Ep 254 – Monthly Round Up October 2024 – Toxicology, Cardiac Arrest and more

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

And I’m Simon Carley

And I am actually at London Trauma Conference to record some podcasts for St Emlyn’s, but this is our monthly update for October 2024.

Simon, you’ll notice I’m in the council chamber, the rarefied environments of the Royal Geographical Society. I have portraits behind me and globes surrounded by pictures of Shackleton and others, but it’s good to see you. And we’re going to be talking about some of the blog content from October this year.

I can’t say that my surroundings are quite as grand as yours and that the pictures aren’t quite as good. But yeah, no, let’s, let’s get on with it and then see what happened back in October.

So we’re still on a catch up, aren’t we? It’s a recording in December, but talking about October. And we have been doing a lot of activity on the blog with both our conference activity, bringing you reports from conferences and lots of podcasts.

We’re delighted to say we’re being able to produce something about every week now. If you check your podcast feed on a Wednesday, you should have a new episode of the St. Emlyn’s podcast sitting there. And dare I say, it may even fit in with your departmental teaching, get people to have a listen, and you can have a chat about it at work as Wednesday seems to be an education day, but there’s lots there, we’ll talk a little bit about it.

But Simon, let’s talk first about the academic science conference that took place, for the Royal College of Emergency Medicine earlier this year. Of course, you’re a big part of the Royal College as the Dean being there as an attendee, as a delegate. What were the highlights you saw that we think really want to draw out for people listening

 There’s lots on the blog, so go and have a look at the three posts across the three days for all the detail and stuff.

But just a couple of things which caught my eye. Not necessarily the highlights, but just sort of stuff which interests me. Because of where we were, there’s a big poison centre up in Newcastle, so we heard a lot. about poisons. That was really interesting. A couple of things there. There’s some really interesting high potency opioids knocking around at the moment.

Simon Hill talked about this. Things like the nitrazines, brophines, the carfentanils and some weird stuff, which has got numbers and letters like MT45. And these are so potent that actually we’re seeing an increase in the number of opiate deaths, which is very sad, particularly in Scotland.

And also we’re getting the phenomena of actually dead on the end of the needle. The police or, people who are in the, in the places where people are taking the drugs are actually finding that people are actually dead literally with the needles still in their arm. They’re that potent.

And the impact for that for us is that these patients might need really quite enormous amounts of naloxone,to counteract that and prolonged ICU stays. So really interesting and, quite worrying stuff because a lot of these people don’t actually know what they’re taking when they’re given the drugs.

 And similarly with the benzos, there’s some novel benzodiazepines knocking around now, again, high potency ones which if used in conjunction with alcohol and things like that, causing those major issues. Emma Morrison spoke about this. she’s a toxicologist, about the use of flumazenil.

So I dunno what your feeling is in your head about, what do you think about flumazenil? Is it, and is it a good antidote for the patient who’s come in with a benzodiazepine overdose? Who we often think is somebody who’s probably dependent on them. And my teaching has always been never do that. That patient will be in status epilepticus forever and they’ll die. You’ll kill them. And she was actually really challenging that dogma. And I love a bit of dogmalysis. So that was really good to see. And actually, if you phone your poison centre now with these benzodiazepines, and they suggest centre, maybe that might well be the right choice.

Not all the toxicologists agreed about this on stage. It was a really good session. but yeah, really something to think about. I don’t know what you think about that. Have you ever used flumazenil? Well, not for 15 years, and it’s stayed in a cupboard and it’s been supportive treatment.

But I think the key thing here is pick up the phone, isn’t it? There are toxicology experts who will keep up to date. It’s like all medicine. It’s almost impossible to keep up with these things, isn’t it? And there will be all of a sudden, I live and work in Southampton. It may have a different drug profile that’s being used on the streets to what is happening in Glasgow, but these things happen very quickly and all of a sudden, there’ll be an influx of these drugs and being very quick to pick up the phone, that’s not a sign of weakness. It’s a sign of strength to admit that you’re not sure what’s going on. And 24/7, the poison centres, toxbase, they’re all updated regularly to keep people like you and I safe and knowing what we’re doing. And if they tell me to get flumazenil, I’m certainly going to follow their advice.

I think that’s true. And we’ve seen it on the blog recently haven’t we? So Greg Yates, who’s relatively new to the team, is doing some fantastic blogs around toxicology. And Greg, he’s a very evidence based medicine guy. he really does like high quality trials.

Also loves toxicology, and there aren’t a lot of high quality trials in toxicology. so there is a lot of judgment there, and whenever you’ve got judgment, then involving an expert is absolutely the right thing to do. So yeah, really interesting stuff. And again, with cannabis,intoxication and, cannabis hyperemesis syndromes.

And one of the things that came out of that is, the number of people that we’re seeing now who may present with cannabis, hyperemesis syndrome, who are not necessarily taking recreation, well, debate whether it’s recreational, but these are patients who, may well be on private prescriptions for,cannabis,compounds and things like that, and also the spice stuff.

So, when you’re taking a history and you’ve got that patient who’s persistently vomiting, “do you smoke cannabis” is not an adequate question. You have to dig into in quite a lot more depth actually, so that was good. so that’s toxicology, the other stuff there as well is great. And there’s another brilliant session on climate and the Green ED.

If you haven’t seen the Green ED project, please go and have a look at it. It’s an RCEM associated project, looking at, the impacts of climate change, but particularly what can we do in healthcare systems. And Sandy Robertson, who I think is just brilliant. . always makes me slightly uncomfortable, but also in equal measures, if not more inspired.

Three big messages. Yes, it’s really bad what’s happening. the experts pretty much agree,that it is bad and it is happening, but there is hope. And the green ED project is about how we can do our bit in emergency medicine to, mitigate the impacts of, of healthcare on climate change, of which there’s a lot.

Other things, self rostering projects. It’s good if you’re not self rostering, get on with it, honestly. it is transformative. It’s a lot of work, to get it, up and running. There are problems with it, but generally speaking, I think it probably is the way forward. A great presentation from, Fiona Lucky and Tim Coates about TARN. Do you remember TARN?, Trauma Audit Research Network based here in Manchester. Brilliant project. but I think it’s, I think it’s public knowledge. it was hacked, and destroyed and so it’s being reborn. Phoenix from the ashes, so to speak, and the new project is going to be even better. It’s going to be much more real time and there’s going to be some better patient related outcome measures.

So actually, I’m really hopeful about that going forward.

There’s paeds imaging is changing and we’ve got a blog post coming out that. And then lastly, on the, on the conference, just want to shout out to Ed Carlton, who’s a brilliant guy and Professor down, in the Southwest. He did his professorial RCEM lecture on dogma, and we do like a bit of dogma here.

He divided dogma up into four phases. Retrograde, which is where we just do stuff in the absence of evidence, because we’ve always done it that way. And he pointed to the COMITED trial, which is about the conservative management of traumatic pneumothoraces. He’s the chief investigator for that. That trial is to get rid of that kind of dogma.

There’s dissociative dogma, where a generation of evidence is a defense mechanism to bias towards our own practice. So that’s just keeping going with what’s to do. Anterograde dogmawhere, practice persists, just keeps doing the same thing, even though we know the evidence is that we should be doing it differently, or, and the uses like TXA and GI bleeds, even though we know it doesn’t work and actually might be harmful, but people got it in the head, they just keep doing it.

But the best one, and the one which really chimed with me, and the one that really irritates me, is post traumatic dogmaand that says all practice must change on the learnings from a single case. Also known as the DATIX Phenomena. And, you could feel in the room, everybody went, oh yes, we’ve all seen that.

One thing goes wrong, or one person has a weird reaction to something, and then we need to change the world. And that’s just bonkers. And so yeah, it was a really good, talk, very entertaining, and with a bit of science behind it as well. So great stuff from Ed. Great.

Ed’s a great guy. He was with us in Southampton as he finished off his registrar training and then obviously went to the Southwest.

He’s produced all sorts of stuff actually already. You’ll remember the SHED study. He was a big part of supporting, the TERN team for doing that. And he also was part of the LoDED study, which we’ve done a blog post in the past, which is about using troponins, below the limit of detection. It’s an early rule out for people with low risk chest pain. So he’s producing really good high quality stuff. And it’s lovely to hear emergency physicians talking in that way to challenge stuff and take us forward. I made me think of a few things as you were talking there. The first is that the medical conference is most certainly not dead.

in fact, it’s a phoenix from the ashes, I think after the post COVID times. I’m sitting here at the London trauma conference. I’ve just come back from Sundsvall in Sweden and hopefully people have heard the podcasts from there. You really lovely atmosphere. Lovely people. There’s clearly a desire to get out there and learn.

We’ve got RCEM doing their thing. We’re really lucky to be part of Incrementum, which is happening in Spain in March. And if you do fancy a bit of spring sunshine, Incrementum has a list of speakers that frankly, most conferences would dream off and do have a look at their website. The tickets are also very cheap and you can fly from the UK pretty reasonably.

So getting the study leave in to get out to Spain, to have those few days in the sun, different culture, but learning some amazing emergency medicine. Conferences are most certainly on their way back, I think.

100 percent and there’s a few more knocking around. So I’m going out to the big sick in February in Zermatt in Switzerland. Went there last year. That’s a cracking conference, actually. The Big Sick and also Incrementum, if you’re interested in the sort of, the resus end and the critically ill and critically injured, I think those are, they are really going to take on the mantle from what we used to do in the early days of SMACC and really push those, agendas forward.

Strong recommend. The Spanish conference is considerably cheaper than going to Switzerland in February. I can assure you of that.

We support all European conferences, wherever they may be. but yeah, do seek them out and study leave budgets. I think they’ve just gone up actually. do make sure you try and make the most of those.

I’ve not managed to spend any study leave for about 10 years. Unfortunately, you can only go back three years to claim it, but, I will be trying to spend that cause I will be in Zermatt as well, but I’m going as a delegate. Which is delightful. So I’m really excited. So conferences are on the way back.

There’s a lot there. We’re hoping to bring stuff to you. And again, we are hugely grateful to Tactical Trauma, London Trauma, Incrementum, that they’re all letting us use some of their content and their speakers to interview them, bring them to you. And if you’re not able to make it, we’re able through the power of the internet and podcasting, bring you a little bit of their content.

So back to the blog site, Simon, there’s more posts in October that we can chat about. And some of these are the evidence based blogs that you and I both love chatting through. These things where we want to try and help you keep up to date with what’s going on in the world of medical literature, because it can feel a bit like, I think we say drinking from the fire hose, can’t we?

Can we chat a little bit about ventricular fibrillation and pad position? Because you wrote a blog post on this and this is one of those things that feels like it could be a big win if it makes a difference.

 So this is, this is almost clickbait this paper.

I don’t mean that badly to the authors done a good job, but it’s Oh, look, this is going to be really interesting. And then maybe let’s have a think. So if you’ve been listening to the podcast and reading the blog, you’ll know that we’re very interested

 in defibrillation as a treatment for cardiac arrest. There’s been lots of research about that recently. The Dose VF trial, we’ve been on about that a lot on the blog. It’s a really cracking piece of research done over in Canada, which demonstrated that you had better ROSC and you had better survival to hospital discharge if you did dual sequence defibrillation in patients with refractory VF, as defined by still in VF after three shocks.

But in that paper, they also noted. that you got better ROSC if you went for an AP position, rather than an AL position. So in the Dose VF, you either, you had your first three shocks in the anterolateral, and then if that didn’t work, you went for dual sequence, or you went for a pad position change, a vector change into AP.

Now for hospital discharge and survivability, DSD was statistically significant. The change in pad position wasn’t for hospital discharge or, long term survival. The question that came from this, and we asked it at the time, was, actually, if AP looks to be better, should we just be starting with it?

And that trial hasn’t been done. It wasn’t argued in Dose VF, but what these guys have done is a really interesting paper published in JAMA is on the basis of the Dose VF, they actually decided to go for, actually what we’ll do is we’ll go AP first. And the logic behind that was that if we’re going to think about doing dual sequence defibrillation after three shocks, we’re It’s actually better to get the AP ones on first, because then you can put something like a Lucas device on and then it’s easier to put the AL ones on afterwards.

And I get that logic. And then, so they did that, and then they did an observational study afterwards to find out whether or not that actually did improve ROSC, because essentially they were doing AP versus AL off the go. But it was observational, it’s not randomized, it wasn’t particularly controlled. But that’s what they did.

And so they took 255 patients. into this study, out of a much larger group, because they were only looking at these patients who were in VF and had a potential for survivability. And so what they found is that it was better in terms of ROSC. So if you got the AP position first, I think you got a 74 percent chance of getting ROSC, whereas if you went to AL, it was a 50 percent chance.

That’s a huge difference and very statistically significant. However, they didn’t see a difference in the number of patients who had a pulse on arrival in the ED, in their survival to hospital admission, or survival to hospital discharge. Now, a couple of reasons why that might be. One is it doesn’t make any difference.

That’s a possibility. The other potential reason is there’s just not enough patients in this trial. And the other reason is that there’s potential loads of bias here. Maybe the people who were going to go do the AP were more up to date. They were more skilled. They were more interested in doing new things.

Maybe they were better. Maybe they were worse. Who knows? It’s a really interesting observational study. It kind of keeps in keeping with what we saw in Dose VF for AP versus AL, but I think this is enough for us to do an RCT. I think there’s enough evidence here that somebody should get out there and do an RCT of AP versus AL first with bigger numbers to see what’s going on.

And when that happens, I think I’d be prepared to change practice. At the moment, no, not so sure.

I’ll bang on again about the fact that cardiac arrest is not one entity and it’s certainly not one disease. And these are the patients who are having acute ventricular arrhythmias, who I think we need to concentrate on when we’re talking about cardiac arrest.

All those patients who’ve gradually got more and more unwell and their blood pressure has plummeted and you can no longer feel a pulse, not because their heart isn’t working in the same way, but they simply have no blood pressure. Two different things altogether. And the biggest wins we can get are on these patients who have sudden arrhythmias where we can get in there, fix the arrhythmia, and save their lives. The ones who are on that other, what we used to probably and still do call a non shockable pathway, that’s a whole other kettle of fish. And that is a big issue. Doing a lot of those things to patients like that, I think we need to be more pragmatic, but for these patients with primary ventricular arrhythmias, I think we do whatever we can because we can make a real difference to people who otherwise shouldn’t die.

And philosophically, I can’t remember who told me, so I can’t attribute it to the right person. but I jumped on it. I thought it was brilliant. If we go to a patient who’s in VF, they should survive that.

And that’s the mentality that we should be going in with. If it’s a sudden onset, VF cardiac arrest due to a, myocardial problem, had a problem with the electrics or with the plumbing, then we should be able to get those people back. And that’s the attitude that we should be going in with.

And at the moment, our, our success rates are nowhere near a hundred percent and probably never will be a hundred percent, but I’m sure we can do a lot better. And if you look around the world, the survival rates from that particular scenario vary so much. It tells us that, gosh, there must be something in our systems in the way that we deal with these patients that we can do.

And I think that’s because we teach the PEA side the same way we teach the VF side. And we see an awful lot of people die on the non shockable side of that algorithm. And that’s because they are. critically unwell. And we are there too late. We are trying to fix that problem too late, or the body just won’t let us fix it.

But we say, Oh, the outcome from out of hospital cardiac arrest is this 6%, 5%, 2%, something awful, but we lump it all together. And really we’re talking about two separate things. As you say, we should be looking at an outcome from the shockable cardiac arrest and the other side of the algorithm, which is just really, dare I say, and I don’t want to be down about it, but the other side of the algorithm for the non shockable algorithm is people who are dying. Often over a long lingering period of time, and we need to reframe what we talk about with that, I think. But anything we can do to find those little wins for these patients, I think, is really worth pursuing, whether that’s pad position, whether it’s how we defibrillate the patient, it’s about initial recognition, it’s about AED access, it’s about all those things, because a lot of these patients often also haven’t done much wrong, they happen to have an electrical abnormality.

And we can say that very easily about the footballers who collapse in the middle of a football pitch because they’re all fit and young. But again, somehow we think about rather pejoratively old people who drop down dead. But often it is just something that they could never have predicted. It’s not their lifestyle.

It’s nothing else. And we just need to do whatever we can.

I think somebody needs to do a paper on what’s the survivability of. being a professional footballer and having a cardiac arrest on the field. It ain’t two percent.

It really isn’t. because we’ve all seen the pictures. So really interesting. I’m sure there’s more to come out of this.

As you say, an RCT for pad position, it wouldn’t strike me as being a high cost one to do. It’s just that organization. And as with all of these trials we see, whether it’s the paramedic trials or these other trials, it’s quite hard to get engagement because this is a difficult area to

 do research in.

Our next paper is one about our old friend TXA. And I think Simon, I think, I think we’re all agreed that TXA is a good thing. I think we’ve all agreed now that it’s an okay thing to give. And now we’re talking about how we should give it.

And now this is a conversation about the dose we should give and again, a blog post written by you about how we get those two grams of TXA in, whether this is an out of hospital bolus of two grams or whether or not this is a one gram plus one gram infusion. And it’d be great to hear your thoughts because I know you’ve got history with this and history on how that first CRASH trial was done and why people decided that an eight hour infusion was a good thing.

 So the eight hour infusion thing as far as I understand it was based on the fact that If you’re bleeding lots of stuff out here, we’re truly having massive haemorrhage, you’d lose your TXA, so it’s to maintain it in the body, so to speak. And that seems entirely reasonable from my point of view. And are we all in agreement that TXA is a good idea?

Pretty much. Even North America has come online, fairly recently, which is good. There’s loads of trials now that show that there’s a benefit in trauma. And this was an interesting paper. So this is a secondary, it’s a pre planned secondary analysis. of the pre hospital TBI traumatic brain injury study, which is a randomized controlled trial of TXA versus placebo.

But in that trial, they gave the TXA in two different ways. They either gave it as a 2 gram bolus, or they gave it as a 1 gram plus the 1 gram. The 1 gram plus the 1 gram is what they originally did, so that’s fine, that’s evidence based. However, what happens in practice a lot of the time is these patients, they get that 1 gram infusion in the hospital, but, If you audit it in your department, you often find it gets disconnected or they don’t get it or they don’t get in the right time.

So there’s a real thought that patients weren’t getting it as they should do. The two grand bolus on the other hand, you’ve given it and they’re fine. You can walk away. So to speak, you can always give some more later if you need it. but then, is it there for as long as it needs to be? Is it the right dosage? All of those kinds of things. And there have been trials that suggest that’s okay. In the UK, some of the ambulance services have been a bit, flip floppy about this. So in a local ambulance service to me they were given one gram pre hospital and expecting the hospital to do the infusion.

Then they went to two grams as a bolus for the head injuries, and then they’ve gone back to one gram and one gram. So it’s not quite definitively agreed about what we should be doing here. So what they did in this study, again, it was a pre-planned secondary analysis of the TBI trial, is they went and had a look at those patients with a GCS of less than 13 and who had an intracranial haemorrhage on CT.

So these are the ones who have got the potential, you could argue, for the most amount of benefit. However, by just looking at this small group, you are excluding some patients who might have got harm from TXA. Although we’ve never really been able to demonstrate that TXA gives harm outside of GI haemorrhage.

So 966 patients in the trial originally, 541 of those had an intracranial haemorrhage. So those are the ones that are included. And they basically showed that the ones who got the two grams seem to do better. 28 day mortality, 17% versus 27%. That’s quite dramatic. but amongst the survivors, there wasn’t a huge amount of difference, at six months, on the Glasgow outcome score extended, but on the DRS, which is the disability score, there was a slight improvement for those ones who had the two grams. And of course, if you didn’t survive, then you weren’t able to take part in the six month outcome. So this suggests that a 2 gram bolus looks better. However, secondary analysis, subgroup analysis, always got to be a little bit cautious with that, or very cautious, in fact, it keeps me thinking that probably a 2 gram boluses is going to end up, we’re going to end up, I suspect, going back to 2 gram boluses.

The evidence isn’t quite there in the way that we’ve got it for CRASH 2, CRASH 3. but if you’re doing that, it seems entirely reasonable. If you’re not doing that and your ambulance services don’t do it, don’t get sacked on what we say, just do what they say, do encourage them to get the one gram when they get to hospital.

It’s one of those things, isn’t it? Where don’t do anything just because you heard it on a podcast. We repeat it constantly, and this is one of those. There are believers and non believers, I think, with TXA, and things do take some time to catch up. I was watching a X discussion between, I presume, Scott as EMCRIT, and another physician talking about the difference between following guidelines and following evidence.

And following guidelines isn’t always the same and just because we’ve got new evidence, it will take time to get into everyday practice. And a lot of our talk at conferences is about human factors. And a lot of the time, if you decide to do something because you think the evidence is there for it, but you don’t have a team that’s alongside you, who believes in that as well, or knows the evidence the way you do, if you lose the team, that is more harmful perhaps than doing the new evidence that you think will help. Everything we need to do as a balance of harm versus benefit and harm can include disengaging your team and having conflict within that team, and that has to be balanced with the, I’m going to do something different because I believe it’s medically the right thing to do. It’s the nuance of team working and resuscitation that actually I find really fascinating, because more and more we talk about the idea that all of these things we read, the papers are important, but making sure your team is on side.

I’m delighted to say we’ve got Cliff Reid on the podcast talking a lot about that, and that’ll be in an episode coming up in the next few months. That’s where some of the biggest gains are. So please don’t do stuff just because you hear it on a podcast, and I don’t think the gains are significant that it’s worth getting into a row over a patient about.

These are the times we need to have the opportunity to sit, reflect, talk, go through the evidence, and dare I say, Winter in the NHS is the time when this is the exact discussion which goes out of the window because everyone’s just struggling to survive. Where probably, what we should be doing is prioritizing this to make sure care is good and we’re all in a really good place where we feel like we’re getting towards mastery if we can.

A hundred percent. All of those things I would agree with. I’m sure there’s a time in my life when I was so happy with guidelines that I thought medicine was easy. And then you come out the other end and you think, gosh, it really isn’t.

It is more complicated and, because it turns out people are complicated and that’s the one bit that we will never have from an AI generated clinical encounter where we’re always dealing with people, but they’re not just the most complicated, they are the most interesting and that’s part of the reason why I quitestill enjoy this job, Simon, that is it for October. That is our blog posts that were not podcasts. There are other blog posts associated with every podcast. So if you’ve been listening to some of the podcasts from tactical trauma, you’ll always be able to find a blog post associated with it that has some background reading, if you’re interested. It’s another way to just let you know that the podcasts are out. And as I say, I’m delighted with some of the things we’ve got there. I never believed we’d have a SWAT commander from the Canadian, Royal Mounted Police on St. Emlyn’s podcast, but we have. And if you get the chance to listen to Kevin Cyr and all the others, I would highly encourage it.

Now, and dare I say, if you can subscribe, like whatever your podcast provider asks you to do, we’d massively appreciate it. as we try and get this stuff out to you and increase our audience a little bit, cause I think it’s good stuff. Simon, it’s December, although that is October, but it’s, Christmas soon.

We’re into that time to keep positive. Any last messages for how you can recommend people maintain a positive outlook over the next few weeks, which will undoubtedly be challenging.

Gosh, it’s a really tricky one, isn’t it? The first thing is it’s not your fault. The systems that we work in, you’re not personally responsible for the way that we are currently operating.

And you sometimes have to have a little bit of dissociation between the problems that are occurring in the department, in terms of particularly things like flow. and yourself. Now that doesn’t mean you can’t look after patients, it doesn’t mean you cannot care about the patients, because you can, but solving the problems is tricky.

And if it’s a problem which you can’t solve because you’re not empowered or unable to do so, don’t feel guilty about it. And talk to your friends, talk to your colleagues, there’s so many of us in the same boat, that, a problem shared and discussed is often helpful. Do try and engage, do try and do the right thing,and just be slightly cautious about anybody who comes down and goes, do you know what, if you just did this, it would all be fine.

The other thing I look for is small wins. So in amongst the craziness, getting a cup of tea for an older person or a blanket or those little bits that are just a human touch. I look for those in every shift because they’re the things that I think make a real difference. And,the odd kind word, the joke, the smile, whatever you can do.

it is important that we get to offload about the situation, but as you say, Simon, it’s not in our gift to fix, but we can fix little bits. And the little bits we can fix is being kind to each other and our patients.

The other one, and we did do a blog post about this, several months ago, maybe it was even as long ago as last winter, is have a think about the stuff which you enjoy doing in emergency medicine, not necessarily just the clinical stuff.

And if you speak to people, it was often things like. a bit of research, a bit of investigation, a new guideline that they’ve put together, and often, and we’re biased, teaching. getting involved in teaching, and teaching somebody a skill, or just interacting with the medical students, and the resident doctors, or whatever.

Those are all positive experiences. This week I taught someone how to put a chest strain in, we took the medical students up to the helipad, we saw some trauma. We had some neck stabbings, which we taught people through. We got them, our senior trainees to act as trauma team leaders and gave them feedback, amongst a sea of incredibly hard work, those are the highlights I would look back on.

 Never forget, just have a stop and a think about what were the things that you used to enjoy doing. Do some of that and don’t just get dragged into just making flow happen.

Absolutely. Simon, it’s great as ever to talk and I’m back into the London Trauma Conference now for some more lectures, some more learning for me, which is a real joy for me actually,

but we’ll chat again next month and take care. And if I don’t see you again, have a lovely Christmas.

 Indeed for you and for everybody else, have a cracking Christmas and a wonderful new year.