the job. They quite like seeing patients, making diagnoses, doing interventions. But the workload, the work stresses, and the environment around us is a bit of a challenge. The college has been doing quite a lot of work in this area and they’ve funded quite a few things. So there’s the PIPP recommendations, which are the Psychologically Informed Practice and Policy. There’s a document about that on the website, if so, look for PIPP on R.CEM. Go and have a look at that about, you know, again, evidence-based things that can help us retain and support our workforce. Whether we can achieve them in practice is a different matter, but we should know what we’re supposed to be doing. This paper is kind of related to that. It’s a qualitative study where they looked at 116 clinical staff and 33 took part in a qualitative interview trial study to look at what were the deep factors which they thought were really making the difference. Causing distress and pain to some extent in emergency working. And they came out with some themes with qualitative papers. I think it’s quite difficult to summarise them by chatting. I think they are the sort of people where you cannot just really have a strike, you’ve got to go back and have a look through all the different comments. So there’s some really good quotes in there. So if you’re interested in this, I would genuinely recommend you go back and have a look at the whole thing. But the summary words, the four things that were stressing people out were the untellable work environments, which I think we know about. That is difficult for us to sort of control. So what’s in our control is they did find there’s a culture of blame and negativity and that’s often the most difficult part of the job. That’s sometimes internal and sometimes from other services and other factors outside the emergency department, I’m sure we’ve all felt that. Getting support, so getting support from various different organisations because as a trainee, you have support from college, you have support from your training programme, you have support from the deanery, you have support from your department, you have colleagues. Lots of different areas that need to be developed. And then compromised leadership. Now they didn’t come out with a real conclusion. The areas where we need to work on our leadership, because within emergency medicine departments, it’s the local leadership and the way that that interacts with the workforce and interfaces with the rest of the hospital where potentially the biggest wins are. And on the back of that, there’s probably something I would agree with is that we do need to make sure that people coming through emergency medicine training are trained in leadership. Something which, you know, I learned years and years and years ago when I was in the British Army and leadership training there was a key thing. I remember when I first started with them, I said, you can’t teach people leadership. It’s something you’ve got or you haven’t. You can definitely teach leadership. And we have the EM Leaders Programme in the UK, which is excellent. But it probably needs a bit of a boost and a bit of support so that we can make that more open and more available to everybody who’s knocking around, not just doctors, but all clinicians are working in emergency medicine.

 This is a really challenging topic, isn’t it? But I’m just going to pick up on the first thing you said, which is most people who work in emergency medicine really enjoy the medicine. They enjoy looking after patients, they enjoy having that effect and being able to take people’s pain away, to make diagnoses, to tell people what’s wrong with them, to reassure them.   

That is the job and that’s the job that we tell school leavers that medicine is. And the bit that’s making this hard is all the other stuff. And it is really worth going to read the actual paper that Joe’s written. This is Joe Daniels who’s led this project. You know, recommendation one, creating an environment to thrive in. And it may not seem relevant, but it makes me think of the England cricket team. Bear with me for this, Simon. So England cricket team are currently led by Ben Stokes and Brendan McCullum. And they have gone and decided that they are going to have a way to play. And it seems to me that Stokes and McCullum will support that team, whatever they do. They will back them up. They will let them play with whatever sort of jouard of Eve they want to play with, and they will back them up. And even if it’s not going well, they keep supporting them. So in the first test match in India, they’ve got a young spinner who’s out there playing his first test match. And for the first innings, he gets hit all over the park. First over is hit for six. And Stokes keeps saying, “I believe in you. You’re going to do it. I believe in you.” And he backs him and he backs him. And most people would have thought after that first innings, this particular player would have wanted to go off and never play cricket again. Second innings, Stokes says, “Look, you keep playing. You’re going to do it.” He takes seven wickets and wins the match for them. And it just makes me think of, “That’s what we need. We need people who believe in you. Psychological safety. People who know that you’re doing a good job, who trust that you’re doing the best.” And we need to get rid of all this other stuff that’s in the way.

 Creating an environment to thrive in, in 2024, is this really something we should be talking about now? To have adequate rest places? It’s actually a recommendation that we need adequate rest places. How have we got to the stage where we don’t support our staff so they’ve got somewhere to sit down?   

I mean, part of these findings are an embarrassment, really. But the key thing is, we’ve got to make sure that people who like the job and are good at the job are able to flourish in the job because actually they enjoy the bits of medicine. And this is what will keep people coming through. If it’s medical students, they need to see the bits of the job that are enjoyable. All the bits that are just frankly a bit crap, we need to get rid of.

 A hundred percent. And as you know, I’ve got kids at university now. I was speaking to one of my colleagues who has children doing similar degrees. One’s doing medicine, one’s doing engineering. My kid’s doing medicine and chemistry. And their first experience of going into the workplace? So going into a big engineering firm, being looked after, being sent your laptop in advance, having a mentor, having the rest areas, etc. All of those kinds of things, really incredibly supportive versus medicine, turning up rapid induction because you’re on call this weekend. It’s very, very different.   

And, Simon, particularly emergency medicine is about the staff and we absolutely have to look after them as best we can. Yeah, and I agree with you, I was a bit embarrassed looking at some of this. And I go back to my own department and think, gosh, how has it come to this? In my department, we have some awesome people doing some brilliant things. We’ve got some fantastic trainee-led projects at the moment looking at all of this. They’ve been running for several years now, running club, climbing club, walking club, we’ve got, we’ve done a whole couple of rooms, which is again led by the trainees. If you engage with people, anyway, I could go on for hours, but we must do better. And we’re putting it into some of the other previous stuff we talked about before, you know, the Maslow hierarchy of well-being, the idea that, you know, before you start thinking about offering people ice lollies, perhaps they need enough toilets, those sorts of things. This is something we have banged on about. And we continue, I think Simon, you and I, we try and influence locally. If whatever voice we have, we can do nationally. I know the college is very strong on this. But the key thing is, is it’s hard at the moment. But the actual work of face to face, talking to a patient and making their day better is what it’s all about. And we need to get rid of all the other stuff so that people can enjoy that first bit.

 100%. Simon, that’s January for us. We’ve got a big episode coming in February where we’re going to be talking about all of the papers you went through in Zermatt, and we’ll talk a little bit more about what you’ve been up to in Whistler. Until then, safe travels. I’ll be looking on from afar, obviously, with a degree of jealousy. I have skied in my life, and do one day want to do it again. If there’s any people out there who feel that, you know, having the other guy from the podcast at their conference would be, you know, ever so benefit. Take care of it and enjoy your travels.   

And you, Iain. Actually, we’ll see you soon.