September 2024 Round-Up – Patient Experience in the ED, Dirty Adrenaline, and More!

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

And I’m Simon Carley.

 Simon, how are you?

I’m all right actually,busy. got lots of things on, doing lots of things, but still loving it.

 Good. And hopefully we can help give a bit of that enthusiasm to our listeners. We know times are tough. We know that emergency medicine is going to start to be tricky. everything in healthcare becomes tricky, isn’t it? It’s not just us. It’s wherever you may practice and our ongoing enthusiasm,

please know that we do get that it is not always straightforward and easy. And actually our aim is to try and just jolly things along a bit, give you a bit of background, make work a little bit more well. informed, and remind ourselves why we do this crazy job that we do. And Simon, at the start of all of that are our patients.

They’re in the middle of everything that we should be focusing on. And Liz started off September writing a paper about patient experience in the emergency department. And this is a great reminder for why we do what we do.

It is, it’s quite a small study and Liz done a really nice review of it. It’s a qualitative study where you often have small numbers of patients, but really get into the why things are. So we know that our patients are having a pretty tough deal, but why is it? And do we truly understand what the issues that are facing them and their families?

 What she found. when reviewing the paper was that there were some common themes that across all the patients, I think we’d probably recognize these, but the big issues that patients are feeling were a loss of autonomy.

So you come into an emergency department with a problem. Then we take away a lot of that, and part of that’s because we don’t really communicate about what’s happening and why it’s happening as we go along. And I think some of that’s because we do get so much time pressure. We lose some of that ability to sit down, spend a lot of time, repeat conversations with people.

So loss of autonomy, a big thing and unmet expectations. So sometimes not understanding what the purpose of the emergency department is and what they’re going to get out of it. And, we are increasingly focused on what is our core business as opposed to the extras. Whatever extras might be. And then, real feeling feelings of vulnerability.

I don’t know whether you’ve ever been a patient, recently, but when you are a patient, you got a significant health issue. And then it is a really scary thing to do. And it was, I had one as you know, and then, I didn’t like it very much at all. It was pretty unpleasant and I knew what was going on.

And so if you don’t, that’s even worse. And then in terms of, suggestions for improvement, it was all relatively basic stuff though. But if you walk around your own department, as somebody who’s never been there before, look at things like signage. Is it really effective? Our signs are all over the place.

It’s terrible. What sort of information do we give people and how do we communicate it? So in our department, there’s been a really good project recently where people move from one area to the other. They can get a QR code or they can get a little piece of paper. if that doesn’t work to say, why are you going to the next place and give a little explanation as they move through the various different areas.

You’re very familiar to us, but not to other people. More information on wait times. Okay, I could appreciate that. And there’s some really basic stuff like,what can we do to alleviate boredom, which is a real problem. for a lot of patients, even if they bring their own electronic devices and of course, many of our patients, don’t particularly elderly, they get so, so bored.

And the last one I thought was quite funny was power sockets. So can we have more power sockets? And I think, do you know what I’ve been in conversations with people who, I swear to God this is true, it hasn’t happened for a while. Who’ve been irritated with patients plugging their phone in to a socket and actually have gone up to them and said, you’re stealing electricity from the Trust.

it’s just, it hasn’t happened for a long time, but if you think about the absurdity of keeping people in other parts for hours and hours and not allowing them to charge their phone. come on, we can do better than this. And I think Liz’s point is we can do better than this,

with relatively inexpensive things. but thinking about all this from the patient’s perspective, as well as us having to move the people through and keep the conveyor belt going. Tricky, but doable.

Qualitative studies can be really powerful for this, can’t they? You don’t need huge numbers, but you need some in depth interviews, and you need time to then go and analyze what’s been said to draw out those different core themes. And sometimes it doesn’t tell you stuff that is ground groundbreaking and that you didn’t know, but.

It’s nice to get that knowledge and be told it by other people. Actually, what we should be doing is taking non ill people into the emergency department and asking them how they feel when they’re there. I often wanted an induction for our new doctors to get them strapped onto a spinal board as we used to do a few years ago and leave them for a couple of hours and see how that felt and maybe get them to sit in the waiting room for two hours.

It was tempting to tell them that induction was starting at nine o’clock and then not starting till 11. I’m just making them all sit and wait in the waiting room. Obviously, we would never do these things because it would be a cruel and unusual punishment and perhaps not the way in which we should be starting things off with all of the kerfuffle that happens in emergency departments, perhaps sometimes we forget just how awful it is to be stuck there as a patient and then add in. Of course, these people have problems that they’re worried about. they think that whatever they’ve got is serious and they are either going to die, or they’re always going to have this pain, or they’re going to have a disability.

And so add fear on top of it all, these are not nice places to be. And the little things you mentioned, signage, access to power sockets. Sometimes the nicest thing I can do for a patient is get them a blanket and lend them a mobile phone charger. And that’s much better than being able to do an echo and diagnose their slight right ventricular dysfunction.

 They want to feel warm and be able to contact their relatives. And these are really useful reminder, I think.

Yeah, I’ve got an architect friend who was doing some work building in another hospital, he came to our hospital to get some ideas. We’ve now been rebuilt and so things are getting better. But he walks in again, this is the worst designed prison reception I’ve ever seen in my life. And his just impression was the feel, the atmosphere, all of those things.

This is many years ago. We’ve done a lot of improvements, but it was just oppressive for somebody who understands space, who understands architecture. So many of our departments previously, and I know it’s getting better. have just not done that for patients. And yeah, we can do better. We can do better.

And if you want to read the paper itself, it’s in the Emergency Medicine Journal. Alex Cranston is the primary author and some other familiar main names on the author list there. Damien Rowland, of course, who is a great friend of St. Emlyn’s. but have a look at that. It’s also a good example of how to do a qualitative study, which are more and more useful and also can be relatively straightforward to do.

You need the time afterwards to do the analysis. So getting the data is all well and good, but you’ve got to have some thinking time afterwards. Onto some other medicine, Simon. Now, I’m not sure that we should necessarily call it a dirty adrenaline drip.

Why don’t you describe what you mean? This is a post from you about a dirty adrenaline or epinephrine drip. Yeah. So this is a really nice paper that came from central Australia. It is an observational, essentially studies a retrospective and observational study of their practice. So essentially what they did is they’ve got people in remote places and they’re going out to retrieve them. And onsite may be, a nurse who’s looking after the patients probably doesn’t see a huge amount of critically unwell patients, but essentially before the retrieval physician and retrieval team arrive, they’re going to look after that patient remotely. And many of these patients with things like sepsis or cardiac failure, particularly sepsis, which was the majority of patients in this study, are hypotensive.

And of course, managing that hypotension is important. If you’re in hospital, we’d give you an inotrope, either some noradrenaline or some adrenaline, get your blood pressure up, perfuse your kidneys, make you better, all of those good positive things. so how have they done that remotely? they’ve set up

essentially it’s an infusion of, adrenaline put into a bag of fluid and then run over a period of time at the discretion of the retrieval team. And what they’ve shown by doing that remotely, peripherally, is that they’ve managed to increase the systolic blood pressures with these patients, running it between 1 and 10 micrograms per kilogram per hour.

And noticeably, the way that they did it, they have a nice table about how you do this, so that you set it up to this level, this is the weight of the patient, this is what you get, so the bottom line is, this works. And it’s really good. Scott Weingart’s done a little, comment about this on EmCrit as well.

He says it’s not really a dirty adrenaline, it’s a slightly murky adrenaline, or some words for the effect of. Because it’s not just chucking it in a bag and opening the valve and just seeing what happens. There is a degree of control over this, and you are measuring the rates that you’re going in.

But actually, it works really well. In my pre hospital practice, and even in the emergency department where things have been a bit fraught, it has been known for, us to put an adrenaline into a bag of fluid and

 running it through, an infusion pump, works very well, actually, and can get you out of a difficult situation quite quickly whilst you’re then setting up the, the appropriate, and more routine, versions of whatever ionotrope you’re going to be doing. So I thought this was good.

Really interesting. I don’t think you should be doing this in your emergency department. You should probably be able to set up your own infusion pumps quite quickly, ideally with pre filled syringes, which is what we have. But if not, if you’re in an austere environment, I thought this is a useful and interesting tip and yeah, good one to go.

So this is from Emergency Medicine Australasia, a great journal actually, and they do include the word dirty adrenaline in their title, and let’s be specific, this is about being struck in the middle of Central Australia, hours away from tertiary or even secondary critical care support, but people still getting ill in the middle of nowhere.

There’s quite a few of this discussion in Sweden recently at the Tactical Trauma Conference that we’ve just been at. and the idea of practicing some of these environments is fascinating to me. but not necessarily something I would be very good at, I dare I say. yeah, 57 cases, as you say, and these were mainly for septic shock.

And it was a way of trying to, I think, keep people alive. Until the retrieval service was able to take them on to another service. So as you say, this probably isn’t something for your emergency department Resus Room in the UK. And as we have always said, just because you hear something on a podcast, doesn’t make it a good idea.

We’re about giving you some ideas, giving you things to think about. And also experiencing how other people might be practicing medicine. But yeah,please don’t start injecting mini jets into bags of saline and saying, Oh, no, Simon told me it was a good idea. Cause, just to caveat, that’s not what we’re saying.

Have a read of the paper. If nothing else, it gives you an insight into the world outside your four walls about just how some people are having to practice medicine in different environments.

And it’s another reminder that you can give vasopressors peripherally whilst you’re waiting to get a central line in, that’s what they did in this study, and that is definitely something which we would say you can do if you need to.

Absolutely. Greg Yates has been doing some great stuff on toxicology on the blog. we’re getting about a post a month from him and they’re fabulous. some of them are case reviews. Some of them are paper reviews. This one is about emergency endoscopy for caustic ingestions. I’m not sure about your hospital, Simon, but anytime we try and get an emergency endoscopy for anything, it really seems to be quite a high bar to get somebody to go and have an emergency endoscopy.

And I think often the endoscopists are correct. I doubt very much they want to be trapped in the smallest room in the hospital in the dark, in the middle of the night with a patient who’s so unwell, they need an endoscopy. And sometimes we do end up doing these in the Resus Room. Yeah, and it actually depends where you are in the world, so caustic ingestions are quite common in some areas of the world and not in others, because there’s quite a geographical variation in how people do, either accidental because it’s an opportunity or deliberate self harm. So yeah, there are those parts of the world where it’s common, not so common here.

I have seen a few, unfortunately, several of the ones I’ve seen have been in young children who’ve had access to really nasty substances and a couple of very poor outcomes, actually. But anyway, This is different. Medical toxicology, the toxicology literature there are very few randomized controlled trials.

There’s a lot of this sort of observational data all from databases, and that’s what we’ve got here. 409 patients over a six year period in 14 hospitals who’ve either ingested a strong acid or a strong alkali, and what they were looking for is what predicts whether or not you’re going to

find something bad on endoscopy. And what they did is they followed all these patients through and found that if the patient did not have dysphagia, dysphonia, vomiting, or any visible lesions in the mouth, the possibility of them having lesions further down, i. e. the ones that you need to see on endoscopy or do anything about,weren’t there.

And interestingly, pain, they said, wasn’t a factor in this. because pain is, they say, it’s subjective and lots of people say they’ve got pain. Interestingly in the UK, National Poison Information Service, or Toxbase, would say you need an endoscopy, if you’ve got drooling, dysphagia, vomiting, haematemesis, stridor, any visible lesions, but they say severe pain as well, would be an indication.

There’s a slight difference between what we’ve got in the UK and what this paper says. But the overall incidence of significant lesions in the oesophagus was 6.6%. So it’s not even that common even if people have ingested a strong acid or alkali and there’s no difference between the two. So they found equal rates between the acid ingestions and the alkali ingestions as well.

So interesting. What would I do? I think I’d probably stick with the NPIS advice at this moment in time. They’re close enough that I’m not going to go against our UK guidelines as it currently stands, but the key message, I think, as you say, is that the vast majority of these patients do not need endoscopy and also they certainly probably almost certainly don’t need it in the middle of the night.

So we do have the option of getting an opinion and seeing what happens later on. And if in doubt, speak to your gastroenterologist and have a chat.

Always. And picking up the phone is, it’s definitely allowed. I think sometimes we’re too slow. We think we have to reach a threshold to pick up the phone. Last month’s podcast, we’re talking about a threshold to do thoracotomy. And sometimes the threshold to do a thoracotomy seems not dissimilar to the threshold to pick up a phone, to speak to a consultant in a, in another complimentary specialty.

And sometimes people will be grumpy when you pick up the phone. I saw something from Rob Orman on Instagram this month about, when you’re making calls, and to remind yourself that. We’re all trying to do the same thing. We’re trying to look after people. I get grumpy in the middle of the night when somebody wakes me up, whether that’s the dogs barking or whether that’s a phone from the hospital.

It doesn’t mean you’re doing the wrong thing. And don’t forget that if people are grumpy with you on the phone, it probably represents where they are in the world and what’s going on in their life than what you’re trying to tell them. So please don’t feel personally responsible and never hesitate to pick up the phone if you think that’s something you need to do.

The next post is about the subarachnoid hemorrhage in ED or emergency department study, the S.H.E.D. Study with Dan Horner. And Dan wrote us a comprehensive blog post, that accompanies the podcast that I did with Dan and Tom, who were authors as part of this paper, which hopefully you’ve gone off and listened to, because I do think this can actually be practice changing in some ways.

And if it’s not practice changing about subarachnoid hemorrhage, it certainly gives you means to think about how you use diagnostic testing, how you think about probabilities of disease and how you think about post test probabilities of disease and how they can change over time. So this is a paper, that again was published in the Emergency Medicine Journal, done by TERN, the Trainees Emergency Research Network, fabulous group of doctors who are getting together early in their careers to do these really important studies that have a real effect as what we’re doing day to day in EDs across the UK and beyond.

And this was one of the first trials or one of the first papers to come out of their work. What this was looking at was the accuracy of CT scanning in patients beyond the six hours, which we’ve generally accepted for the diagnosis of subarachnoid hemorrhage. And the bottom line is, two bottom lines, firstly, have a listen to the podcast, because you’ll learn lots about how the study was done, as well as some in depth discussion about the results. But actually, CT is a good investigation modality in this group of patients when you take into account their pretest probability, prevalence of disease, and other factors about the patient group we’re seeing in UK emergency departments, CT is generally where it’s at.

And it may change how you look at patients after six hours who have a normal CT brain. These are all patients with GCS of 15 and no other neurological compromise, but it may mean that you have fewer patients who need to have. depending on your risk thresholds and how you view it, ongoing investigations, particularly lumbar punctures, particularly those patients who are admitting under acute medics.

Have you thought about doing this in your department? Is this something you might change? Are you going to stick at six hours or go beyond?

I think what this does is, and it says so in the blog post and on the podcast, is it’s now about having a sensible conversation with the patients. So we can now have a much better conversation because we’ve got better data about what these things mean.

So I can now go and have a conversation and do some shared decision making with these people. I think the interesting thing for me was that the performance up to 24 hours is actually pretty good. it was better than I thought it was going to be. So you’re only missing aneurysmal,subarachnoid hemorrhage, you’re only missing, what, 1 in 200 if you go up to 24 hour limit.

And I think that’s the conversation I would have with the, with the patient.

I think actually, aneurysmal might be one in a thousand.

Another thing that I drew from the podcast was this difference between venous oozy blood and arterial aneurysmal blood. It’s really the latter that we’re interested in.

The sort of mysterious venous subarachnoid hemorrhage. they all get better and people don’t do anything. They just observe them and what we’re trying to find are the aneurysmal ones. And so yeah, and I, gosh,, I love shared decision making. I blooming love it. I think it’s one of the panaceas to some of the stuff that we’ve got going on to go to a patient and say, this is what I think is going on, these are the probabilities of you having a problem. These are the options that we’ve got together to decide. And normally patients make good decisions. about what they want to have happen next. And actually, I think they make generally quite safe decisions. So wherever, whatever you take from this, particularly shared decision making and discussions with patients using data like this is really useful.

Goodness. I think it’s almost, that’s the game changer.

I’d agree. yeah, great study, and also fantastic stuff going out to the TERN Network who have done amazing work. What was that? Numbers? three thousand six hundred and sixty three patients. And we’re including this study and they’ve been recruiting for about a month or something. It’s crazy.

I know they’ve got more topics on the horizon and the positive feedback from our podcast about it means that I’m very optimistic about getting Dan and Tom back to talk about more of this stuff in the future. and so if you haven’t listened already, please do now.

Simon, the next and final paper of September is one I’m wondering that we may not actually agree on. This is about arterial blood pressure monitoring in the pre hospital environment and the use of arterial lines. You wrote the blog post, it’s only fair for you to have first dibs on it. So tell us a bit about this. This is about putting art lines in, in the pre-hospital environment.

Is this a good thing?

 So it’s an observational study again. this is from Thames Valley Air Ambulance between 2020 and 2023. And what they did is they looked at those patients in whom they put an inter arterial line in, majority radial, and compared that to what blood pressures are we getting out of their, normal machines using oscillometric techniques.

And what I found, which is not massively surprising, I don’t think, is that the, oscillometric techniques were often inaccurate. In fact, they defined acceptable limits of agreement, which was within 20 mms of mercury for systolic or diastolic blood pressures, which is quite a big range in my opinion, or within 10 for a mean arterial pressure, which tends to be what I’m using a bit more of these days anyway. And they found that in terms of agreement, 64% of the time it was agreed about the systolic blood pressure, i.e. within 20. 54% of the time for the mean arterial pressure and 75% for the diastolic. And it was worse if your patient was sicker, again, not surprising, and yeah, it’s just not very good.

I’m afraid. So with oscillometric techniques, the blood pressure that you’re seeing on the screen may well be wrong in many occasions. And the sicker the patient is, the worse that is. Now for me, when I’m dealing with a patient who I think has got a condition which is, blood pressure dependent, for example, a head injury or a spinal cord injury, I actually want to know what the blood pressure is.

And if I do want to know what the blood pressure is, I think this paper tells me, put a line in. And I put lines in all the time now, and it takes hardly any time at all.

And there’s many things that you say that I agree with. I am going to present a contra discussion point really, which is just because we can do something doesn’t mean we should do something. And the main thing about this paper was there is not patient oriented outcomes. So this is all about numbers and completely agree with you about the discrepancy in the numbers.

And they do make quite startling reading, but we don’t actually know if this makes a difference. And I do worry. that some of these tasks, yes, they can be easy, but in some of these patients, you’re in a field, you’re in the back of an ambulance, everything’s dirty, everything’s grimy, everything’s dark, and you can get task focused.

If you’re not very disciplined, I’ve got to get an arterial line in. And before you know it, 15 minutes has passed. You’ve tried using a landmark technique. Then you pull out an ultrasound probe. then you’ve rogered the right radial. And then you thought, I better have a go at the left. And before you know it, you’ve done both of the radial arteries, and then you’re, you’ve not even left scene. So while I take on board everything you’ve said, I think it is also a pragmatic decision about distance from hospital, need for intervention and what it’s going to do to change your management beyond what you see in front of you. Cause a lot of the clues we can get from the patient themselves will tell us what that blood pressure is and what that perfusion is and whether or not they’re getting oxygen to their brain.

So, take on board all of the problems with the measuring and the monitoring. I would want to think very carefully before I was doing this on every patient. I think it has to be pretty descrete about who you’re deciding to do it on. And these are tend to be primary patients who were scooping up and taking to a hospital. We’re not discussing here the long transport times of secondary transfers to tertiary referral units from one hospital to the other.

No selected, but if I take the patient who’s got a significant brain injury or a significant head injury suspecting a significant brain injury or spinal cord injury, as an example, those are the patients who I think there is a lot of evidence, that says that managing the blood pressure well in that group of patients is important.

And not from this study, but from other studies, we know that blood pressure is an important factor in terms of control, in terms of patient related outcomes. So for the select group of patients, not doing it for everybody, but for select group of patients and then your other aspects about, time on scene and stuff like that.

There’s a paper from, I think it’s from London air ambulance, it could have been from KSS, which shows that by putting an arterial line, the average increase in scene time is two minutes. And the way that we do it is we set stopwatch. So we say, I’m going to put an art line in. If the art line is not in, connected, and ready to go within five minutes, we abandon it and just go back to oscillometric.

So you have to have, that’s part of your SOPs and it’s part of your strict discipline around human factors. So I’m not actually going to disagree with you. I think you’re right. If you do it as badly as you just suggested, I think it would be a terrible idea. But if you’re disciplined about it, if you have a system and you choose your patients correctly, I think this could, and in my experience, I think it really does make a difference.

I had a patient not so long ago with a significant spinal cord injury and we were managing their blood pressure to maintain the MAP above 90, which is obviously very important. And I had the oscillometric on and also the invasive. If I’d been going off the oscillometric, I’d have been doing some very wrong things because the numbers on the machine were not the same as getting through. The invasive might’ve been wrong, but I don’t think it was.

 I think we’re probably both agreeing here that it’s like all of our interventions, isn’t it? It’s also, it’s about doing the basics well first. it can’t be, A stands for airway, not arterial line. I’m being a little bit facetious, but

we mustn’t get distracted from doing the basics really well. And this is the cherry on top of the cake of the basic care we’re providing for patients. This isn’t the thing that we need to hang our hats on if we’re going to a patient out of hospital. and it’s the same in hospital, isn’t it? You can get task focused on, before I go to CT, I want to have an arterial line in.

Let’s just think about the different outcomes from those two things and how we can, it’s more nuanced. Medicine, it turns out at times can be relatively difficult to make decisions. but this is good evidence from SJTREM and there’s a further discussion of this on the Resus Room podcast. Again, friends of St. Emlyn’s highly recommend if you’re a podcast enjoyer, the Resus Room have loads of great stuff. And their monthly paper review is always an excellent listen. So head over to Simon and Rob, talk this through. they also talk about the SHED study. In the most recent podcast. So lots of other stuff beyond St. Emlyn’s to listen to. And as a group of people who believe in this sort of education, we’re always happy to point you in their direction, Simon, I think it’s worth, particularly at this time of year to remind ourselves about some of the positives and you reminded us all of a post from Cliff Reid, which was some years ago, but I think it’s about where we focus on our jobs and how we get things out of it. And this is about whether emergency medicine is a great job. 11 years ago, Cliff Reid told us it was. is it still a good job?

 Actually, if I listen back to Cliff’s video, many of the things that he talks about, they’re actually still relevant today. He still talks about crowding and overwork and the difficulties and people being mean to you and shoving the ECG under your nose and saying, do this while you’re trying to concentrate.

All of those things existed 11 years ago, but maybe worse now than it was then. But what he does do is talk about positives and really focuses on those. And talks about some of the great cases and some of the big interventions we do. And I’ve got to say, myself in the last three or four weeks, I’ve had a few cases which have been really tremendous, opportunities for us to do good.

And there’s been some really positive outcomes out of just being there and doing the job. And I think. It’s a really good reminder to say that you need to think about the balance, and there’s lots of sort of cognitive techniques about, focusing on positives and writing three positive things that happened at the end of the day, which I don’t, I tried for a while, it worked. But, there’s an awful lot of what we do, which has got a huge amount of value to other people, but it’s also got a huge amount of value to us if we just remember to stop every so often and remember that actually a lot of what we do is pretty good.

And as winter approaches, it’s important to remember that you can only control the things you can control. You’re not in charge of government guidance. You’re not in charge of Government policy, but you are in charge of who you are every day when you turn up. And there’s a lot of reminders in Sweden about this, and there’ll be more coming from Liz Crowe on the podcast to talk about how we can look after ourselves.

We’ve tried to move away a bit at St. Emlyn’s away from the idea of wellbeing and more about personal development, I think, and this idea of getting the most you can out of a day in the emergency department, all around you seems to be going. Crazy. There is still stuff we can get out of it. And of course, one of the other things we try and encourage is mastery.

And the more you try and develop mastery, the better your work can feel. And Simon, I know you’ve just, I wanted to mention briefly at the end, you’ve been involved with the SPEAR course, I think, and I wondered if you’d just mind sharing that with listeners.

Not involved in it as such as just a delegate on the course.So SPEAR about using arterial monitoring and potentially some techniques to improve the outcome from cardiac arrest.

Really interesting, not full ECMO, but a halfway house. And it’s just an example of, you know what, you’ve been doing the job for a long period of time, and then somebody comes along, in this case, Paul Rees,Haldon Hutchson Bailey, who’s done work with us from East Anglia Air Ambulance, and they go, look, you’ve been doing this for 30 years, but hey, do you know what, we might be able to do this somewhat better.

Here’s some new stuff to learn. It’s really interesting. We don’t know whether it works yet, but we’re going to go and find out, medicine’s always going to be like that. It’s always going to be innovative. It’s always going to be interesting. And if you’ve got a curious mind, which I still say is the most important thing for any doctor to have or any paramedic or any nurse or any clinician, have a curious mind, you’ll have a good life.

if you have a curious mind, when these things come along, when they rock the foundations of what you’ve been doing, it’s just wonderful. It’s really good. And I’m really excited and looking forward to doing stuff.

And as you’ll have heard from our podcast from Tactical Trauma, there’s lots of people who are doing that around the world who we can learn from, lots of people locally as well. And if you are looking for a conference in the next few weeks or months, I always point you in the direction of the London Trauma Conference, another group of like minded individuals, not too far from home for many of us.

And London at Christmas is always twinkly lights and sleigh bells, isn’t it? Which is a nice place to be. So do seek out whether you’d like to go on the London Trauma Conference. Myself and Natalie May will be there recording some podcasts and other stuff. The thing I’ve also noticed, Simon, is the world of conferences does seem to be coming back.

After a COVID lull and everyone liking being online, actual interpersonal, talking to people, being around people, even for a crazy introvert like me can be really fulfilling. So if you can, I know that it’s not affordable for everybody, but you will have a small study leave budget and use it wisely and seek out places where you’ll be inspired and generally give you a little bit of that jujsh that you need to get you through the darker times when you’re in your emergency departments.

Absolutely. Have a great time and we’ll see you again soon.

Thanks for listening, everyone. And we’ll be with you again next month.