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
Welcome to the St. Emlyn’s podcast. I’m Iain Beardsell. And I’m Simon Carley.
And this is our blog post update for August 2024. We’re still catching up, Simon, after a long summer and lots going on, but it’s been a fun time. You’ve been at Gateshead’s, scientific conference with the RCEM.
I’ve been in Sweden. Tell us a bit about Gateshead. How did that go?
It was really good actually, we’ve got a couple of posts up on the website which you can go and have a look at. It’s really nice to meet people face to face again and there’s some really fantastic talks there actually. One which sticks in my mind was about the sound landscape of the emergency department. Absolutely fantastic talk. it’s all on the blog post so you can go and have a look at that for day three. Changed my whole idea about what a soundscape in an emergency department should be, could be, or might be. Yeah, really fascinating stuff.
And while you were off in the northeast, we were a bit further north and a bit further east actually in Sweden in Sundsvall. I was up there with Liz Crowe and we have got lots and lots of content coming your way. So podcasts, we’ve got some lecture recordings. It was Tactical Trauma 24. A crowd of people who I have to say were inspirational and opened my eyes to all sorts of stuff.
Some of it probably isn’t relevant to my job in Southampton as an emergency physician. I’m hoping I won’t have to operate care under fire. I mean, you never know, but let’s hope not. but I learned so much and I can’t recommend that conference highly enough. And you’ll be getting lots of stuff coming out that will either interest you, be relevant to you, might just open your eyes to some of the future.
And actually the future, it turns out, is happening now. We’ll have a podcast coming up very soon about the use of eCPR on the streets of Paris from somebody who’s actually doing it today, these days, and it was quite something to listen to. But Simon, let’s crack on. We’ve got August to talk about. Plenty to think of, and way back when, in the beginning of August, you spoke about optimal timing for life saving procedures in critical care, a Goldilocks moment.
Yeah, so I think we all know the story of Goldilocks and the three bears, don’t we? And the issue of the porridge, it’s either too hot, too cold or just right. And it got me thinking about some of the procedures that we do. So something, the conversation I was originally thinking was around Lateral canthotomy.
Well, let’s, let’s take thoracotomy as an example. So thoracotomy is about the timing of when you decide to actually open the chest and somebody who’s been stabbed in the chest. There’s got to be a right time to do it, but it’s quite difficult to define because you could say, actually I don’t want my patient to completely exsanguinate and completely die.
because that’s obviously, I don’t want to miss the boat at the right time to do something to save the patient’s life. But you also want to be certain that person actually needs the procedure doing. So you go along to a patient who’s been stabbed in the chest. I think we’d all accept that if they’ve got, GCS 15 and they’ve got normal blood pressure and they’re talking to you then you’re not going to do a thoracotomy on that patient. That would be insane.
But actually you could argue from a pathophysiological point of view that if they do have a condition which is going to get worse and they’re subsequently going to get a tamponade or they’re subsequently going to exsanguinate, you want to do it as early as possible. But you can’t do it for everybody.
You get my point. So you do it too early. You have to do it to everybody. And that’s going to put more harm because you’ve been doing an unnecessary procedure on people who don’t need it. And if you wait too long, so that you’re absolutely certain that this patient definitely needs it. i.e.,, they’re asystolic and you’ve been doing CPR for 20 minutes, you definitely, they definitely needed a thoracotomy, but you’re way too late. So it’s this idea of getting the right time for the optimal balance of certainty of indication against the pathophysiological process and the need that the patient has. And the Goldilocks moment is choosing the right time.
And the reason why it came up in thoracotomy is because traditionally, the right time to do a thoracotomy for penetrating injury to the chest would be at the point where the patient arrests. And I think what we’re seeing now is some of the observational data from around the world is that if you sit there and wait until the patient arrests that you’re actually probably a bit late.
And I’ve been in the absurd situation where we’ve had a patient who got a central stab wound to their chest, whose blood pressure is falling and falling, they’re looking worse and worse. They’re becoming more and more unconscious and you say, this patient needs a thoracotomy and someone say, ah, yeah, but they’ve still got a pulse and they’ve still got a tachycardia, so it’s not time to do it yet. And you think, that’s wrong that we don’t, we’re not going to sit around here and wait until they’re dead. That doesn’t make any sense. And so it’s getting that concept of the Goldilocks moment and you can apply it to pretty much all of the high acuity, lower currency techniques. So Caesarian section in resuscitation and thoracotomy, thoracostomies to some extent, surgical airways. lateral canthotomies, all that kind of stuff. It’s a model. It’ll help your teaching and it’ll help you potentially help you debrief some things like sims and stuff like that.
And do you think that’s taken your thinking any further about how you find that moment? Or does it depend a bit on your personality? Whether if you’re like an early adopter or you want absolute certainty, it makes me think a little bit about when we make a diagnosis, you need a certain amount of information to start a treatment.
Even if that’s something straightforward, anticoagulation in pulmonary embolus, you need to be that sure that you’ve got to P.E. before you start it. There are parallels there, it’s just these are high impact procedures you’re talking about.
They are, and I think the, in the blog posts that we’ve done, we’ve given a couple of suggestions about how you train for this. Now you can do it retrospectively, so you can go to your mortality and morbidity meetings. You can discuss previous cases and then argue whether people did the right or the wrong thing.
It seems to be horse, door bolted, type training to me. The other way of doing it is, peer review. If you’ve got people who can watch what you’re doing and look at how you make decisions and you can get a feel for where you are, I accept that there’ll be different grades of certainty and enthusiasm for these things.
You can just train to be really good at the procedure because one of the, one of the delays that happens with people not being prepared to actually put knife to skin in these situations is they don’t feel confident in the procedure. So you can be better at it. But I actually really like the idea of shadowboxing, which is a concept that came, that I first heard about through Scott Weingart, and I read in a book called Streetlights and Shadows. And this is something Scott Weingart does on his site. I would recommend you go out and have a look at that. Essentially in shadowboxing, what you do is you give a story. to your colleagues and you get to a decision point and you ask people what they would do at this point and then you discuss it and then you explain where it goes next and now the key part of that and why it’s different to any other tutorial is getting the fact that these are judgment decisions and getting a panel of experts to try and explain why they made a decision not just saying what the decision is and also you accept that there’s a high level of uncertainty with these things when you’re doing the teaching.
If you want to know more about shadowboxing then please go and have a look at EMCrit and it’s really good. and read the book Streetlights and Shadows. Fantastic book.
It’s that thing again, isn’t it, about thinking about what we do and why we do it and deeper thought. It’s not as straightforward as yes, no, and emergency medicine is grayer and grayer. I think the older you get, whether that matches both our hair or not, but it does seem to go along with it, doesn’t it? So plenty to think about with those big procedures, the high impact type stuff where you’re really anxious about doing the right thing.
And, you may not be doing it that often, so you can’t actually have a lot of experience about it worked in this occasion or it didn’t work or whatever the outcome might have been.
The next post from slightly later on in the month is from me about cessation of smoking. it’s a trial that was done in emergency departments about if you put in some information and you have a specialist nurse or researcher talking to people about giving up smoking, are people in emergency departments, are they a captive audience who you might be able to persuade?
That stopping smoking is a good idea. this was published in the emergency medicine journal earlier this year, Pope and colleagues. And I found this sort of stuff really interesting. I’ve always been quite interested in the idea that, we’ve got these people sitting and waiting to be seen by us for some medical problems.
Some of them are not urgent. That don’t mean that they can still talk. They’re sitting in a waiting room. Why not try and get to these people and talk to them about their health? We talked in the past about chlamydia screening and other sexually transmitted diseases, the idea that the cohort in the emergency department are perhaps younger than we normally seek from other healthcare providers.
And they are a real source of ready made people for us to approach. Now, the thing about this trial was it is pretty aspirational for many of us. It included a lot of input from specialist nursing teams to go and talk to patients. There was ways in which you had to check about what was going on with their smoking history. And then they provided them with an e cigarette starter kit, a sort of pod type device. that they weren’t funded by the manufacturer, it was all independent of them, but a way of a nicotine replacement. And it’s all very attractive. And they did have some good results, not huge numbers of patients, but in the intervention group they did manage to get more people to give up smoking and maintain that over a period of time.
Have you ever seen stuff like this in your department, Simon? Is it something you think is possible?
I’m not seeing it for smoking so much. We do have, we do recommend people to stop smoking, obviously, and there was a small project that was running locally to do that, but we’ve seen similar sort of things with drinking, haven’t we? So alcohol, and actually, the underlying point is the emergency department is potentially a fantastic area to do a bit of public health information and to some extent a bit of screening as well.
It would be great, wouldn’t it? I just wonder whether or not everyone’s bandwidth, another phrase we’re using all too often, is a bit limited and their cups are too full. And whichever metaphor we decide to use, the idea of trying to take on more into the ED will just strike fear into the hearts of everyone and it’d just be too much.
Ideally, this would come with extra funding and extra people and not affect the people who are currently working in the E.D. It may be a topic that some people who want to take a little bit of extra time away from the shop floor in the emergency department could focus on and do something with. Let’s be honest, the way things are, people need more and more in their portfolio careers to keep themselves sane and healthy.
and I think it’s aspirational. And I think the results are there, but I think if I went to my Trust and suggested we employed a nurse, full time, a team of nurses or others to counsel people, and then we want to have funding to make them not call nicotine replacement, and then we’re going to follow them up, I think they’d probably look at me in a funny way. And I think a lot of whatever we’re calling our local health authorities these days would do the same, which is a bit of a shame. Because maybe there are lots of things we could do with this group.
It is, but the new government strategy is supposedly about prevention rather than disease. And, there may be funding that comes along with that. Probably worth giving a shout out to Gareth Roberts, who’s been a contributor to St. Emlyn’s for many years, who put a project into, because we’ve got quite a high incidence of HIV and other bloodborne diseases in Manchester, and he’s put a project in that’s screening EM, patients coming through the door, who are at risk. And, we’ve picked up loads of undiagnosed HIV and other blood borne diseases, and he’s done an absolutely fantastic piece of work. So he’s an emergency medicine clinician, working with public health, dealing with a really serious condition, and actually having real world benefits to patients.
I think it’s one of the best projects I’ve ever seen, in the sort of the QIP nature, going through an emergency department. So yeah, well done, Gareth, and, well done for all the people he works with. sexual health, public health, emergency medicine, acute medicine coming together. Absolutely wonderful project.
Undoubtedly, in the future, if we want to cope with demand, we have to reduce demand and we have to make people healthier. Ideally, but, maybe that’s outside the arena of us, but we can always try and input where we can. And I think this is a paper that’s worth reading, worth thinking about, and it may work for your emergency department.
Think about other things. It may not be that it’s smoking. It could be blood pressure intervention. It could be about HIV intervention. It could be other sexual health interventions, but we have a cohort of people sitting, waiting who maybe might just be receptive enough to make it cost effective. So that was a post from earlier in August.
And then we’ve had some more of the podcasts from the Premier conference. It’s always great when we partner up with different conferences, we’ve done the same, as I say, with tactical trauma, and we still have some podcasts coming from Premier 24. which is about pediatric emergency medicine. And we’ve done a couple of those this month, one about pediatric palliative care and one about pre hospital neuroprotection.
really the beginnings and ends of different patient journeys, but how we can have a little bit of knowledge about these specialist areas and can make a real difference. So I would really recommend you go and have a listen to those podcasts. If you haven’t come to them already, there’s comprehensive blog posts alongside them and the podcasts themselves, Premier is designed like many conferences with short talks, so it won’t take you long to get the information, quick learning points, no guff surrounding it, or just the real information you need, as you’d hoped for, and I push you in the direction to have a look at those and the other podcasts we’ve had from Premiere, because they’re really high impact and worth a read, and a listen, of course.
Now, Greg Yates did an intranasal ketorolac. Shoving stuff up people’s noses seems like a good thing to me. Simon, this seemed to work. Do you think so?
Yeah, so it’s a reasonable study actually. So a double blind randomized control study looking at patients who come in renal colic with significant pain loads. I think that their initial pain scores somewhere 8. 5 ish out of 10. in a lot of pain, and renal colic, I’m sure we’ve all seen,
it’s not a pleasant experience if you’ve ever had it. Their inclusion criteria with the pain score more than seven, but they actually averaged out about 8. 5 when they got it. It’s only 169 patients, about 85, 84 in each of the groups. And what they did is they basically randomized them to either give them intranasal or intravenous, Ketorolac.
Ketorolac, but I know other people pronounce it differently, but there you go. And they looked at the pain scores at 30 and 60 minutes and really didn’t find much of a difference to be honest. So they said you could use one or the other and I thought that’s fine. it’s really good to see, but as Greg put out in the blog post, the problem here is that neither of these have what I would say would be our standard comparator, which would be for many people would be an alternative non steroidal either oral or rectal, diclofenac. So without a comparator, I’m not sure how this changes my practice. I have used intravenous, Ketorolac in renal colic patients before. but there was a dosing regime that was looking at either 10 or 30 milligrams of Ketorolac and finding no difference in renal colic patients.
So it’s certainly a reasonable. approach and not everybody likes shoving medication at the bottom. So yeah, fine go for it
I had a choice between my nose and my bottom, I would go for my nose. and if I had a choice between my nose and my vein was available, I’d probably go for my vein. The key here is speed, and ease, and as we will constantly describe, I have no doubt, Simon, over the next few months, we are all time limited, perhaps in what we’re able to do. And having easy access to access points of patients and to the drug themselves are useful. We all know that opioids require at least two people, it seems, a set of keys and some form of secret code that only James Bond knows to be able to get into the cupboard. And if this is more available and can have some efficacy, then that’s a good thing.
And yeah, nasal medication. For some reason, we seem probably more comfortable doing the rectal route than we do the nasal route sometimes because I suppose it’s been around longer, and there’s a bit of a disbelief, but there’s all sorts of things that we can use nasally, and I think they’re a good idea.
Some of them are opioids, some of them are like the Ketorolac, and we have other things, Naloxone, other things that will work nasally, so do consider other options. If you’re in the emergency department with a patient who has something that needs medication urgently, and let’s not forget pain is something that we really should be looking to treat urgently. It is an emergency. And if you’re ever in doubt, just remind yourself that another word for pain is suffering. And so the patient is suffering, the patient is in pain, they’re the same thing. And it will encourage you to get that medication into the patient as fast as possible.
Simon, it’s always fun for me to listen to people like you and Rick Body talk about how we do critical appraisal and how people do research and it was one of the great things about being in Sweden at the conference was just listening to these bright people tell me stuff I didn’t know about. I’ve never really given peer review much thought.
And Rick has, unsurprisingly, as a professor and somebody who’s publishing papers all the time, this is about open and ongoing peer review. I have to say, you’re going to have to start a bit of the beginning for me here, cause I’m not really sure what that is.
Okay, so we all know that if you want to get something published in a journal, which is a right of passage or for some people It’s the whole purpose in life, isn’t it? And it’s got to go through a peer review process. The idea of peer review is great. So you send it to people who are expert in the field.
They pass comment on the manuscript and You get comments back, it improves the manuscript, and then it goes forward. But the problem is, and I’m going to quote, somebody here called Richard Smith, who concluded in a book about peer review, which I’ve read, it’s a really good book, that peer review is slow, expensive, profligate of academic time, highly subjective, prone to bias, easily abused, Poor at detecting gross defects and almost useless for detecting fraud.
Now, the point about Richard Smith is he wrote that when he was editor of the BMJ. So this is a man who really knows what he’s talking about. And everything that he said in that is actually evidence based itself. We’ve done lots of studies of peer review, which demonstrate that it doesn’t work very well.
And, I’ve published a couple of papers and I’ve also been an editor on a journal and I’ve seen it from both sides and we’re so reliant on people who do peer review and I still do peer review for journals, but we all know that it’s not a perfect system. So the open peer review approach has been done in other sciences for many years.
And we saw a bit of it coming along, into the mainstream during COVID, when we saw a lot of publications going up on pre publication servers, so that people would put their paper up on a pre publication server, which the journals were happy with, and they could get comments back on it and they could understand what’s going on.
That’s one version, but what Rick’s talking about here, and he’s put a couple of trials through, links of which are on the blog post,looking at qualatative study to evaluate facilities and barriers to pre hospital point of care testing, amongst paramedics. So what they’ve done, is they’ve put up the peer review process and actually put up both their methodology and also the results and invite anybody to review who are genuine peers and they can see those comments coming through and on the basis of that you can almost do a real in time improvement of the paper and I think it’s quite a good idea actually.
I mean it’s not exactly trip advisor for papers which is what it could end up as,it allows the authors to hear what’s being said, to add or delete or to expand on areas. And I think it’s, potentially the future because the current system is rubbish.
Peer review has always struck me as a little bit of an inner club. You have to know how to write, you have to know who to send it to, and it doesn’t really necessarily reflect the quality of the work you’re doing. It reflects something else that’s a little bit different, and so I, making that more egalitarian and a bit open does make sense, although it you do wonder whether the people who will be responding, a bit like TripAdvisor, a lot of people write on TripAdvisor because they didn’t like something, don’t they? if you thought something was fine, you tend not to go on TripAdvisor and go, Yeah, it was all right. You tend to go, Oh, it’s brilliant. Or God, I hated it. and maybe there will be a little bit of self selection bias in the people who would want to do that sort of thing.
But these things should be. More transparent, I think. And you’re right. Lots of people’s careers depend on this.
Yeah. the whole world of publishing is just very murky when you get into it. companies like Elsevier, make literally billions out of the publishing industry. and I published, I say, I published a couple of papers and never been paid for any of them, to provide them with the content, which they make billions of dollars from.
And now if I want to get a paper published in an open access journal, it would cost me several thousand pounds to do that, which is okay if it’s part of your grant, but for your average,individual who wants to go down that route, they’re not going to fund that out of their own pocket. So there’s all sorts of barriers to publication.
It’s not good for, lower middle income countries. where do you want to start? it’s just horrendous. And Stevan Bruijins has done a number of blog posts on St Emlyn’s about the particularly issue of lower and middle income countries having difficulty for their researchers to get published because of the economic and other biases which stopped them getting there.
So maybe this might help them as well. I hope it does because it’s not a level playing field at the moment by any means whatsoever.
Simon, it’s good to talk. And that is August. Quick, sharp. We’ve got through it with a degree of speed, but we always want to try and make St. Emlyn’s quick and snappy. So just enough time for your commute to work or the dog walk, or this is probably twice as long as I would go on a run, but that’s another topic altogether.
it’s great to chat again. It’s great to go through some stuff on the St. Emlyn’s blog. Please do check out the blog site. Have a listen to the other podcasts. Keep an eye out for new stuff that’s coming. There’s lots more content coming your way. And as ever, as winter draws in the UK, please take care of yourself and keep, if you can, enjoying your emergency medicine.
Have fun.
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