We’ve made it back to the International Convention Centre in Birmingham for the final day of what has so far been an amazing RCEM Annual Conference, the streams have all been fantastic, the keynote speakers have been inspirational and the company has been joyous.
If you haven’t caught up on the first couple of days, you can find our learning from day 1 and day 2 on the linked blogs, please do have a read and then come back for day 3. We’ll give you a few minutes.
Ok, back? Let’s go!
HALO sessions: Thoracotomy
Simon was over in the main hall watching the thoracotomy demonstration…
On stage simulations at major conferences are really tricky to pull off, but they did it well here. A live demo with a pretty good mannequin that talked through the process of thoractomy, and then a presentation by Zane Perkins on the London data, and then a panel discussion. There was loads in this session, but a few highlights….
- Use tuff cuts to get through the sternum, but always have a second pair as it may take 2. Gigli saws defo work, but most people are too slow at using them unless well practiced.
- Every second counts in resuscitative thoracotomy. So although it may sound strange, it may be worth doing it in the car park outside the ED if it gains you a few minutes (as opposed to bringing into resus).
- The LAA data shows that you can predict the likelihood of tamnponade vs. exsanguination from the location of the wound. The cardiac box I was taught, is smaller than you think.
- The approach to exsanguination is different to that of a tamponade. RT does not solve an exsanguination problem in itself.
- Speed is a really important factor in survival
- Once tamponade is relieved you will probably have to occlude the aorta in order to get enough coronary perfusion to get a meaningful rosc
- There are lots of things to do i na short period of time. So you really have to prioritise based on most likely pathology.
- Big lines IV or central (I love a subclavian >8F) are what you need for rapid volume administration.
- Inverted T incisions are the way into the pericardium. Go vertical first. Do worry about the phrenic nerves, but if you only cut what you can see you should be OK.
- The cephalad part of the inverted T should extend all the way up the aorta otherwise you will potentially occlude the left ventricular outflow tract during cardiac massage
- The rate of cardiac massage is determined by the time taken for the heart to refill (aortic compression helps with this).
There was lots more, with a lot of it being contained in recent papers from London’s Air Ambulance.
Research studies reporting
Over in the research stream, Chris was learning about some of the findings from recent studies.
First on was Professor Catherine Pope on the ED-WAITS project, a mixed-methods design consisting of secondary data analysis and qualitative case studies/interviews trying to see if those in lower socioeconomic groups wait longer for emergency care. Initial research shows that how patients access emergency care seems to underpin variation in waits and outcomes, and we’ve already seen from other talks at the conference about the difference in care between those at the top and bottom of the socioeconomic scale. There were lots of areas that the system falls down and a call for advocacy to the decision-makers to improve this.
Next up was Professor Matt Reed presenting findings from the DENS study, a randomised controlled trial comparing early removal of a hard collar with 12 weeks of hard collar in older or frail adults with odontoid fractures. Key take home messages were that the trial was underpowered with low numbers but there was no signal towards a disadvantage in quality of life, and likely no equipoise for a further RCT. Matt’s advice was to ensure decisions around collars involve the patient as well as neurosurgical/spinal and radiology specialists as older adults tolerate collars poorly and the study supports early collar removal to priotitise independence and comfort, and possible lower the care burden for these patients.
The COWS study, presented by Dr Owen Hibberd, looked at 517 paediatric trauma patients, predominantly male and blunt trauma, and measured calcium levels and associated outcomes. Sadly, the data presented on the screen was too small for my eyes but the general gist was that low calcium was frequently observed in injured children and associated with physiological derangements, but that there was no change in patient-oriented outcomes such as mortality. On the other hand, high calcium levels were associated with poor functional outcomes and mortality. Aiming for normal calcium and monitoring to avoid hypercalcaemia was the advice here.
In 2017 the James Lind Alliance partnered with RCEM to set 72 priorities for emergency medicine research. Over £8 million was allocated by NIHR and good progress was made with the top 10 priorities, such that in 2022 a new top 10 was created with a shift in research for vulnerable patients and staff wellbeing. All ten priorates have at least two projects completed or ongoing with even more funding allocated than in 2017. Dr Jaden Groves and colleagues used the JLA priorities alongside NICE recommendations for future research and presented their findings of what projects they had uncovered to answer these issues. It was great to hear about the wealth of studies taking place, we already have results from some of these and it’s almost certain we’ll hear the results of more of these at future conferences. Gaps uncovered include head injuries, limb and spinal injuries, ED staffing, ED organisation, and neurodivergence in the ED. Hopefully this review to highlight current projects will lead to some inspiration to plug those gaps.
To round the session off, a mind-blowing presentation around the marvel of the human body (at a young age) to heal fractures with good results. Professor Daniel Perry talked through the FORCE study, which showed there was no difference between cast/splint and soft bandage for patients with distal forearm buckle fractures. Next the SCIENCE study where there was no clinically significant difference in functional outcome for displaced medial epicondyle fractures managed with casting rather than fixation. And finally the CRAFFT study, looking at surgical reduction +/- fixation vs casting without reduction in children aged 4-10 with displaced wrist fractures, again with function as an outcome. 750 children were randomised, and the short version is there was no difference, and good support from patients and their families. Gamechanger, but surely a hugely uncomfortable step to implement, and it will be interesting to see where we are in the next year or two.
AI and digital transformation
We’re seeing more and more artificial intelligence coming into medicine, I’m sure we’ve all seen AI imaging analysis, and ambient voice technology (or scribing) is being trialled in Virchester and likely somewhere near you too. Dr Annabelle Painter highlighted that there are a lot of new AI tools for governance or administration, but fewer around clinical practice. This is because if something is used to prevent, monitor, diagnose, or treat disease, then it is classed as a medical device and there are more hoops that it needs to jump through and there needs to be evidence of safety. The Prime Minister’s AI Exemplars programme, alongside scribing, lists the use of AI for diagnostics, emergency department demand forecasting, and assisted discharge summaries as promising opportunities to improve efficiency.
Professor Alex Novak talked on AI-assisted fracture detection. His studies have shown that AI can help to improve accuracy and sensitivity in fracture detection, particularly for more junior clinicians. Addition of AI also tightens confidence intervals which improves consistency. The SAMURAI-Fracture study is a cluster-randomised crossover trial where the AI reporting will be turned on and off for periods at a time to identify how this affects minor injuries services.
Dr Chris Humphries has been looking into using large language models to improve NHS coding – most of the information from a clinical encounter is free text and this can be difficult and time-consuming for non-medical human coders to sift through to ensure that data accurately represents the issues that the patient came to the emergency department with. If the data aren’t correct, it means we can’t then rely on them for things like audit, commissioning decisions, and qualtiy improvement measures.
Radiologists have probably been the most involved with artificial intelligence out of all of us and their Royal College has developed their approach to making sure that the AI transformation is safe, evidence-based, and led by clinicians. Professor Fiona Gilbert outlined some of the steps the RCR is working through, including education, such as their AI conference, forming standard and guidelines for AI use, the creation of a registry to track use across the NHS and learning that can be gained from it, and contributions to national commissions and policies to shape the future. All very fascinating stuff.
Trauma – 4 talks.
Prof Michael Barrett presented the MAGPIE trial of Penthrox in kids. Bottom line is it works and should be something we can offer to children in our departments. You can read the trial here
Nick Mani brought us up to speed on chest blocks, notably the serratus anterior and erector spinae blocks. We do both in my practice and I think they are awesome. I want people to consider them the fascia iliaca block of the chest in that all patients who are going to be admitted should get a block in the ED before going to the ward. Although the evidence could be better, I think this is something we should move on now. The blocks are easy to do and can be really effective in my experience. So if you’re not doing them, maybe put it on your CPD program for next year. Read more here https://www.stemlynsblog.org/jc-serratus-anterior-plane-blocks-for-rib-fractures-in-the-ed-st-emlyns/
Kate MacKay gave a great talk on why we should consider children as little adults in trauma. Now obviously there are differences, and we need to be mindful of that, the core principles of trauma care are the same. There is a real risk that if we consider children a different species to be scared of, then avoidable harm will happen. So a sensible, pragmatic, principles and safe approach with use of appropriate guidance (e.g. imaging guidelines) makes sense.
Simon then did his top 10 papers talk, but we will leave that to a separate post
Well, what an end to the conference. We’ve certainly had a wonderful time in Birmigham for RCEM Annual Conference 2026. We can’t wait to see you in Manchester for RCEM Annual Conference 2027! Registration is already open alongside calls for talks and abstracts so please put it in your calendars and get involved. We’ll all be there and we hope you will too.
vb
Simon and Chris
I’ll leave the final word to Dr Summers
