August 2024 Round-Up – Goldilocks Moments, Nasal Analgesia, and Public Health in the ED

As the summer wraps up, we’re back to bring you the latest updates from the captivating world of emergency medicine. This August, we have quite an array of topics discussed in our podcast to share, from high-stakes procedures to innovative health interventions. Let’s dive into the summary of our August 2024 podcast episode.


Listening Time – 20.59


Optimising Timing for Life-Saving Procedures: Finding the “Goldilocks Moment”

In early August, Simon discussed what he calls the “Goldilocks moment” in critical care interventions. The analogy draws on the “just right” timing for interventions, balancing certainty of indication with the physiological needs of the patient. This idea applies broadly to high-stakes, low-frequency procedures like thoracotomies, emergency C-sections in resuscitative settings, surgical airways, and lateral canthotomies.

The Thoracotomy Example: Knowing When to Act

The timing of a thoracotomy, particularly after penetrating chest trauma, highlights the importance of acting neither too early nor too late. For instance, waiting until a patient has fully arrested can be detrimental. There is growing evidence that acting before complete arrest in cases of central chest trauma, where a patient’s blood pressure is plummeting, may lead to better outcomes. This “Goldilocks” approach encourages clinicians to become more comfortable with early intervention, optimizing training and confidence to perform these critical procedures.

Training for the Goldilocks Moment: Techniques and Tools

St. Emlyn’s has emphasized various training methods to achieve this balance, including simulation debriefings, peer reviews, and “shadowboxing.” Shadowboxing, a technique popularized by Scott Weingart, involves walking through a scenario to a decision point, discussing possible actions, and weighing the judgment involved. This approach encourages clinicians to think critically in real time and consider why certain decisions are made, making it ideal for scenarios with high degrees of uncertainty.

Smoking Cessation Interventions in the ED: A Public Health Opportunity

Moving to a public health initiative, Iain reviewed a trial published in the Emergency Medicine Journal exploring smoking cessation interventions in the emergency department. The study targeted ED patients with educational resources and e-cigarette starter kits, aiming to capitalize on the “captive audience” of patients in ED waiting areas. The results showed promise, suggesting that patients are receptive to smoking cessation guidance in this setting.

Can Public Health Thrive in the ED?

While the ED may not seem the ideal place for public health outreach due to workflow constraints, it has proven potential for interventions like chlamydia screening and HIV testing. The smoking cessation trial demonstrates that patients visiting the ED for unrelated issues may be open to health interventions, especially if presented in a way that’s relevant and accessible.

Challenges and Potential of Public Health in the ED

Implementing such initiatives on a large scale would require dedicated funding and staffing, but it presents an exciting vision for emergency departments as hubs for preventative healthcare. As Simon pointed out, adding public health responsibilities could be feasible if extra resources are allocated, though these demands are challenging amidst the already high-stress environment of the ED.

Pain Management Innovations: Intranasal Ketorolac for Renal Colic

Another noteworthy update from August is the discussion on intranasal ketorolac for renal colic. Greg Yates highlighted a double-blind, randomized control study that explored the effectiveness of intranasal versus intravenous ketorolac in managing renal colic pain. While both methods proved effective, the study’s lack of a standard comparator like oral diclofenac limits its immediate clinical applicability.

Intranasal Administration: A Time-Efficient Alternative

The potential of intranasal ketorolac, especially in time-sensitive settings, can be substantial. For patients with renal colic—a condition often associated with extreme pain—having multiple options for rapid, effective pain relief is beneficial. While IV administration may be preferable for its speed, intranasal delivery provides a viable alternative in cases where IV access is challenging or when faster, non-rectal administration is required.

Rethinking Peer Review: Toward an Open and Ongoing Process

A significant topic at St. Emlyn’s this month was the open peer review process, discussed by Rick Body. Traditional peer review is a hallmark of academic publishing, but its limitations have come under increasing scrutiny. Rick introduced an alternative approach, using open peer review to facilitate transparent feedback on research, creating a real-time, interactive process where researchers can receive comments and adjust their work before final publication.

The Benefits and Challenges of Open Peer Review

Open peer review can foster collaborative improvement and streamline the path to publication, offering advantages like timely feedback and reduced publication delays. However, this method could also be subject to bias if the review pool is not diverse. During COVID-19, preprints and open reviews surged, providing a model for this transparent approach.

By involving genuine peers in the review process and making feedback accessible, open peer review could democratize research and foster inclusivity, particularly for researchers in low and middle-income countries who face economic barriers to traditional publishing.

The Future of Emergency Medicine

St. Emlyn’s August update provides a comprehensive look at innovations, challenges, and emerging strategies within emergency medicine. From redefining the role of soundscapes in EDs to rethinking traditional approaches to peer review, these insights reflect the dynamic, ever-evolving nature of emergency care. Emergency professionals can expect more content from recent conferences in upcoming podcasts and blog posts.

The Role of Continuous Learning in Emergency Medicine

As we move forward, it’s crucial for emergency professionals to stay updated on best practices, both clinically and academically. St. Emlyn’s aims to provide a concise, actionable summary of the latest knowledge in the field, helping clinicians enhance their practice, innovate in patient care, and understand the wider public health impact they can have—even in brief patient interactions.

Whether you’re reading this post on your commute or catching up between shifts, we hope you find value in these insights. As always, keep an eye on St. Emlyn’s for new podcasts, updates, and resources. As we head into winter, take care of yourself, continue to enjoy your work in emergency medicine, and keep striving for excellence in every patient encounter.


Podcast Transcription


Where to listen

You can listen to our podcast in numerous ways, ensuring you never miss an episode no matter where you are or what device you’re using. For the traditionalists, Apple Podcasts and Google Podcasts offer easy access with seamless integration across all your Apple or Android devices. Spotify and Amazon Music are perfect for those who like to mix their tunes with their talks, providing a rich listening experience. If you prefer a more curated approach, platforms like Podchaser and TuneIn specialize in personalising content to your tastes. For those on the go, Overcast and Pocket Casts offer mobile-friendly features that enhance audio quality and manage playlists effortlessly. Lastly, don’t overlook YouTube for those who appreciate a visual element with their audio content. Choose any of these platforms and enjoy our podcast in a way that suits you best!


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Cite this article as: Iain Beardsell, "August 2024 Round-Up – Goldilocks Moments, Nasal Analgesia, and Public Health in the ED," in St.Emlyn's, October 30, 2024, https://www.stemlynsblog.org/podcast-july-2024-round-up-2/.

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