The new year has dawned, but let’s rewind and explore the lessons, events, and insights from the St Emlyns blog in November 2024 in this emergency medicine podcast. Clinical challenges, professional growth, and international collaboration have been a whirlwind. This month’s highlights encapsulate the essence of St Emlyn’s: supporting emergency medicine professionals through education, reflection, and shared experiences.
Listening Time: 31.53
Winter Pressures: A Familiar Story
Emergency departments across the UK faced immense pressures this winter, with record-breaking patient numbers and widespread internal critical incidents. Simon and Iain shared vivid accounts, including a staggering sight of 23 ambulances queued outside an emergency department in the North West. The message? Stay resilient. While every day may not be easy, small reminders like upcoming conferences or moments of camaraderie can provide solace.
Exciting Conferences Ahead: The Big Sick and IncrEMentuM
Two major events on the horizon are lifting spirits in the EM community:
- The Big Sick (Zermatt, February 2025): A unique, intimate conference focusing on critical care in an incredible skiing destination.
- IncrEMentuM (Murcia, March 2025): Spain’s flagship English-speaking EM conference celebrates emergency medicine being recognized as a specialty. Speakers like Scott Weingart, Sarah Crager, and Haney Mallemat promise to make this event unforgettable.
Tickets for IncrEMentuM are still available at incrementum2025.com, and St Emlyn’s readers can us an exclusive discount code INCREMENTUMEMLYN
Building a Learning Culture in Emergency Medicine
Simon reflected on his recent talk at the African Emergency Medicine Conference in Botswana. Emergency medicine in Africa ranges from cutting-edge private-sector care to regions where one emergency physician serves millions. Yet, one unifying theme emerged: the importance of fostering a learning culture over merely teaching.
Key Ingredients for a Learning Culture:
- Curiosity: Embrace a mindset that seeks to understand and improve.
- Growth Orientation: Recognize the potential for continuous improvement.
- Knowledge Sharing: Encourage the excitement of teaching and mentoring others.
Creating the Environment:
- Psychological safety ensures team members feel comfortable admitting uncertainties and mistakes.
- Open communication and reflection help shorten hierarchies and promote growth.
- Commitment to learning and teaching fosters overall satisfaction, as demonstrated in a study correlating positive clinical supervision with job satisfaction, regardless of workload.
Advancements in Resuscitation Research
eCPR and the Sub30 Trial
A recent blog post reviewed the Sub30 trial, the first UK study of eCPR. While the results were mixed, it underscored the feasibility of ECMO in selective scenarios. Alice Houten’s presentation at the Tactical Trauma Conference provided fascinating insights into liquid ventilation and therapeutic hypothermia—concepts that may shape the future of resuscitation.
Arterial Line Monitoring in Out-of-Hospital Cardiac Arrest
A study from the East Anglian Air Ambulance team explored the utility of intra-arrest arterial blood pressure monitoring. Findings suggest achieving a diastolic BP of 35 mmHg is crucial for ROSC. Though not yet standard practice, the potential for target-driven resuscitation is promising.
Small-Bore vs. Large-Bore Chest Drains
Simon’s review of a meta-analysis in the Journal of Trauma and Acute Care Surgery questioned the traditional preference for large-bore chest drains in traumatic haemothorax. The study found no significant differences in mortality or complications between small-bore (≤14 French) and large-bore (≥20 French) drains. Instead, smaller drains had shorter tube durations and comparable drainage volumes.
Navigating the “Hot Zone”: Lessons from Tactical Trauma
Claire Park’s insights from the Tactical Trauma Conference highlighted critical strategies for care in active threat environments. Her “40-70 Rule”—making decisions when 40-70% of information is available—resonates far beyond prehospital care. It’s a call to embrace timely, informed risk-taking in emergency medicine.
Toxicology Spotlight: GLP-1 Receptor Agonists
The rise of drugs like Ozempic for obesity management has brought new challenges to emergency medicine. Greg’s recent blog post explored their toxicological profiles, offering essential insights for managing potential overdoses or adverse effects.
Combatting Bad Behaviour in the ED
Liz Crowe’s talk on workplace behaviour delivered a crucial reminder: small actions, like an eye roll, can have a significant impact on team morale and patient safety. Emergency medicine demands high-functioning teams, and fostering kindness and psychological safety is paramount.
Tips for Building Trust:
- Reflect on your behaviour and its impact on others.
- Value feedback from colleagues at all levels.
- Recognize that stress is no excuse for rudeness.
A Look Ahead: St Emlyn’s in 2025
As St Emlyn’s enters a new year, we’re committed to expanding our content and resources. Whether through podcasts, blogs, or conferences, we aim to support the global EM community. Want to contribute? Reach out to join our passionate team.
Thank you for being part of this journey. Let’s continue learning, teaching, and improving emergency medicine together.
What were your key takeaways from November 2024? Share your thoughts in the comments or connect with us on social media. Let’s keep the conversation going.
Podcast Transcription
Welcome to the St Emlyn’s podcast. I’m Iain Beardsall.
And I’m Simon Carley.
And this is our blog post review for November 2024, but it is in fact 2025. Happy New Year, Simon. We are into a new year, a new dawn. It is that time when emergency departments are busy, they are full, they’re making the news. Hopefully, you’re getting through it in Manchester.
Yeah, Manchester’s busy. we are really struggling under the weight of numbers. and you’ve seen, haven’t you, this sort of internal critical incidents going off everywhere. I was outside a hospital not too far away from here. in a place where they have a slightly Liverpudlian accident, shall we say.
And I think I counted 23 ambulances outside their emergency department. It’s a tough old time at the moment. and it’s quite, it’s really difficult to get through the patients. And I think we’re all struggling. Possibly more than I’ve seen for quite a long period of time.
It’s not been an easy couple of weeks. I think it does depend on the day of the week. So sometimes you go and it seems okay. And the next day it’s hell on earth, but keep going, winter will end. I know it doesn’t feel like it. And actually, Simon, we’re very lucky because we have two events that we are both looking forward to that can keep us going and it’s probably worth a mention.
The first one, I don’t think there’s any tickets available, but it’s the Big Sick Conference in Zermatt. one of the nicest skiing resorts, although I know you’re not a skier. But we will both be at that, which is hugely exciting. Looking forward to that. Got your talks planned?
It is a wonderful place. I think it’s one of those conferences, which is, limited in size and will always stay small, which makes it really good for networking, meeting people and the people you get there going fantastic. If you like skiing, great.
I don’t ski. but wonderful people, wonderful place, great talks.
So that’s The Big Sick. That’s coming up in February. And then even more exciting is IncrEMentuM. It’s probably worth us spending a few moments on, because this has been a conference that we’ve known about since the beginning. It’s in Spain. English speaking. There are many, many people going who would be known to our listeners.
Scott Weingart, Sarah Crager, Haney Mallemat, all sorts of names. Yourself, Simon, will be speaking. I’m doing a little bit in pieces here, but really want to support them. Spain, as we know, has just accredited emergency medicine as a specialty. This is a big flagship event for them, and I think it’s going to be great.
Now, I do think there are still some spots available, so if you are interested, incrementum2025.com is where to look. The flights from the UK are not too expensive. The accommodation is also not too expensive. And dare I say that the tickets are not that bad either. And if you look carefully on our website, you will find a code that means you get a little percentage off, which will help even more with getting you out there.
So IncrEMentuM, do have a look at that. Simon, it looks fabulous.
It really does. And, I’ve been involved with RCEM conferences for a long period of time, and you should definitely come to those as well.
An incredible group of speakers. I think we’ve not seen this kind of line up and this kind of focus on the critical care emergency medicine Resus Room type thing since SMACC, Big Sick and IncrEMentuM are doing similar things in this respect. but yeah, I’d go to both if I could.
I’m going to both, but I think both are gonna be really fun. go to one of them if you can.
And if you yearn for a bit of sunshine and it’s all getting too much in this cold UK winter, then what nicer than Murcia in March. So do take a look, have a look at those flights. There’s a lovely group coming from Southampton. it’s one of those where a few people got interested and that’s grown. So there’ll be a group of us from Southampton.
And, if you’re going on your own, please, there’ll be lots of us there who you can hang out with and have a fun time. Now, while we’re talking about all this Simon, one of the tricky things, and this is the first blog post from November is building a learning culture. And again, you were talking at a conference last year about what a learning culture in the emergency department means and why that matters.
And now more than ever with the winter and it being a struggle at work, having that atmosphere in an emergency department is more vital than ever. Tell us a bit about what you believe we can do to build a learning culture.
Yeah, it was an interesting, when I was out in Gabarone in Botswana for the African Emergency Medicine Conference. And again, what a fantastic group of people. I’d definitely, if you do go to international conferences or have the ability to do I strongly recommend doing that. An incredibly friendly and I learned so much, but I was asked to do a talk and it’s quite difficult to do a talk in that setting because emergency medicine in Africa varies from a sort of middle income countries where it in the private sector, it would look very similar to in the UK, Australia, New Zealand, America, etc., right down to some areas where emergency medicine may not even exist in any form that we would recognize, or where there may be only one emergency physician for several million people. And really unbelievably inspiring individuals there who have done just such most incredible work, to develop emergency medicine, particularly in places like Nigeria, which is really coming on.
And I think, We’re training quite a few Nigerian emergency physicians at the moment and I’m hopeful that they will go back and expand that even more. We’re trying to find a topic which is generic to everybody, everywhere and everything in emergency medicine. I thought, what is it that we all do?
And actually one of the big things about emergency medicine is we learn and we teach. I think it’s so embedded in what being an emergency physician is to learn and teach. And so I thought we’d talk about that. And the idea was, is that to build something which is a learning culture, which is different from a teaching culture.
Teaching culture is what people like me and Iain do to people. And so we deliver information, but actually what we’re trying to do is to get them to learn and to change what they do and to be better people. And that’s, it sounds like not a big difference, but actually it’s huge. If you change your attitude to my intention here is to allow people to learn inside their heads, it’s so different.
So what are the three things that a learning culture has got? The first is all the people involved in learning cultures. The first is a, an element of curiosity. And if I had to choose one word about the people who I like working with, it’s curiosity. That the people who look at any problem go, Oh, that’s really interesting. I wonder if this, I wonder if that, could we do it better? Could we do, can we change what we do? I love those kinds of people. And definitely the best people I work with. And the other is about growth. We want to get better. We actually actively want to get better, which actually means that we realize that we’re not as good as we can be now we can always go better. And the third thing, which really, makes people stand out. And the greatest people, the people like you mentioned, going to IncrEMentuM and TBS are the people who want to share their knowledge. So they’ve learned stuff and they’re just so excited about telling other people about it.
If I had to choose one person in the world, it’d probably be Cliff Reid, who I think is possibly the most excitable person when he’s teaching people. He’s just so excited about other people getting better. So four key principles in the emergency department, what you want to do is you’ve got to have an environment which is psychologically safe, So people are comfortable about admitting their mistakes, comfortable at admitting where they are uncertain, and comfortable about admitting where they want to know more, and a commitment to continuous improvement.
So always, every case, everything that we do, we’ve always got that curiosity to go around. Everything is an opportunity to learn. Communicate well, open communication at all levels. We talked about it before about lowering, shortening the hierarchies in emergency medicine, which we generally do very well, listening to people irrespective of who they are, because you can learn from anybody and then that reflection and accountability.
So we admit to when things haven’t gone well, we talk about those issues, we share them and we reflect on them and we take that responsibility for our own growth and that of others. So it sounds a bit New Agey and all that kind of stuff. But I put a blog post together, and actually, you know what, I’ve worked in lots of different departments, and everything I wrote in this I recognize about the ones which I enjoy working in, irrespective of how busy they are.
And there’s a project we did years ago, and it’s at the beginning of the blog post, where we took the GMC survey, And we looked at what, the overall satisfaction score for all the posts in emergency medicine across the UK. you do the GMC survey, and there’s lots of different elements to it, but there’s one question that comes out about how is you, how is your overall satisfaction in that post?
So we took that data, and then we compared it against all the other factors. is your body, what’s the workload like in your department? What’s the supervision like? what’s the teaching like? And all of those kind of things. And really interestingly, we did a correlation with this and we found that there was basically no correlation between how satisfied people were with their job and how busy it was.
There’s no correlation. It’s not related, which is not what people think. They think that if you make it, if it’s not as busy, then it’ll be a better job. That’s not true. There’s no correlation. But if you look at clinical supervision and learning elements, that’s where they’re linked. basically, it’s not how busy you are, it’s whether when you’re there, it’s got value, you learn, you teach, and you become a better person.
And that is my big message at this time of incredible busyness, is don’t lose sight of the fact that there’s people all around you who want to learn stuff. And if you take a little bit of time to teach them so that they can learn, That will make a huge difference to their overall satisfaction in their departments, and their lives, and their careers.
So please do that. Read the blog. it’s really important.
There’s so much you’ve said there. And this is not easy. Don’t get us wrong. We don’t believe that this is straightforward and easy. And it does take a lot of effort from individuals to make this happen. And I think starting with psychological safety is the main thing, isn’t it? That trust between team members, that you’re working together, that you believe in each other.
I remember that’s the one thing you notice about Ben Stokes and the England cricket team. They seem to have absolute psychological safety, don’t they, to play cricket in whichever way they believe they should play, and they will be backed up and supported. And there’s something about that culture where if you feel like everyone’s got your back all of the time and you’ve got That’s when it all settles and begins.
I feel for those departments where that doesn’t happen, where there’s a little bit of sniping and biting back and all of that other stuff, and actually emergency medicine, we’ve got to admit that there are times when we pick fights and we have fights. Sometimes with others, we operate in silos with inpatient teams and being psychologically safe for your team members, don’t forget it’s about those who are visiting your department as well.
Negative emotional contagion has a big impact and so if people see negativity around them that makes them feel less psychologically safe. That is so hard though Simon, when you’ve got patients in corridors, people in waiting rooms having heart attacks, that is the key though isn’t
It is, but it doesn’t take a huge amount of time. And actually, people are going to come and talk to you about cases all the time. So why not just take a little bit of extra time to just see what you can do. Find out what they want to know and help them through on that journey. I see people do it really well, better than I can do it all the time. And I see people do it badly, come up, ask a question. I’m really busy. Just do this. Fine. people learn a bit when you do that, but it’s a missed opportunity.
It is tempting isn’t it when you’ve got many patients to get through and a queue of people asking you questions to just give the answer. But just to take one thing away from every shift for every person who’s there is enough to keep you wanting to go back. And I’ve got to be honest, I’m the sort of personality that actually enjoys the chaos.
When department is relatively quiet, I get so bored. Now that doesn’t suit everybody’s personality, but I know for me that I thrive in this situation. And I’m probably better for it. That’s taking into account. I’ve been doing this for ages. I feel comfortable in the department. I feel relatively comfortable most days in my decision making and have to remember that for others, it’s not the same, but you can, even in these times, make that day, that shift, that moment mean something. And I think we forget how much those little interactions mean to those who are new to the department or haven’t been doing it as long as us. Those little words that senior people say make a huge difference.
So we can try and build a learning culture. There are certain things in emergency medicine we’re not in control of, but we are in control of ourselves. That’s the one thing we can do. So in all this chaos that’s going on, then do remember that making those moments happen is important.
Simon, there’s been all sorts of podcasts that we’ve released from tactical trauma. Again, thanks so much to that team for letting us visit. It was great to see Liz Crowe and have the talks and do the recorded interviews. There’s more to come by the way, in the coming months. And we could just talk very briefly because this is a hot topic.
We had one talk from Alice Houten, who’s from France about pre hospital ECPR, and that’s become more of a hot topic recently. The idea that ECMO may one day come to the UK.
Yeah, there’s if you jump on the blog right now, there’s a really great review from Hutch on the Sub30 trial, which is the first UK trial of eCPR. Questionable results there, but certainly worth looking at. I think it can be done, I think that’s been shown that it can be done around the world.
It’s choosing the right people, the right place, and the right locations, I think. And it is expensive, at a time when we’re struggling with other things. So who knows? I’m quite keen. I think if we can select the right patients, it’ll be good. You can’t just jump in and do it. it’s quite a big system change and an awful lot of people need to be on board to make it happen.
Lots of parts of the world have got lots and lots of opportunities to put people on ECMO and keep them on. We don’t have that. I thought there’s some really interesting stuff in here about how to get things working and about looking at the process of how SAMU works and how the ECMO service works in Paris.
I thought it was brilliant. I thought some of the things she was talking about liquid ventilation in the future and therapeutic hypothermia down to really low levels of hypothermia were fascinating. Whether we can achieve that at scale, I don’t know, but honestly, physiologically, fascinating and definitely worth a listen.
And I’ve said before on the podcast, that it’s so important. invigorating to hear people who are passionate about these things and that there may well be change for us afoot in emergency medicine where we can push the frontiers and keep doing things a little bit differently. Even sometimes Simon thinking about doing things differently that we have done for the same for many years.
And how many times have we heard somebody tell us that you have to put in a large bore chest tube for a haemothorax? We’ve heard it forever. But you did a review of a paper talking about small bore versus large bore thoracostomies for traumatic haemothorax. This is a topic that’s again being actively researched, but this paper goes some way to help convince others, I think that you don’t always have to open the massive hole and put a big tube in it.
No, and we’ve reviewed quite a few papers over the years on the blog, looking at this issue, looking at small bore versus large bore, chest tubes for haemothoraces or pneumothoraces. And generally the trend, I think we’ve talked about it before, is the trend has been we can get away with much smaller than we thought we could.
Because I, when I started, we were putting 40 French chest strains in for simple pneumothoraces after trauma. And you think, oh, that’s crazy nuts. And I think for pneumothorax, then we’re definitely going down and using much, much smaller bores. now and that’s fine, but for haemothorax has always been the concern that it’s going to clot off and you’ll have to put some more in.
what this paper is published in the Journal of Trauma and Acute Care Surgery. It’s a systematic review and meta analysis, They’ve gone all the way back through pub base, PubMed, EMBASE, Scopus and Cochrane, looking for, papers. I think they, in the end they found 11 papers with 1,847 patients in them. Some randomized control trials, some observational.
So it is a bit of a mix. The defined small bore is 14 French or lower. And that’s pretty small. I think, in my general practice at the moment, I put in a 20 French, and I think that’s pretty small, but these are going much smaller than that, and a larger was considered to be 20 French or more.
So, in their world, I’m actually still putting large bores in. I thought I was, I thought I was smaller. But no. Anyway, there you go. Headlines are, the small bore seems to be better. So in terms of complication rate, there’s no real difference. In terms of mortality, they didn’t find a difference.
It was actually the small bore had a mortality of 2.9 % versus 6% for the large bore. that wasn’t statistically significant, it is a difference. No statistical difference in complications. There was higher drainage volumes in the small bore. Which makes you wonder, doesn’t it?
And fewer tube days for the small bore. So, looking at the data which is available in the world, you go small bore. However, quite a few of these trials are observational or retrospective cohort type studies and therefore they’re not proper randomised control trials and they’re vastly open to bias. So maybe people were put in bigger drains in the patients who had a bigger volume or a bigger injury or a bigger mechanism.
So we’ve got to be a little bit cautious but in general, it does look as if you’ve got a fairly uncomplicated haemothorax, in your average patient with not a lot going on, you can probably go for a smaller bore chest drain than you did last week. But as always, follow your local guidelines and don’t get sacked on anything I said.
And this is one of those papers that really starts a conversation, doesn’t it? I don’t think it’ll convince some cardiothoracic surgeons that this is the way forward, but it certainly starts a conversation. And there’s other trials going on at the moment. I know Ed Carlton’s running something out of Bristol, similar to do with a drain size for these sort of traumatic injuries, but Journal of Trauma and Acute Care Surgery- have a look. It’s a good one for a journal club review. These are not necessarily straightforward to look at these, systematic reviews and meta analysis. They are tricky and methodologically, although they can be useful, understanding them can be quite tricky. a perfect one to sit around with a few colleagues and have a look at, The references on the blog as always, and as Simon says, please don’t change your practice based on what we say.
Have a look and maybe in the future, Simon, this will be one of those things where we can think about doing something a little bit differently and it might even be better for patients.
One of the things we see quite commonly, even these days is out of hospital cardiac arrest and we’re always pushing to get better at management of out of hospital cardiac arrest.
And again, you reviewed a paper about intra arrest arterial blood pressure monitoring. We have talked about on the podcast before. I know I’m a bit of a naysayer when it comes to intra arterial monitoring, but this paper presents an interesting opinion really about whether this is something we should be doing in out of hospital cardiac arrest.
I know you’re a little bit more signed up to this as an idea as I am, but what does the paper say?
Ah, signed up. I’m bordering on evangelical. but without which is bad for me, because I don’t think the evidence base is really there for it yet, but I’m really excited about this because I think it, the potential for cardiac arrest management, if you look at most of what we do in ALS at the moment, it’s about following a process and hoping that it works.
It’s not target led resuscitation. So we’re doing things and hoping that they, that things get better, but we’re not actually measuring the effect of our CPR. We’re not measuring the impact of things like ventilation, apart from with end tidal CO2, but there’s lots of other things we’re not looking at.
And if we just wind back a bit, when we went to, I went to a brilliant talk at Austria, which is on the blog where the experience of paediatric intensive care units in the U.S. when they changed from a process based resuscitation to a outcome based resuscitation based on intra arterial blood pressure showed a dramatic increase and improvement in the, outcomes from cardiac arrest.
So there is an evidence base that in paediatrics and intensive care. Now, moving that to the road is obviously clearly nuts. This is a paper, from EAAA, which is East Anglia Air Ambulance. So they’ve been putting art lines in for their cardiac arrest patients for some time.
And what they were looking at in this paper is whether or not there’s really a threshold for when you get ROSC. There’s quite a lot of animal work that shows that if you don’t have a sufficient diastolic blood pressure, you don’t perfuse your coronary arteries. And if you don’t perfuse your coronary arteries, you don’t get ROSC cause you’re not perfusing the myocardium.
And, this seems to be really good evidence in animal data, and there’s some pretty good evidence actually in humans, but it’s not great. Anyway, in this study, big database of, patients, they actually, over the period of time, they actually went out to over 4000 were potentially looked at, but of those, only 80 patients actually got into the study.
So that’s the first caveat, is that this is a very small group of a much large group, who are also seen by air ambulances, which is a smaller group than lots of the rest of the world get to be seen by. What they found essentially was, is you put the art line in, and unless you got the diastolic blood pressure to a decent level, you didn’t get ROSC.
And the optimal cutoff as a predictor about whether or not that would happen was 35 mmHg. So what does that mean? What that means is, that during resuscitation, we’re, if we believe the pathophysiological data, the laboratory data, the animal data, and these observational stuff, we should be doing what we can to achieve that.
So what can we do? We can change the position of CPR, because now we’re reading other studies that show that maybe the centre of the chest and the lower third of the sternum isn’t the best place to do CPR for everybody. For some people it might be further over the left, for some people it might be higher up, for some people it might be maybe even a bit lower, but probably not.
So we could alter that, alter the position. I’ve certainly seen that with an arterial line in. I’ve moved the LUCAS and seen the blood pressures rise by 20, 30 mmHg. Quite remarkable. We can use drugs and maybe different drugs and maybe do drugs in different ways. And we can use, REBOA, potentially partial REBOA to increase, systemic vascular resistance effectively, and then increase coronary blood flow and maybe get ROSC.
Not so long ago, I did a thoracotomy, in a patient who was exsanguinated, and with aortic pressure, and with some volume resuscitation, you could see the heart fill, went into VF, and then ROSC was achieved, with pretty much nothing else done. And that was the same thing. I’m fairly well sold on this.
The data that they’re finding in humans here is the same as what they’ve found in laboratory and experimental data. I think there’s something in this, not ready for prime time, definitely need more research, but isn’t it exciting?
I think it is really exciting and I should caveat my comments earlier in that I am a big fan of arterial lines during resuscitation. I just think that you’ve got to make sure that you’re moving constantly towards a hospital environment if you’re in the pre hospital team, because if that patient does need coronary intervention, that’s where you need to be.
So my only reservation is about that in the pre hospital environment, this can’t stop you keeping moving towards a big white building, with some bright lights in it. Cause that’s the thing that some of these patients will need. And as they mentioned in the paper, about 50% of these patients are having myocardial infarctions. And so that’s where they need to be. Arterial lines. I use them. All the time in out in cardiac arrest in the emergency department. I use them in trauma. I think having those targets for blood pressure and I, although flow and pressure are two different things, the idea that you need oxygen to your cells in order to make ATP is something I bang out constantly, regardless of your level of training, you will hear it from me most days.
And it makes sense to me that in order to have enough umph for that heart to restart, you need to have an oxygen supply going from those coronary arteries into that muscle and that may give it enough energy for it to crack on into a spontaneous circulation. So I think this is exciting stuff. Hats off to EAAA, they’re a great service.
They have very strong research arms. I was privileged to meet Rob Major when I was over in Sweden and they’ve got a really strong research outlook coming out of there and they’re working very closely, I know, with the London team talking about the management of the traumatic shocked patient as well.
So all kudos to them. If you want to read this paper yourself, as ever, you can find it in Resuscitation, Volume 205. Please do go and have a look and think about when you might use an arterial line in the management of patients. Whether that’s in the pre hospital environment or in the emergency department, it’s a very powerful tool to make us more accurate in what we’re doing.
And remember that ALS is the beginning. It’s got advanced in the name, but it’s the beginning of targeted resuscitation. And what we’re aiming for is nuanced targeted resuscitation in these patients to really make sure we’re doing the best we can to get those hearts back beating and hopefully those patients well enough to leave the hospital. Now, Simon, a very brief mention, because Greg has written a great book blog post on this, but there are new drugs that come out all the time. And one of them that we’re hearing about at the moment, I heard about it a lot of the Golden Globes is Ozempic. One of these drugs that is treatment for obesity.
And these are new things we need to know about with toxicity. And thanks again to Greg, who’s doing a whole series of toxicology posts, which is a whole part of emergency medicine that I think we all need to be familiar with. And this was a study from the journal of medical toxicology, trying to put together some data.
about the glucagon like peptide 1 receptor antagonist, the GLP 1RAs. Toxicologists love that sort of naming, don’t they? And what we might need to do with them. There’s more in the blog post. Simon, anything you wanted to add about that?
No, it just sounded like you were at the Golden Globes, which was impressive.
One of the podcasts, I think it’s worth mentioning from November, Simon is the care in the hot zone with Claire Park. Claire is an anaesthetic doctor in London, and also a member of the team at London’s air ambulance, as well as working very closely with the police services, in London.
And this was a talk again, given in Sweden. And all about what you do in an active incident when there was still an active threat to those who are trying to provide care. This was one of those talks I went to and sitting there with Liz Crow with our mouths wide open. about some of the things our colleagues are doing, around things like the London Bridge attack on Fishmonger’s Hall and others.
I’m just what you might need to do in these things. Now, a small amount of our listeners I know are in the pre hospital frame, and doing this on a day to day basis, and the truth is, this could happen anywhere. it was recently the anniversary, wasn’t it and the publication of the inquiry into the Manchester attack, and it doesn’t matter where you seem to work in whatever country, there is a chance you may find yourself in one of these environments and Simon working in the prehospital environment, this could be you.
Gosh, yes, that’s an interesting thought. Claire’s great. I’ve heard her speak before. And then she’s a really impressive, educator. I thought this was really good actually. And a listen for everybody. You might think it’s about, just about marauding terrorist attacks and things like that. It’s not.
There’s so many common themes in here for what we face in our lives. I thought the stuff around risk and decision making was really clever. We all have different levels of risk tolerance, and making decisions can be difficult. And decision inertia, where people just don’t make a decision because they don’t know what to do, or they’re frightened of the consequences, is really there.
I really like the way she talks about three types of risk. So there’s a physical risk entering a potentially dangerous scene, professional risk in that decisions may later be scrutinized. And that really is a thing if you’ve been involved in any inquiries. And then the psychological risk in that you might actually be long term affected and even the roughty toughty people who think they’re very hard they you know, we’re all human and everybody can be affected. I also really liked and this last thing I’ll mention but go read the full blog because there’s so much gold in here Is the 40 70 rule officer guideline to act when you have 40 to 70 percent of the information.
If you have to wait until you’ve got 100 percent of the information, you’ve lost the moment. And we talked about that. I talked about the Goldilocks moment. Do you remember that one, Iain? Where if you dive in too soon, then you’ll make mistakes. But if you wait until you’re absolutely certain you’ve missed the best opportunity for saving your patients.
So lots of corollaries with what we talked about on the blog there before. Great presentation. worth a listen. And also have a look at the notes on the blog.
And we’ll finish this month mentioning again, Liz Crow and a talk she gave in Sweden about bad behaviour. Now is a time when it’s worth reminding ourselves of just how damaging small things can be to the morale of a team. We’ve talked to her already about how tough it is in the emergency department at the moment, how difficult things can be, and just how much worse that can be made if for whatever reason,there is bad behaviour.
Now, bad behaviour can be anything. From a little eye roll to being dismissive, to being rude. All of those things can affect how a team is functioning. And Liz talks very eloquently as ever about how that might happen. And the thing for me with this was actually more about to look at yourself, think about your own.
Your own behaviours and what could be seen as being bad and difficult. I know that some days I might do the little gesture or the sigh, or the look to the heavens that I think is not being seen by anyone else, but it is, and it doesn’t matter who’s seeing it, whether it’s the person to whom you are sighing or someone nearby that will affect that team and how they work.
And all of this is that culture of safety we talked about before and building up trust and don’t believe that if you get into an environment where the team needs you and they need someone they can trust. They don’t forget these things. These have add up over time and don’t believe you can just all of a sudden be nice and buy a packet of sweets and everyone will like you and believe in you.
This is built up over time and even the little bits can damage that. Simon, obviously you and I are close on perfect. But I’m sure you’ve had similar times where you’ve caught yourself perhaps saying something or just a little gesture that you regret and wish you hadn’t done. It can happen to us all.
Oh, gosh. Yeah. about a year ago, I think, I did an eye roll on somebody, which was unintentional. but it was, the eye roll was intentional, but it was perceived as against the person who was talking to me, which it wasn’t. Completely changed the dynamic of the whole environment and took a long time to recover from that.
Change the dynamic of what was going on entirely. It was really difficult to recover and took a lot of apologies later. So yeah, absolutely agree with all of that. And none of us is perfect. Absolutely not. one of the problems you get when you’re more senior is you can be as important, you can get increasingly imperfect and people don’t come in and tell you that you’re getting like that.
and I do appreciate. when, the people, the person who comes and taps you on the shoulder and says, do you know what Iain, Simon, whoever, I’m not sure that went well. I think you’ve made a bit of a mistake there and that didn’t go down well. You need to do something about it. Those people are really valuable,and I count some of the best people I’ve worked with. Some of them are on the blog and the podcast, people like Nat May, when she was a trainee, she was really good about coming up and going, we need to have a chat. Even though I had the seniority and value those people, they’re awesome, cause we all make mistakes, but we can recover from them.
And as Liz pointed out from her own research, we’ve talked about eye rolling as an example, but they found in their research that eye rolling is as dangerous for patient safety as sexual harassment.
But it’s just a reminder, isn’t it? And particularly at these times, I’m afraid to say being busy is not an excuse for rudeness. Being stressed is not an excuse for rudeness. If anything, you need to go the other way. One of my favourite ever colleagues, Diana Hulbert, who is one of the kindest people I know.
Working with her in these sorts of environments we’re in at the moment is an utter joy, because I know that I will feel safe, there’s kindness, and I can be a better doctor because of it. And I strive every day to be a bit more like Diana, and that’s perhaps a nice message to end on. Simon, that’s the content we have for November.
We are still catching up. We’ll soon get to December, hopefully at some point in 2025. It’s important to say that 2025 is a big year for St Emlyns. Simon and I are working very hard on all sorts of new things that we hope to bring you. This has been a passion project of Simon’s and mine and others for about a decade, maybe more now.
And we’re trying to push the boundaries of what we can achieve to bring it to you as an educational resource. We’re keen to hear from people. It’s great. We’ve had a couple of emails recently from listeners and readers who are keen to get involved. If you would like to get involved writing a blog post, just get in touch.
I promise we’re very friendly and we’d love to have you on board. Many hands make light work, as they say, and part of this project in 2025 for St. Emlyn’s is to keep growing, giving you the content that will provide you with the education and hopefully a little bit of light relief from what is going on at times in your emergency department.
Simon, it’s good to see you. 2025 is looking good. keep going and, all of our listeners, thanks for listening and we’ll speak to you soon.
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