Podcast – May 2024 Monthly Round Up – RCEM conference highlights, being EPIC and more

Welcome to the St Emlyn’s podcast. I’m Iain Beardsell and I’m Simon Carley. This is our monthly roundup of all the blog posts and goodness from the blog site from May 2024.

Lots to talk about. Simon, you’ve been busy?

Oh yes, absolutely. Here there and everywhere it’s been great.

That job as Dean is keeping you on your toes, I imagine, at the old Royal College.

Yeah, that and other stuff also did the ATAAC course. Recently, it was always fantastic to go back and spend some time with the attack team.

Now just tell me a little bit more about ATAAC because I see it a lot on social media. I know you’re quite involved with it and we should just mention this is a private company with which we don’t have any financial ties with them. But they’re obviously getting bigger and bolder and these courses look pretty fantastic if you’re into that sort of thing.

Yeah, I think we’ll do something more on this. I’ve got a podcast to hopefully line up with some of the people who run it. I teach on it again. I’ve got no financial interest in it. And it’s really developing very well. I originally went on the course because I wanted to learn more about how they do their simulations, which are by far the best I’ve ever seen. I think probably the best in the world. So if you’re interested in education, just go on the course for that. It’s also a really great blend of in-hospital and pre-hospital work. And I just learn loads every time I go. It’s great faculty and lovely people. And it’s one of those courses where people come away with the biggest smiles on their faces. And they really bond. They learn so much over the three days. And I’ve still got groups. What exactly I meant all the one of the teams from teaching. I still got what’s that groups from teams from four or five years ago who are still in touch with you. That’s such as the bond that they make over the course. Bloody hard work. It’s really tough. It’ll push people to their absolute limits. But it’s fun. It’s educational. It’s different. You know, it’s great. So something to look out for if you’re into that sort of business, the ATACC course.

I think there’s a waiting list to get on it. But do keep an eye out for that. And the simulations do look pretty high fidelity. And really quite something that you won’t see in normal education. As you say, Simon, the bit about conferences, which I think we’re getting back to after COVID is that ability to just see colleagues and to talk about the job and to be together. And I think that idea of community is really strong, isn’t it?

We saw that recently when we went down to Newport for the RCEM CPD conference, which is really great. I mean, great lectures and really good stuff. We’ll talk about in a second. But the biggest thing for me was to spend time with colleagues. And you get so much out of chatting in the coffee breaks over lunch and just having those conversations about what it’s like in your world, what are you doing, what’s new, what’s innovative, what’s fun, what’s not so fun, what challenges you’re facing. And, you know, we all get that in our own department. So maybe even within our regions. But when you start speaking to people from different countries and different health economies, it really, really does bring things in perspective. And you get some really fantastic new ideas. It’s invigorating. It’s regenerating. And it’s so important.

So Simon, as we’re talking about conferences and last month, we’re able to talk about the conference in grass. Let’s talk a little bit about Newport 2024, the RCEM CPD conference that you’re able to attend. Talk us through some of the clinical stuff.

Yeah, obviously I wont talk to the whole conference. There was so much going on there, but I’ll give you a couple of highlights and things that I found interesting. I mean, a Gareth Grier, yeah, great guy. He’s done so much in pre-hospital and trauma care and many other things of the world of course. He gave the Maurice Ellis lecture. Maurice Ellis, if you don’t know, was the first consultant appointed in emergency medicine in the UK in 1952 in Leeds. It’s a really important lecture. It’s a real honour to be given the opportunity to do it.

Gareth talked about brain injury. It’s a really interesting stuff. What would they head-on things? I think the first one is that if you go back to gosh 2006 say, and look at what we did for head injury care, you know, give them an anaesthetic if they’re poorly, give oxygen, control the CO₂, put them head up, give them hypertonic saline if they need it, loosen the collar, talk to neurosurgery. And that’s about it. And you think, well, actually what’s changed that much?

If you follow the blog, you’ll know there have been loads of attempts to look at various drugs and various techniques over the years to improve the outcome of major head injuries. But very few of them, if any of them have really made a massive difference. The other thing that he mentioned, which I think is quite important, is that major head injury is considered a neurosurgical disease. Whereas actually, when you look at the number of patients who require surgery, particularly surgery immediately after their head injury, even when they’ve got a major head injury, low GCS, etc, etc. It’s actually quite small. And so one thing we need to maybe think about is what can we do differently with this group of patients around there? The non-surgical management of their neurological type problems. And when you delve into that, it changes your perspective a little bit of it. And again, it’s about optimizing oxygenation, the CO₂ and all those kinds of things. But it’s also looking about systems. Because so much damage can occur in those early moments after a head injury. And you’ll be familiar with the concept of primary and secondary brain injuries. Primary happens at the point of injury. And secondary is the stuff we can do about. Well, we can. But there’s quite a therapeutic window, isn’t there between the primary injury occurring and people like you and me, paramedics and other health care providers turning up. And in cardiac arrest, we wouldn’t say, “Oh, just wait for the ambulance service. Do nothing between the point where you’ve had your arrest and do the BLS. Do those things. Have good Sam on your phone. All of those kinds of stuff.”

And so what Gareth was saying is that there’s lots of things we could do for head injury. You know, we could optimize the airway. We can, you know, position people the concept of impact brain apnea, which we’ve mentioned so many times on the blog, where you just stop breathing away about a good ol’ whack around the head. Now, all of those kind of things can be dealt with. And if we have better systems where we can coach people online to manage the airway, manage the ventilation, the positioning, all of those kind of things, maybe there’s an opportunity there to decrease the morbidity and mortality from what goes on. So Gareth actually showed a really nice telephone advice thing where somebody had phoned the ambulance service, 999 call, obviously dispatching all the heavy resources out there to go and deal with the patient. But actually getting that call handler to improve the care of the patient to optimize them for when we arrive. Absolutely brilliant.

So Gareth’s always been a headline act, hasn’t he? And been massively involved with Hems over the years. And it’s great to get him as part of the college. And I’m sure seeing him talk.

Adrian in his presidential address probably covered as I always does some really important stuff. It’s a really important time in the UK at the moment. We’ve got a general election going on. We still got junior doctor strikes. And it’s great to know that our College is there banging the drum and flying the flag and doing all the other things it can do. Were there new messages from Adrian, do you think?

Not especially new. I think most of the themes are well known to us. Things are generally not doing very well in terms of crowding. I mean, crowding is the big thing. We’ll talk about that a little bit later when we talk about what Higgi talked about. But crowding is the issue, workforce is an issue. There’s no easy solutions at the moment. There isn’t a magic money tree knocking around the corner. Star thing is an issue. We actually think we don’t have enough trained clinicians in emergency medicine, I think. I think we still have a lot of people who are working in emergency medicine doing great jobs. But they’re not core career emergency physicians as they would be in other parts of the world. But getting the workforce strategy right in the longer term is complex. And we are campaigning for more training posts, but it’s going to be difficult for us to get them. The PA question came up, the physician associates, which I’m not going to say too much about now because the college is about to release a statement on it. I hope we’ll be well received difficult times. There’s an election on. We’re doing we the college you me we’re all part of the college. We’re doing a lot of work with whoever is going to be in for the next government to try and make them understand that we need to resuscitate emergency care, which is the, you know, the the shop line for the arch and policy for making emergency medicine better. And yeah, lots of work to do. I actually think and you know, I am biased going part of the college, but I think from a campaigning point of view, from a policy point of view, from a politics point of view, RCEM is really good.

Absolutely. And it does get quite a lot of traction on social media. And I think the positivity, there’s always ups and downs with colleges aren’t there. And I think at the moment, RCEM kept consistently positive and consistently helpful with what it’s doing. One of the more positive things after agent, I think, was talking about the team voted best for training. And looking at this, it was Banger emergency medicine department that was voted the best for training. Banger’s been on the radar for years Linda Dykes, who’s not there now, who’s moved on to Hereford, I think. She set it all up with a mountain medicine and all that other business, but it’s clearly kept going. That’s where Rob Perry is as well, isn’t it? So what is it that Banger is doing that makes them the training department of the year?

Well, it’s obviously incredibly complex and I’m going to only be delivered in banger because it’s just such a difficult thing to do. And, of course, it’s not. It was a great presentation. But what I took away from this is that you do the simple things well, but you look after the people, look after the team, and create a sense of team and belonging. So they talk through how they do that. So their induction program doesn’t start when you arrive on day one. It starts weeks before and particularly because there are rural areas about helping people find accommodation. It’s helping them get into WhatsApp groups so they develop friends when they arrive. It’s having groups within the department that support people, you know, outside of work, walking group, that kind of stuff. And it’s about introducing new members to the department in a way which is not just this is somebody who’s going to be with us for six months, but this is somebody who’s going to be part of our team. It’s making learning available to all with lots of teaching opportunities, lots of professional development opportunities, and having fun. They’ve got a real positive attitude and it is, you know, if this was on here, she would talk again about what she describes as the work like blend. So it’s not about just sorting out what you like at work, but it’s making sure that we’re looking after people in and out of work, particularly if they’re traveling from afar, particularly if they’re not known to the system or particularly if they’re from different areas. Lots of analogies here with what we’re talking about.

Remember in last month’s podcast, when we talked about the race session about an international medical graduate coming to the UK. Same sort of thing here, making your team work, teamwork, compassion, excellence, bringing together, nothing particularly complex, just care about your staff and work with them. Lots of simple things we can all do, I think, and I think I’m going to take the one about the pre-induction phase back to my department. It’s coming up now, isn’t it? We’ve got the August induction looming and actually to get people part of the department, although I have to say some people tend not to want to become part of a new department till they join it. Yeah, that’s true, and that’s again, that’s entirely their option, and Banger may be selecting people who particularly have that kind of feel to them. But on a small note, when I have my medical student come see me, I will get notification of that they’re coming to the department about two weeks out. So I will write to them all. I’ll just email them out, I’ll give them information about the department, I’ll tell them when our teaching sessions are. And all of that information goes out two weeks before I show my medical students. They think that’s amazing, and I go, why isn’t everybody doing this? And when you arrive on day one, they already know what their expectations are. They get introduced to the team. It’s a really positive experience, but it’s not difficult, just takes a bit of planning.

There are some really easy wins on there, but is that thing about asking busy people to do more and trying to make them those little bits and pieces? I do the same with, we have first year medical students come into the ED in Southampton. They do four hours on a weekend during their first year as part of an experience, it’s almost like a observe ship. They come in almost like work experience students, but with the medical student badge to see what we do. And two days before they come down, I send them the email to say where they need to go, what time they start. I give them the names of the consultants who are going to be on at the weekend and who they’re going to meet. And you’re right, it’s these little things that somehow in undergraduate education, they feel like we’ve moved heaven and earth for them. But all I’ve done is cut and pasted an email. So do think about the simple things because it’s the simple things that are going to get us out of this mess. It’s not necessarily the really complex service redesign. It’s little bits and pieces, I think, that aren’t that hard to do and can be thought of. So interesting to learn from Banger. They’ve always been good. And I think they are pretty much self-recruiting now, aren’t they? Instead of them having to go out with an advert, they get people ringing them up and saying, have you got any jobs? What a place that is to be worth mentioning as well.

There was also a talk about rapid assessment and treatment. What we call pit stopping. This seems to be a real trend in emergency medicine in the UK. This idea that when patients come in, we front load investigations and get things going early. I have pros and cons about this. How do you feel about it? It was Matt Jones spoke very well about it. He’s an advocate for it. He likes it. I’m a little bit sceptical of them. Larger because I’ve read the evidence base behind it, which shows that you can get sort of short term gains. But if your problem is, and again, we’ll talk about it in a second when we talk about Higgi’s talk, rats are designed to sort of front load your systems at the front door. Obviously, see the patients do the organisations. That can, you know, speed the patient getting to the care that they want. You can identify sick people. The flip side is, you know, it’s not necessarily as good for education and training as other systems. And also, if your back door read department is blocked, then seeing the patients, you know, marginally quicker in organising their blood tests, margin quicker at the front door. Makes no difference to things like crowding, which are the big players in our departments about how the working life and experiences. So it’s one of those techniques which front loads the front door problem, whereas at the moment are major issues of the back door.

I do really struggle a little bit with this. Let’s do investigations before we actually know what’s going on with the patient. And then try and fit the patient to the investigations. It’s a complete opposite of everything I’ve tried to learn and teach. And my favourite clergyman, the Reverend Thomas Bayes, he’d be turning in his grave, I imagine, if this was what was happening when he was sort of trying to think of the Bayesian theories of how we look at things.

Yeah, I suppose the alternative approach, and it depends how you do it. So the devil is always in the detail. You have somebody like you at the front door. You might stop people doing investigations. So could go either way, but it’s so dependent on, you know, who’s there, how your systems work and other things. And now what happens after the patient’s gone out of rat and stuff like that? So that was pretty much very good at using. You give it very balanced and very sensible presentation. He thinks it’s probably better for patients. For most patients, but it’s certainly not a panacea and it’s not a golden bullet. And if anybody comes along to you department and says, we’ll solve crowding by putting in consultant at the front door, then, you know.

Let’s lead on nicely to talk about Ian Higginson known affectionately as Higgi from Plymouth talking a bit about crowding. He’s one of the vice presidents of the college and for anybody who’s been around emergency medicine in the UK for any period of time, not know him, or at least know his name well speaks very well. And I imagine gave a really good talk. So we’ve thought a little bit about the politics of things we talked about ratting, but crowding is the big deal, isn’t it? And then we’re taking into a department these days with patients in corridors, the blow to staff morale and that moral injury you get from having patients having care that you don’t think is quite where it should be us chatting with a colleague the other day. You’d had a really difficult night shift and they just felt helpless. They didn’t know what to do. And we talked a bit about the little wins you can sometimes get to try and get you through the shift. But this is the big deal, isn’t it? So what was it that Higgie came up with when he was talking about crowding?

I’ll give you a couple of things that really struck home with me. One was that we often have an inverted model about how we deal with crowding. So if you just think about all the different strategies that we’ve had about how do you solve crowding is often about preventing people come to the emergency department or streaming people away from the emergency mile or preventing them from coming through the door or preventing our missions. And actually, none of that really makes any difference at all. If you’ve got a crowded department is because you got problems at the back end. So he talks about inverting the approach to this. So the inversion of the approach means think about output first the back door. Then think about throughput what we actually do well. So patients in the emergency bomb and then think about demand. But you’ve got to do it in that way. And unfortunately, that’s the complex way of doing it. And unfortunately the big decisions that need to be made around that are not in our gift is emergency medicine clinicians to do. So we’ve given all the problem. We’ve given all the risk. We’ve given all the difficulty but we’re not empowered to actually make the changes and that is a problem. What does that mean? It means that we, as our management clinical needs, etc, need to get involved in those conversations, which I’m sure they do really find difficult. And he also shined a bit of a light on most departments and said you know, when not without problems in terms of crowding. We do need to have a look at our culture and behaviour.

We need to think about what is reasonable philosophically. Do we accept that we are now in a stage where crowding exists? And if you accept the crowding exists and corridor care exists, should we do the very best possible for the people on the corridor? Well, kind of yes, but we’re often resistant to doing that because we just don’t think it should exist. But if it does exist, we’re going to do something about it and therein lies that philosophical difficulty about if we go into well, this is just normal for now. We normalize practice. We normalize corridor care. We then stop putting training packages and systems and people and processes to manage that. Is that a necessity? Is that a failure? Is it the right thing to do? Really interesting sort of just stop philosophical questions about what we do in the future. I’m a pragmatist as you know, I think you are too. We’re just going to deal with what we got in front of us.

And that leads us nicely on to talk about Stevan’s post about being an EPIC, what some people call EPIC, which is emergency physician in charge. We started calling it a cod many years ago, it was a clinician of the day. Although ironically, there’s often three or four clinicians of the day during the day because you can’t really do it for more than four hours. But this is about being the lead clinician in an emergency department and how you run that department and how that works for you. Now, I’m sure this is very different compared to different departments that we all work in, you and I, someone, both working pretty large, university hospital teaching hospitals. That’s probably a bit different to working in where Stefan works down in Yovl, but the core themes are the same. He also gives some really good advice about how to psychologically go through those shifts where you are the epic emergency physician in charge. And I think this is worth the read because even if it doesn’t completely change what you’re doing, it gives you pause for thoughts about how you’re doing what you’re doing. Because I don’t think this is an easy skill. And actually one of the biggest training things we do with our registrars when they come into the end of their training is to do an ESLE –  an extended educational supported learning event to try and give them guidance on what we’re doing.

We’re doing consultant ELSEs now as well where we look at each other’s practice. But this is a hard job, isn’t it?

I think it’s one of the most difficult things that we do. And what I really like about this is it gives you a structure when somebody comes along to you and say, “Well, just how do you manage the shift?” It gives you a structure that you can actually use to sort of talk people through how that works. Those are stuff in there, things I took away, I really like this concept of what you call circles of care. So we have three circles of care and in a circle, high priority time dependent stuff that’s got to be done within an hour. So that’s what he’s got to have that focus on is either doing that or delegating it. Second circle is about looking after the team, looking after the staff, well being breaks, debriefs, those kinds of things. And then the third circle is these high risk issues which may not be completely time dependent, but you can see coming. So that is things around congestion, crowding, availability, getting people down to departments, problems with specialities, all of those kind of things. But he moves backwards and forwards all because consciously between these other things. And it’s really quite helpful. He also does it when he goes into the shift and sort of can identify what the jobs are and kind of prioritise them. He also divides things up into the four S’s, staff, space, stuff in systems. And if you’re a fan of the avatar nation, he talks about those as the different nations within the group. So the Fire nation being staff, earth kingdom being stuff, Air nomads being space and water trying being systems. Quite like the idea of breaking things down into what four elements here can I mould, manipulate, nudge, develop, support, whatever to achieve those three circles. So the overlay of the four S’s back onto the circles of care worked really well for me as a model. I think I can use that in teaching a lot. And the other thing he uses frequently, I think I definitely want to take this on board, is bookmarks. Which is basically just, you know, reminders. He has constant reminder lists which keep telling him what to do. Because I don’t want to slightly do it. But I constantly forget where I’m at. You have so many questions, so many distractions that you have these. You know, is it so easy to lose track of what is an important, but not essentially immediate task. So you can do those with EPRs or you can just do on paper, I don’t mind, but I think I should start doing that.

I think there’s loads of different little bits and pieces that we can all take from it. For me, the key to this role is being kind to yourself. We talked a bit about this last month when we talked about choosing with intention and choosing how you choose to do this role is really important. Because it can feel like if you are ever not visible or you’re absent for any period of time, the department will fall around your ears. I don’t think that’s true. I think you can give yourself five minutes of breathing space where the world will not collapse if you’re not standing in majors directing traffic or answering questions. And I think we’ve got to empower our doctors and clinicians to also make decisions. Always being available does mean that often some of our clinicians are reluctant to make those decisions on themselves. So although there’s that key, is that balance again with ranting, isn’t it? We want to keep the system going, but we have to think about how we’re training the next generation of clinicians to do these jobs. And how we look after ourselves. I don’t know about you Simon, but my decision density doing this means after four hours, I’m pretty beat and I’m not as good. I’m simply not as good and we’ve used the analogy before. If your troponin machine wasn’t working and it was giving you out fake results, you’d stop using it. And I’m not like I’m like a broken troponin machine after four or five hours. I need a break and I need some lunch. So you’ve got to think of that as well. Don’t just keep ploughing on, hoping that you’re going to make it through and everything will be okay.

Yeah, and also I quite like seeing patients still and spending the whole day just talking about other people seeing patients isn’t really my happy place. There’s all the, there are models of how you take a referral answer a question, but one of the things I do like, which is guessing a lot of the models, is getting whoever you’re talking to to commit to a decision. So I’ve been fine when people come and they’ll start off with this long talk about something. I’ve got no idea where the conversation is going. I actually sort of pause them and say, look, what is the question you’re asking me and what do you think you’re going to be doing about it? Okay, so commit to your decision. Now let’s talk about it. And then we explore the decision making and that’s that’s a little bit more fun and also a lot more educational.

And I use constantly now from a talk you gave some years ago this idea of what is it you want from the conversation with me. I think if you don’t make that, when that’s patient sometimes as well, why have you come to hospital? What is it you want from me today? Same with clinicians. Okay, we’re going to have a conversation. What is it you need from me? And I come back to what you taught me, which is those three things of affirmation, coaching or evaluation. So each interaction with the clinician is going to be one of those three things. The majority of your affirmation. I’ve done this. I’ve made this decision. I want you just to nod through and say, yeah, that’s a good idea. Then a couple of them a shift will be coaching. I’ve got an idea what I want to do, but I’d really like you to tell me some more about it. And then the final one, if you can really do is evaluation. So I try and get our clinicians to aim for one evaluation a shift. And that’s really just taking what we’re doing here with a little bit extra that they can take away as something they can put in the portfolio. And I do about 70% affirmation, 20% coaching and 10% evaluation will be about where I was. But we can link you to the post in the blog site, which goes over that. I think it’s about 2017, but I’ve used that since I find it really useful.

Let’s move on and think about something completely different. So ChatGPT Simon. It’s taking over our world, artificial intelligence. It’s everywhere. And this was a post written by Charlotte Morea, who’s actually a Final year medical student with me in Southampton. She was doing an elective in the emergency department, and we offer a joint elective in emergency medicine and digital learning. And Charlotte chose to do a blog post for us about chat GPT. And this was related to a paper that had come out relatively recently. And that paper is a medical teacher published just this year on March 13th. And this talks about could chat GPT write both clinical vignettes and MCQs. There’s a lot in the papers, a lot to think about chat GPT actually, but the bottom line is it’s not so bad that the vignettes, but the MCQs you probably do need a human. Do there some, we’re using chat GPT more and more in our lives. And I think on the blog site, we’re using it to try and make our blog post writing more effective. Is this the way of the future?

I am completely convinced of this and that’s a game changer. So I think we’re going to see incredible developments around AI over the next few years. I recently read a book, AI, having just called AI Medicine, which is really, really, really interesting. I use it for generating job descriptions, even if it’s just giving me the job titles, what I need to sort of put in. So lots of little tools like that, but the latest incarnation of chat GPT for a couple of new innovations on it. The first is it will maintain context so it can keep the thread of the conversation learn as you’re going along, which is really interesting. And it’s got a better database to go through it, but it’s also it develops. It’s almost like the old internet was giving you information, whereas the ChatGPT-4 model is giving you more intelligence interpretation and possibly. There’s borderline, bordering on understanding and thought, or it certainly gives a great illusion of it at times. So if you’re not used to already, if you’re not used the latest version, I would recommend having to go at it. I think for writing questions, for doing the hard work of getting the basics of what a question looks like. Yes.

Let’s talk a little bit about trauma and talk about rib fractures. We’re always looking for things we can do in the emergency department, perhaps above and beyond what we’ve done traditionally. And this is a journal club post about Serratus anterior plane box for rib fractures. This is a paper entitled Serratus anterior plane block for early rib fracture pain management, the SABRE randomized clinical trial. I love how people works are hard at their acronyms. I almost think the acronym comes first and the paper comes second. Anyway, this is from a paper published in JAMA Surgery in May 2024. You’ve reviewed this. Is this the future? Should we all be thinking about how to do Serratus anterior plane blocks?

Yes.

It’s that easy? I’ve never done them, so I don’t really know. I’ve always thought I want to do them, but I’ve never done it. I’ve said before I work on a major trauma ward as well, so I see patients who’ve been through the ED and then how they are on the ward. There’s no doubt the patients who’ve got multiple rib fractures. I really struggle. So, the elderly are a real disaster problem. They get pneumonia and they die if you don’t treat them well. So, options for analgesia or analgesia, IV, analgesia, PCAs are quite good. And what we’ve done traditionally is we’ve put them, what’s called an ESP block, an erector spine block, which goes at the back of the… just parallel to the spine, and it gives you really good analgesia. It’s fantastic. The problem with it though is really unique. It’s almost… you need to be set up to do it, really. I mean, you can do it on the side, but it’s pretty tricky. And if you don’t know whether your patient’s got a spinal injury or you’re waiting for that MR scan or they have got a spinal injury and it’s tricky, it’s quite difficult to do. So, it’s struggled. So, the serratus anterior plane block goes in on the lateral side of the chest just underneath the serratus muscle. And that gives really quite good analgesia, supposedly for lateral anterior rib fractures. And this is something you could do in the ED. Very easily. It’s no more difficult to do a fascia-illiaca block, really, genuinely. So, if you can do a fascia-illiaca block with ultrasound, there’s absolutely no reason why you couldn’t be able to do a serratus anterior block.

And what this study shows is that in this… they randomized patients who either getting a block in the ED or just their normal care, normal care did vary a bit, but just their normal care patients did so much better with this. So, they looked… their outcomes were dropping two points in a pain score at four hours or having a pain score of four or less. And the top level numbers from that were 41% achieved it if you had a block and 20% if you didn’t. Which is a pretty remarkable difference. So, I think yes, it’s something we could do. There’s a bit of a chat on Twitter afterwards for this. A few problems, so maybe you’ll follow the patients a bit more, have a look at other complications that they may have got. Actually, the analgesia lasted for hours and hours and hours just after the four hours. But also whether or not you put a catheter in, because there’s no reason why you can’t put a catheter in when you do the block and then have a constant infusion, a bit like an epidural or the ESP blocks. So, yeah, work to be done. And, yeah, not a difficult technique. I’ve done an ED, I think they’re great.

So, let’s just for a moment go to the idea that these are helpful. At which point does this become part of core emergency medicine work? And when does the college… I’m asking you now in your college role… When does this become like a fascia iliaca block where we think actually this is something that we expect our doctors to be able to do? And what’s the time frame for that? We also used to talk about 13, 14, 15 years for knowledge translation. How would this become part of a curriculum that our chem would support and then would become part of training?

That’s a really good question. I can tell you the process through it. So, I know that the ultrasound group are looking at this now and then the big recommendation to the curriculum committee. And then if they’re on the curriculum committee, then as we do periodic updates to the curriculum, it could be added if it was felt worthwhile to be put in. Now, the problem with these techniques, and this is me not speaking as dean, but this is me speaking as somebody just generally, is… When you introduce something like this into a curriculum, you’re potentially got a bit of a problem because the current consultant workforce may not be skilled in it themselves. So, when you just introduce it, you have to think about how… how you train for it, how you put it into practice, and how you make sure that the trainers… I’ve got the skills to be able to supervise, train and develop. It’s not easy.

I don’t think it’s a particularly complex technique. I think it’s good. And it’s good for patients. It’s one of those things that actually comes to bite you four or five days down the line, doesn’t it? When you get your infection and perhaps we’re not as… we don’t see that as obviously. We’ve started doing battle scores and we’ve got a rib fracture pathway in Southampton, which I think makes these a bit more obvious. But again, this is that group of older patients sometimes. Maybe a fall from standing. They’ve managed to fracture a few ribs. And before, I think we just sort of told them to go home. Then we told them to go home with some painkillers. Then we told them to slap on a lignocaine patch. But now this is maybe the time to take this a bit more seriously.

Talking again a little bit about trauma. First part success in pre-hospital emergency anesthesia. Another journal post here with a review by you. Taken this time from the Scandinavian Journal of Trauma Research Foundation and Emergency Medicine or SJ Trem. This is a little bit looking at… well, we talked last month about first-part success. Is that a good measure of airway competence and excellence? Yes, so basically what this paper says is that just looking at first-part success is not enough. If you’re trying to quality assure your intubation in pre-hospital or emergency care, first-part success, yeah, it’s kind of a marker whether or not people can intubate. But that’s not what we’re about here, really, is it? What we want to know is that people have a good anesthesia. So we should probably be looking at things like hypertension, hypertension, hypoxia, cardiac arrest events and stuff like that. First-part success. There’s also a weird paradox. So if FPS is your major marker whether or not you’ve done a good RSI, you could get in there. You could say, put a three blade in. All this is a real struggle. But if I take the blade out, it’s going to contound as a failure. So I’ll just keep on struggling with this three blade. Instead of coming out and saying, “I’ll have a four. Thank you very much.” I’ll come out and have a VL. It puts perverse sort of incentives in the system, I think. So don’t just use FPS. Think about what is the patient-related outcome for pre-hospital or emergency development anaesthesia. And it’s not just whether you got the tube in and whether you were good at luring us could be an intubation.

And finally for this month’s Simon, let’s just mention measles. So I don’t know if you’ve seen much measles. Measles I’ve seen the first three cases of my entire career, I qualified in 1998, in the last three weeks I’ve seen three cases of measles. It’s definitely on its way back and it is something that, I mean, whenever I see a rash in the emergency department I tend to go, “It’s viral.” And in this case I was still correct, but it’s a special kind of viral. And it’s worth knowing about measles because it’s so contagious. It’s so easy to get it and our trust is most certainly taking this seriously to the extent that we’re almost back to PPE that we were using in COVID times when we’re seeing patients who might have measles. We haven’t quite got there yet, but there’s a real worry that if we don’t spot measles and we’re not careful about it, people who are immunocompromised, whether that’s staff or patients are at real danger from getting some of the nastier complications of this disease. Now why measles is coming back is multi-factorial and we don’t need to revisit all of that, but it is certainly back. And I think the reason for this post is really to raise awareness because if it hasn’t come to your hospital yet I think it’s on its way. Have you seen any cases in Manchester some? I have, yes. And the one that caught me out initially was in a young adult. In my head, I’ve seen quite a bit of measles over the years because we did it with a certain population in our locality who traditionally not had the MMR vaccine for a long period of time. So we’ve seen it intermittently, but having somebody who’s taller than me, who’s bigger than me, with the rash and go, “Oh that’s an interesting rash.” And just measles didn’t flag up in my mind because I’m not used to seeing it in adults. So just be aware of it and I think we’ll do a post coming up in the future about pertussis as well because that is most certainly coming back and that also has nasty complications particularly for pregnant women and very, very, very small babies. So keep an eye out for that, but just to be aware measles, it may come to your emergency department and you can’t just dismiss it. You might need to think differently and also check you’ve got your vaccine and check your immune, your occupational health department. I’m sure we’ll be keen to make sure that you are safe because that will help make other people say to Simon. We’ve talked about lots. We’ve even missed one post out from Natalie about Noosa, but we’re going to cover that next month when we talk more about paediatric emergency medicine. I’m about to go off to the Premier conference in Winchester, and there’ll be even more paediatrics coming your way both as podcasts and on the blog site. So if you look after children, keep an eye on the site, lots more to come and just a plug for the tactical trauma course, which is in October. We’ve been invited to go and do some blogging and podcasting from there. So we will be there. Liz Crowe is coming all the way from Australia to join the team, which is great.

As ever, please do get in touch if you’d like to write for us or have anything to do with St Emlyn’s. We’re growing. We hope over this year we’ve got lots of work going on in the background exciting stuff. And we’ve covered a lot today. Please do check out the posts on the blog site because there’s always more detail there. Simon, as ever, thanks for your time. Thanks for talking and we’ll talk to you all again soon.