Welcome to the St.Emlyn's podcast. After a few years messing around with the blog at stemlynsblog.org the Choirmaster at St.Emlyn's has decided that some audio contributions are necessary. We will therefore be relaunching the podcast in a uniquely British way. Please, put the kettle on, make yourself a nice cup of tea (I recommend Lady Grey or Gunpowder), sit back, relax and listen*. Congo will take place every couple of weeks so keep checking iTunes for this weeks order of service. We have the honour to be, always, your most faithful servants. Yours etc. The Choirmaster at St.Emlyn's *If you are listening to this podcast whilst driving do not put the kettle on....

Welcome to the St.Emlyn's podcast. After a few years messing around with the blog at <a href="http://stemlynsblog.org" rel="nofollow" target="_blank">stemlynsblog.org</a> the Choirmaster at St.Emlyn's has decided that some audio contributions are necessary. We will therefore be relaunching the podcast in a uniquely British way.  Please, put the kettle on, make yourself a nice cup of tea (I recommend Lady Grey or Gunpowder), sit back, relax and listen*.   Congo will take place every couple of weeks so keep checking iTunes for this weeks order of service.   We have the honour to be, always, your most faithful servants.   Yours etc.   The Choirmaster at St.Emlyn's   *If you are listening to this podcast whilst driving do not put the kettle on....

Ep 1 - St.Emlyn's the podcast.

The St.Emlyn's choirmaster has asked Iain and Simon to deliver a sermon on the importance of attending the SMACC Chicago conference in May 2015. After their pilgrimages to Australia in 2013 and 2014 they came back enthused and at times rather annoying about how jolly marvellous it all was.  We felt that it was important for them to share their thoughts and to ask if anyone wishes to join them on their planned trip to the Northern Americas next year. AS Choirmaster at St.Emlyn's I have reluctantly decided to give them some air time. I have the honour to be, as always, your most dutiful servants. Yours etc. The St.Emlyn's Choirmaster

The St.Emlyn's choirmaster has asked Iain and Simon to deliver a sermon on the importance of attending the SMACC Chicago conference in May 2015. After their pilgrimages to Australia in 2013 and 2014 they came back enthused and at times rather annoying about how jolly marvellous it all was.  We felt that it was important for them to share their thoughts and to ask if anyone wishes to join them on their planned trip to the Northern Americas next year. AS Choirmaster at St.Emlyn's I have reluctantly decided to give them some air time. I have the honour to be, as always, your most dutiful servants. Yours etc. The St.Emlyn's Choirmaster

Ep 2 - SMACC Chicago

A podcast discussing sensitivity and specificity of diagnostic tests and how we can use this in our everyday medical care of patients.  This article from the Centre for Evidence Based Medicine is also useful. 

A podcast discussing sensitivity and specificity of diagnostic tests and how we can use this in our everyday medical care of patients.  This <a href="https://www.cebm.net/2014/03/sppin-and-snnout/" rel="nofollow" target="_blank">article</a> from the Centre for Evidence Based Medicine is also useful.

Ep 3 - Understanding diagnostics 1. SNout SpIn and Probability. St.Emlyn's

Dear all, It would appear that the organ member was correct and we cannot be certain about the organ pipes. Apparently there are doubts about whether they are safe or need replacing.  We will once again turn to Dr Beardsell and Prof. Carley to see if there is anything more that we can do. As I am due to allocate funds for repairs to musical instruments this year then we must ensure that these are spent wisely.  If there is a less than 2% chance of failure we will wait. If there is a greater than 50% chance of failure then we should spend the money.  The situation is uncertain and we need help. I have the honour to be et. etc. etc. The Choirmaster at St.Emlyn's

Dear all, It would appear that the organ member was correct and we cannot be certain about the organ pipes. Apparently there are doubts about whether they are safe or need replacing.  We will once again turn to Dr Beardsell and Prof. Carley to see if there is anything more that we can do. As I am due to allocate funds for repairs to musical instruments this year then we must ensure that these are spent wisely.  If there is a less than 2% chance of failure we will wait. If there is a greater than 50% chance of failure then we should spend the money.  The situation is uncertain and we need help. I have the honour to be et. etc. etc. The Choirmaster at St.Emlyn's

Ep 4 - Diagnostics 2. Beyond simple yes vs no diagnostics. St.Emlyn's

Iain and Simon tackle the effect of prevalence on diagnostic performance. Mrs Trellis of North Wales makes a return appearance to discuss the delicate issues of sensitivity and Rick Body joins us by mail to raise concerns about the difficulties of missing patients with myocardial disease.  Listen and enjoy, visit the blog site and keep in touch.  Don't forget to subscribe to the podcast via iTunes, to subscribe to the blog site and to like us on facebook.  vb  S

Iain and Simon tackle the effect of prevalence on diagnostic performance. Mrs Trellis of North Wales makes a return appearance to discuss the delicate issues of sensitivity and Rick Body joins us by mail to raise concerns about the difficulties of missing patients with myocardial disease. Listen and enjoy, <a href="http://stemlynsblog.org" rel="nofollow" target="_blank">visit the blog site</a> and keep in touch. Don't forget to <a href="https://itunes.apple.com/gb/podcast/st.emlyns-ebm-in-emergency/id547326956?mt=2" rel="nofollow" target="_blank">subscribe to the podcast via iTunes</a>, to subscribe to the <a href="http://stemlynsblog.org" rel="nofollow" target="_blank">blog site</a> and to <a href="https://www.facebook.com/stemlyns" rel="nofollow" target="_blank">like us on facebook.</a> vb S

Ep 5 - Understanding diagnostics 3. Why prevalence helps us stay in practice

Hopefully you will have already seen and listened to my SMACC talk on 'What to believe and when to change'. If not then please whizz over to the site now and have a listen. I really enjoyed exploring the uncertainties that exist around when we decide to adopt or abandon therapies.  My belief is that it's really difficult to define the perfect moment and that it's only in retrospect that we can define it.  Since appearing on the ICN network and St.Emlyn's, Scott Weingart, one of the best and most innovative clinicians I know has come back and argued for early adoption. You can check out his rationale on his site and see what you think.  I actually agree with many of the things he tells us, although he has confined himself to one side of the argument. In terms of a defence of early adoption he makes a good case, but like all debates there needs to be another side to the story, so sit back and listen to why we must reflect hard on the decisions we make in deciding what we do, why we do it, and most importantly when.  vb  S

Hopefully you will have already seen and listened to my SMACC talk on '<a href="http://stemlynsblog.org/believe-change-st-emlyns-smacc/" rel="nofollow" target="_blank">What to believe and when to change</a>'. If not then please <a href="http://stemlynsblog.org/believe-change-st-emlyns-smacc/" rel="nofollow" target="_blank">whizz over</a> to the site now and have a listen. I really enjoyed exploring the uncertainties that exist around when we decide to adopt or abandon therapies. My belief is that it's really difficult to define the perfect moment and that it's only in retrospect that we can define it. Since appearing on the ICN network and St.Emlyn's, Scott Weingart, one of the best and most innovative clinicians I know has come back and argued for early adoption. <a href="http://emcrit.org/wee/on-the-beliefs-adopters-straw-men/" rel="nofollow" target="_blank">You can check out his rationale on his site and see what you think.</a> I actually agree with many of the things he tells us, although he has confined himself to one side of the argument. In terms of a defence of early adoption he makes a good case, but like all debates there needs to be another side to the story, so sit back and listen to why we must reflect hard on the decisions we make in deciding what we do, why we do it, and most importantly when. vb S

Ep 6 - SMACC Back-Back on What to believe and when to change.

Iain and Simon chat about how we can start to translate research findings in to natural frequency summaries that help clinicians and patients alike understand the value of therapeutic interventions.  The NNT site we mention is just fantastic. Visit them here  Great revision page here by the amazing LITFL crew   The NNT for tranexamic acid is 67 not 50.  S

Iain and Simon chat about how we can start to translate research findings in to natural frequency summaries that help clinicians and patients alike understand the value of therapeutic interventions. The NNT site we mention is just fantastic. Visit them <a href="http://www.thennt.com/" rel="nofollow" target="_blank">here </a> Great revision page <a href="http://lifeinthefastlane.com/education/ccc/risk-and-numbers-needed-to-treat" rel="nofollow" target="_blank">here </a>by the amazing LITFL crew  The NNT for tranexamic acid is 67 not 50. S

Ep 7 - Delving into the Number Needed To Treat, RRR and ARR. Why we love natural frequencies

Iain and Simon discuss the challenges of getting our trauma patients to the CT scanner within 30 minutes of arrival.  The 30 minute target is a UK standard, and we did not set it! All UK trauma centres are judged against the target and (rightly or wrongly) it has become a real issue for many centres.   We would be really be interested in what our International colleagues think about the target and the resultant strategies outlined by the team. There's more on this at the St.Emlyn's website.  As always, we'd love to hear your comments.  vb  S

Iain and Simon discuss the challenges of getting our trauma patients to the CT scanner within 30 minutes of arrival. The 30 minute target is a UK standard, and we did not set it! All UK trauma centres are judged against the target and (rightly or wrongly) it has become a real issue for many centres. We would be really be interested in what our International colleagues think about the target and the resultant strategies outlined by the team. There's more on this at the St.Emlyn's website. As always, we'd love to hear your comments. vb S

Ep 8 - Trauma Team Leadership

It is a little known fact that to be successful as an emergency physician in the UK it is vital to take a three month rotation in Archery. Archery is a key skill for us all dating back to Medieval times when we introduced the longbow into warfare. This devastating tool could cause panic in opposing forces, scattering them into many wide and ineffective directions. In short they were an effective tool to cause and disruption inthe opposition ranks whilst the noble English armies of old strode forward with their visions of the future. Soldiers trained using targets to hone their skills and to focus on the aim - meeting the target. Of course these days we do not have real bows and arrows in the emergency department, but archery remains alive and well. In the modern NHS we still train our troops in archery, or at least in the principle aim of archery - to meet the target. With our long history of target setting and target hitting it is therefore no suprise that we are world leaders in standards/targets/indicators....., whichever term you prefer in fact and it has to be said that a target culture in the NHS has been criticised widely, even being blamed for the exodus of trainees to Southern climes, but there is arguably more to it than that. In last weeks episode we touched on new targets around trauma care in the UK and that raised many questions and opened a debate on twitter. This week we want to take those thoughts further and ask what we, as the archiest of arch archers across the entire NHS can do with these externally set targets. What we forgot to say in the podcast is the absolute need to work alongside a short stay admissions unit under the ED umbrella. Without that you would really struggle to deliver safe and efficient care. We both work in units with short stay admission units that allow us to deliver safe diagnostic and therapeutic interventions to our patients. So, with some trepidation Iain and I ask whether all targets are a bad thing.... vb S

It is a little known fact that to be successful as an emergency physician in the UK it is vital to take a three month rotation in Archery. Archery is a key skill for us all dating back to Medieval times when we introduced the longbow into warfare. This devastating tool could cause panic in opposing forces, scattering them into many wide and ineffective directions. In short they were an effective tool to cause and disruption inthe opposition ranks whilst the noble English armies of old strode forward with their visions of the future. Soldiers trained using targets to hone their skills and to focus on the aim - meeting the target. Of course these days we do not have real bows and arrows in the emergency department, but archery remains alive and well. In the modern NHS we still train our troops in archery, or at least in the principle aim of archery - to meet the target. With our long history of target setting and target hitting it is therefore no suprise that we are world leaders in standards/targets/indicators....., whichever term you prefer in fact and it has to be said that a target culture in the NHS has been criticised widely, even being blamed for the exodus of trainees to Southern climes, but there is arguably more to it than that. In last weeks episode we touched on new targets around trauma care in the UK and that raised many questions and opened a debate on twitter. This week we want to take those thoughts further and ask what we, as the archiest of arch archers across the entire NHS can do with these externally set targets. What we forgot to say in the podcast is the absolute need to work alongside a short stay admissions unit under the ED umbrella. Without that you would really struggle to deliver safe and efficient care. We both work in units with short stay admission units that allow us to deliver safe diagnostic and therapeutic interventions to our patients. So, with some trepidation Iain and I ask whether all targets are a bad thing.... vb S

Ep 9 - What can we do about targets in the ED?

If you're starting out in EM then it can be a scary time. Iain and Simon talk through some of the initial anxieties and ask what you need to know to be safe, sensible and super.Remember our top ten tips...Respect those around you and value their opinion The History is everything There are 4 key treatments we give in the ED – think whether every patient you see needs any of these and you will save lives and relieve painOxygen Fluids Analgesia Antibiotics  Think ‘What difference have I made to this patient?’. Always try to make a difference, however small (it may “just” be getting them an extra blanket) No patient (almost) wants to be in the ED. They really don’t. It wasn’t what they planned for their day. Spend twice as long with patients you don’t like or don’t get on with. Look the part. Be smart. Behave in the way you would expect anyone to behave towards you. Be on time. Always. Ansd leave on time if at all possible. Take your breaks – eat when you can and drink water when you can’t. Enjoy yourself…

If you're starting out in EM then it can be a scary time. Iain and Simon talk through some of the initial anxieties and ask what you need to know to be safe, sensible and super.Remember our top ten tips... <ol><li>Respect those around you and value their opinion</li> <li>The History is everything</li> <li>There are 4 key treatments we give in the ED – think whether every patient you see needs any of these and you will save lives and relieve pain <ol><li>Oxygen</li> <li>Fluids</li> <li>Analgesia</li> <li>Antibiotics</li> </ol></li> <li>Think ‘What difference have I made to this patient?’. Always try to make a difference, however small (it may “just” be getting them an extra blanket)</li> <li>No patient (almost) wants to be in the ED. They really don’t. It wasn’t what they planned for their day.</li> <li>Spend twice as long with patients you don’t like or don’t get on with.</li> <li>Look the part. Be smart. Behave in the way you would expect anyone to behave towards you.</li> <li>Be on time. Always. Ansd leave on time if at all possible.</li> <li>Take your breaks – eat when you can and drink water when you can’t.</li> <li>Enjoy yourself…</li></ol>

Ep 10 - Intro to EM: Staying safe in your first job

A UK based Emergency Medicine podcast for anyone who works in emergency care. The St Emlym's team are all passionate educators and clinicians who strive to bring you the best evidence based education.

The St.Emlyn's Podcast

Tim Harris

Do you think you're awesome at assessing shock?  Think again!  The stupendous Prof Tim Harris (who St.Emlyn's loves) tells us that all is not quite as it seems.....  Listen, learn, be awesome.  vb  S

Do you think you're awesome at assessing shock? Think again! The stupendous Prof Tim Harris (who St.Emlyn's loves) tells us that all is not quite as it seems..... Listen, learn, be awesome. vb S

Ep 39 - Prof. Tim Harris on Shock Assessment (LTC 2014)

Back in late 2018 we gathered in Manchester for the inaugural #stemlynsLIVE conference. Our friend Dr George Wills gave a great talk on Aortic Emergencies. All emergency physicians know that it's all to easy to miss an aortic catastrophe. Listen to George's wisdom on common pitfalls and top tips to make you a better emergency clinician. vb S   Also check out these excellent #FOAMed resources. Subscribe to the blog (look top right for the link) Subscribe to our PODCAST on iTunes Follow us on twitter @stemlyns PLEASE Like us on Facebook Find out more about the St.Emlyn’s team 

Back in late 2018 we gathered in Manchester for the inaugural #stemlynsLIVE conference. Our friend Dr George Wills gave a great talk on Aortic Emergencies. All emergency physicians know that it's all to easy to miss an aortic catastrophe. Listen to George's wisdom on common pitfalls and top tips to make you a better emergency clinician. vb S Also check out these excellent #FOAMed resources. <ul><li>Subscribe to the blog (look top right for the link)</li> <li>Subscribe to our <a href="http://stemlynspodcast.org/" rel="nofollow" target="_blank">PODCAST</a> on<a href="https://itunes.apple.com/gb/podcast/st.emlyns-virtual-hospital/id547326956?mt=2" rel="nofollow" target="_blank"> iTunes</a></li> <li>Follow us on twitter <a href="https://twitter.com/stemlyns" rel="nofollow" target="_blank">@stemlyns</a></li> <li><a href="https://www.facebook.com/stemlyns" rel="nofollow" target="_blank">PLEASE Like us on Facebook</a></li> <li>Find out <a href="http://www.stemlynsblog.org/about/authors/" rel="nofollow" target="_blank">more about the St.Emlyn’s team</a></li> </ul>

Ep 132 - Aortic Emergencies with George Wills at #stemlynsLIVE

A first podcast with Simon Laing from the RCEMFOAMed team. We look back at influential trauma related papers from 2014-2015. This talk was presented at the Trauma Care Conference in Telford 2015. It's a great conference and I'd encourage you to attend. If you want to know more visit www.stemlynsblog.org for more discussion and links to all the papers discussed. vb S

A first podcast with Simon Laing from the RCEMFOAMed team. We look back at influential trauma related papers from 2014-2015. This talk was presented at the <a href="http://www.traumacare.org.uk/home" rel="nofollow" target="_blank">Trauma Care Conference in Telford 2015</a>. It's a great conference and I'd encourage you to attend. If you want to know more visit <a href="http://www.stemlynsblog.org" rel="nofollow" target="_blank">www.stemlynsblog.org f</a>or more discussion and links to all the papers discussed. vb S

Ep 45 - Top 10 trauma papers 2014-2015.

The number of patients seen in each ED with problems relating to  early pregnancy in the UK is very variable - some hospitals have rapid  referral pathways for patients who know they are pregnant. It's still  worth thinking about early pregnancy problems though as all EDs see  young women and many of these may not yet know that they are pregnant. Our induction podcast covers our approach to women presenting to the ED   Nat and Iain :-) 

The number of patients seen in each ED with problems relating to early pregnancy in the UK is very variable - some hospitals have rapid referral pathways for patients who know they are pregnant. It's still worth thinking about early pregnancy problems though as all EDs see young women and many of these may not yet know that they are pregnant. Our induction podcast covers our approach to women presenting to the ED Nat and Iain :-)

Ep 34 - Intro to EM: Problems in Early Pregnancy

Liz Crowe

In this episode, the fabulous Liz Crowe (@LizCrowe2) discusses how to approach debriefing after critical (and non critical) incidents in healthcare. We focus on the debriefing that takes place 5-7 days after an incident. For more on a "hot" debrief listen to this podcast by Ashley Liebig and Rob Orman 

In this episode, the fabulous Liz Crowe (@LizCrowe2) discusses how to approach debriefing after critical (and non critical) incidents in healthcare. We focus on the debriefing that takes place 5-7 days after an incident. For more on a "hot" debrief listen to this <a href="" rel="nofollow" target="_blank">podcast</a> by Ashley Liebig and Rob Orman

Ep 106 - Debriefing in Critical Care with Liz Crowe

Recently we published part one of our series on cardiac troponins.  If you haven't checked it out yet, you can find it here.     In the second part, we're going to take a look at high sensitivity  troponins and some of the more advanced areas around understanding  cardiac troponin and its use in practice.  We'll give you a quick run  down on the troponin lingo - the language you need to be able  to speak in order to fully understand how to use high sensitivity  troponin in your practice, including terms like the limit of blank, limit of detection, co-efficient of variation and 99th percentile. We'll also ask whether Joe Lex had a point when he stirred up controversy around these assays with this legendary tweet: What if we called it "low specificity troponin" instead of "high sensitivity troponin?" Would that knock some sense into people? — Joe Lex (@JoeLex5) October 9, 2012  So, check out the associated BLOG POST here and listen to the podcast. There is more on diagnostics and troponin to come very soon.   Hope you enjoy! Please keep the feedback, questions and comments coming. As always, we'd love to hear from you. Rick DOI:  Much of my research work involves HsT. To help with this I have  received reagents from companies who make HsT assays, but I not received  any other financial benefit or gifts in kind as part of my work and  have no financial ties to any companies.

Recently we published part one of our series on <a href="http://stemlynsblog.org/cardiac-troponin-basics-st-emlyns/" rel="nofollow" target="_blank">cardiac troponins</a>.  If you haven't checked it out yet, <a href="http://stemlynsblog.org/cardiac-troponin-basics-st-emlyns/" rel="nofollow" target="_blank">you can find it here</a>.    In the second part, we're going to take a look at high sensitivity troponins and some of the more advanced areas around understanding cardiac troponin and its use in practice.  We'll give you a quick run down on the troponin lingo - the language you need to be able to speak in order to fully understand how to use high sensitivity troponin in your practice, including terms like the limit of blank, limit of detection, co-efficient of variation and 99th percentile. We'll also ask whether Joe Lex had a point when he stirred up controversy around these assays with this legendary tweet: What if we called it "low specificity troponin" instead of "high sensitivity troponin?" Would that knock some sense into people? — Joe Lex (@JoeLex5) <a href="https://twitter.com/JoeLex5/statuses/255635042674565120" rel="nofollow" target="_blank">October 9, 2012</a> So, check out <a href="http://stemlynsblog.org/high-sensitivity-troponin-st-emlyns/" rel="nofollow" target="_blank">the associated BLOG POST </a>here and listen to the podcast. There is more on diagnostics and troponin to come very soon. Hope you enjoy! Please keep the feedback, questions and comments coming. As always, we'd love to hear from you. Rick DOI: Much of my research work involves HsT. To help with this I have received reagents from companies who make HsT assays, but I not received any other financial benefit or gifts in kind as part of my work and have no financial ties to any companies.

Ep 15 - Understanding Troponin Part 2

Iain Beardsell and Natalie May talk you through a wise and safe approach to the child with moderate shortness of breath. Listen and learn from the St.Emlyn's team.

Ep 26 - Intro to EM: The ED approach to the child with shortness of breath

Rick Body and Kerstin de Wit discuss the role of NOACs in clinical management. Part 1 addresses the basics, stuff you should know if you are prescribing these drugs.   Part 1 tells us the good stuff, don't forget to listen to 2 and 3 in the next few weeks as not everything is perfect ;-)  Check out the BLOG POST HERE  vb  R

Rick Body and Kerstin de Wit discuss the role of NOACs in clinical management. Part 1 addresses the basics, stuff you should know if you are prescribing these drugs. Part 1 tells us the good stuff, don't forget to listen to 2 and 3 in the next few weeks as not everything is perfect ;-) Check out the<a href="http://stemlynsblog.org/get-noac-knowhow-novel-oral-anticoagulants-part-1/" rel="nofollow" target="_blank"> BLOG POST HERE </a> vb R

Ep 35 - New (or are they really new) Oral Anticoagulants and the Emergency Physician PART 1

Breathless patients are a challenge in the ED. Shortness of  breath can be a frightening presenting complaint for both patients and  doctors. As always, think about the possible life threatening causes and  actively rule them out. For breathless patients think especially about: Pneumonia Asthma/COPD Pulmonary Embolism Acute left ventricular failure Pneumothorax    Breathless Patients PodcastIn  this podcast Iain and Simon discuss their approach to  breathless patients in the ED which we hope will provide you with a good  starting point.  For  those of you who are more visual learners here is the video recorded a  few years ago for SEMEP featuring our very own Iain Beardsell. http://vimeo.com/35310564   Take Home PointsOxygen should be used in the patient with shortness of breath and the patient monitored closely. Hypoxia kills Always rule out life threatening causes first These patients are sick - do not be afraid to ask advice from a senior colleague early Look for clues - you don't have to wait until the penultimate page of the story to solve the mystery.   What have you learned about breathless patients? Oxygen - or no oxygen??   Oxygen administration is rarely a problem in the immediate and acute  setting - and can save lives. So yes, when you first approach a patient  who is short of breath, get that oxygen on while you make your  assessment then think about the finer points of respiratory failure  afterwards.  Where do I begin?  A focused history, including asking the patient about previous conditions and whether they know what's going on!   And then - initial assessment and examination including vital signs  (especially respiratory rate), looking for clues as to the underlying  cause of their breathlessness, remembering the five common causes.  What treatments might be useful?   A small fluid bolus might help and carries relatively little risk;  think about the need for nebulised bronchodilators for patients with  asthma or COPD, and remember that antibiotics given early to patients  with sepsis save lives.  If the patient has pain we should definitely treat that too. Which investigations might help me find out more? A  chest x-ray is often useful in patients who are short of breath; your  ED seniors might be able to use bedside ultrasound to further ascertain  the underlying pathology, so get help early! ECGs are often useful in these patients Blood  gases can also provide lots of useful information - think carefully  about whether you need arterial gases and if so, please use local  anaesthetic. If nothing makes sense - get a blood sugar,  remembering that metabolic disease may cause an acidosis, presenting  with an increased respiratory rate (although not often true dyspnoea). And  GET SENIOR HELP (including getting your seniors to assess you for those  all-important workplace-based assessments; definitely start those  early)   Other resourcesChest RadiographsOne  of the key investigations in patients with shortness of breath is the  humble chest radiograph. There are some phenomenal FOAM resources for  interpretation of CXRs (along with other XRs) at Radiology Masterclass. Well worth bookmarking for your ED shifts (but do ask a senior if you're unsure). Chest X-Ray Anatomy  -  Chest X-Ray Abnormalities  -  Chest X-Ray Systematic Approach  Blood GasesThink! Do you really need an ABG? If the answer is yes, please use local anaesthetic! Your patients will thank you... Further Reading on Shortness of BreathThe Flipped EM Classroom - Shortness of Breath (with further links).   Natalie May 

Breathless patients are a challenge in the ED. Shortness of breath can be a frightening presenting complaint for both patients and doctors. As always, think about the possible life threatening causes and actively rule them out. For breathless patients think especially about: <ul><li>Pneumonia</li> <li>Asthma/COPD</li> <li>Pulmonary Embolism</li> <li>Acute left ventricular failure</li> <li>Pneumothorax</li> </ul>   Breathless Patients PodcastIn this podcast Iain and Simon discuss their approach to breathless patients in the ED which we hope will provide you with a good starting point.  For those of you who are more visual learners here is the video recorded a few years ago for SEMEP featuring our very own Iain Beardsell. <a href="http://vimeo.com/35310564" rel="nofollow" target="_blank">http://vimeo.com/35310564</a>   Take Home Points<ul><li>Oxygen should be used in the patient with shortness of breath and the patient monitored closely. Hypoxia kills</li> <li>Always rule out life threatening causes first</li> <li>These patients are sick - do not be afraid to ask advice from a senior colleague early</li> <li>Look for clues - you don't have to wait until the penultimate page of the story to solve the mystery.</li> </ul> What have you learned about breathless patients? Oxygen - or no oxygen?? Oxygen administration is rarely a problem in the immediate and acute setting - and can save lives. So yes, when you first approach a patient who is short of breath, get that oxygen on while you make your assessment then think about the finer points of respiratory failure afterwards.  Where do I begin? A focused history, including asking the patient about previous conditions and whether they know what's going on! And then - initial assessment and examination including vital signs (especially respiratory rate), looking for clues as to the underlying cause of their breathlessness, remembering the five common causes.  What treatments might be useful? A small fluid bolus might help and carries relatively little risk; think about the need for nebulised bronchodilators for patients with asthma or COPD, and remember that antibiotics given early to patients with sepsis save lives. If the patient has pain we should definitely treat that too. Which investigations might help me find out more? <ul><li>A chest x-ray is often useful in patients who are short of breath; your ED seniors might be able to use bedside ultrasound to further ascertain the underlying pathology, so get help early!</li> <li>ECGs are often useful in these patients</li> <li>Blood gases can also provide lots of useful information - think carefully about whether you need arterial gases and if so, please use local anaesthetic.</li> <li>If nothing makes sense - get a blood sugar, remembering that metabolic disease may cause an acidosis, presenting with an increased respiratory rate (although not often true dyspnoea).</li> <li>And GET SENIOR HELP (including getting your seniors to assess you for those all-important workplace-based assessments; definitely start those early)</li> </ul> Other resourcesChest RadiographsOne of the key investigations in patients with shortness of breath is the humble chest radiograph. There are some phenomenal FOAM resources for interpretation of CXRs (along with other XRs) at <a href="http://radiologymasterclass.co.uk/tutorials/tutorials.html" rel="nofollow" target="_blank">Radiology Masterclass</a>. Well worth bookmarking for your ED shifts (but do ask a senior if you're unsure). <a href="http://radiologymasterclass.co.uk/tutorials/chest/chest_home_anatomy/chest_anatomy_start.html" rel="nofollow" target="_blank">Chest X-Ray Anatomy</a>  -  <a href="http://radiologymasterclass.co.uk/tutorials/chest/chest_pathology/chest_pathology_start.html" rel="nofollow" target="_blank">Chest X-Ray Abnormalities</a>  -  <a href="http://radiologymasterclass.co.uk/tutorials/chest/chest_system/chest_system_start.html" rel="nofollow" target="_blank">Chest X-Ray Systematic Approach</a> Blood GasesThink! Do you really need an ABG? If the answer is yes, please <a href="http://stemlynsblog.org/self-experimentation-medical-education-la-abgs/" rel="nofollow" target="_blank">use local anaesthetic</a>! Your patients will thank you... Further Reading on Shortness of BreathThe Flipped EM Classroom - <a href="http://flippedemclassroom.wordpress.com/2013/11/18/approach-to-shortness-of-breath/" rel="nofollow" target="_blank">Shortness of Breath</a> (with further links). Natalie May

Ep 13 - Intro to EM: The patient with shortness of breath

Do you remember when it took three days to 'rule in' or 'rule out' an acute myocardial infarction (AMI)?  When I was a medical student doing my first clinical attachments, I remember doing ward rounds on the CCU seeing patients with suspected AMI.  The way they were managed is a million miles from what we do now.  Back then, patients would have serial ECGs and then be admitted for cardiac enzyme evaluation over the course of the next 3 days.  We'd measure CK, AST and LDH.  'CK' was the so-called 'early marker', which would rise early after the start of an AMI.  Today we use CK as a marker of skeletal muscle damage (e.g. rhabdomyolysis).  AST and LDH (today we think of these as liver function tests, I know) were the 'late markers' - and by late I really mean late - we might see a rise on days 2 and 3. Could you imagine for a second, in today's world, ruling out AMI because their CK and LFTs were normal?  It's completely unthinkable.  That's how much cardiac troponin has changed our practice.  We rely on it so completely to diagnose AMI.  And yet, it's one of the most misunderstood tests in medicine.  Given how much we use it, I guess we feel that we all should know lots about this test.  But doctors still have so many questions.  Here are just a few: What is cardiac troponin? Why is it a marker of AMI? What else causes a raised troponin and how? Should we be doing troponins at 3 hours, 6 hours, 12 hours?  What's the difference and what's the evidence? What is a 'delta troponin'? What do you need to 'rule in' AMI? How do you use cardiac troponin in patients with renal failure?  This is just a brief list.  With the research I do in this area and my experience developing protocols/guidelines, people get in touch to ask questions like this quite a lot.  There are loads of questions that people ask - but there are lots of themes in common.  We thought it was about time we produced a handy run down in the true spirit of #FOAMed. Take a listen to Part 1 of our troponin podcast.  While Simon and Iain have been prolifically churning out spectacular stuff for some time now, this is my debut on the St. Emlyn's podcast.  I really enjoyed talking about troponin with Iain - and I hope we covered some useful stuff. We'll cover more in part 2, when we'll move on to discussing high sensitivity troponins, what they are, how to use them and how to speak the troponin lingo.  Please get in touch if there's anything we haven't covered that you'd like us to, or if there's anything you'd like us to elaborate on some more! Rick

Do you remember when it took three days to 'rule in' or 'rule out' an acute myocardial infarction (AMI)?  When I was a medical student doing my first clinical attachments, I remember doing ward rounds on the CCU seeing patients with suspected AMI.  The way they were managed is a million miles from what we do now.  Back then, patients would have serial ECGs and then be admitted for cardiac enzyme evaluation over the course of the next 3 days.  We'd measure CK, AST and LDH.  'CK' was the so-called 'early marker', which would rise early after the start of an AMI.  Today we use CK as a marker of skeletal muscle damage (e.g. rhabdomyolysis).  AST and LDH (today we think of these as liver function tests, I know) were the 'late markers' - and by late I really mean late - we might see a rise on days 2 and 3. Could you imagine for a second, in today's world, ruling out AMI because their CK and LFTs were normal?  It's completely unthinkable.  That's how much cardiac troponin has changed our practice.  We rely on it so completely to diagnose AMI.  And yet, it's one of the most misunderstood tests in medicine.  Given how much we use it, I guess we feel that we all should know lots about this test.  But doctors still have so many questions.  Here are just a few: <ul><li>What is cardiac troponin?</li> <li>Why is it a marker of AMI?</li> <li>What else causes a raised troponin and how?</li> <li>Should we be doing troponins at 3 hours, 6 hours, 12 hours?  What's the difference and what's the evidence?</li> <li>What is a 'delta troponin'?</li> <li>What do you need to 'rule in' AMI?</li> <li>How do you use cardiac troponin in patients with renal failure?</li> </ul> This is just a brief list.  With the research I do in this area and my experience developing protocols/guidelines, people get in touch to ask questions like this quite a lot.  There are loads of questions that people ask - but there are lots of themes in common.  We thought it was about time we produced a handy run down in the true spirit of #FOAMed. Take a listen to Part 1 of our troponin podcast.  While Simon and Iain have been prolifically churning out spectacular stuff for some time now, this is my debut on the St. Emlyn's podcast.  I really enjoyed talking about troponin with Iain - and I hope we covered some useful stuff. We'll cover more in part 2, when we'll move on to discussing high sensitivity troponins, what they are, how to use them and how to speak the troponin lingo.  Please get in touch if there's anything we haven't covered that you'd like us to, or if there's anything you'd like us to elaborate on some more! Rick

Ep - 11 Understanding Troponin Part 1

Simon and Iain debate how the management of opiate OD has changed in the ED.  Surely you're not still giving massive doses of naloxone IV and IM are you? Really? Maybe this will make you think again.  vb  S

Simon and Iain debate how the management of opiate OD has changed in the ED. Surely you're not still giving massive doses of naloxone IV and IM are you? Really? Maybe this will make you think again. vb S

Ep 40 - Opiate overdose in the ED

It's prehospital and helicopter day at #LTC2014! Iain and guest podcaster Caroline Leech chat through the key points of the day. Download the GoodSAM app! https://www.goodsamapp.org BW Nat

It's prehospital and helicopter day at #LTC2014! Iain and guest podcaster Caroline Leech chat through the key points of the day. Download the GoodSAM app! <a href="https://www.goodsamapp.org" rel="nofollow" target="_blank">https://www.goodsamapp.org</a> BW Nat

Ep 31 - London Trauma Conference: Day three round up.

Old, young, pregnant, social, airways, cricoid and dogmalysis. There is loads to catch up on from #LTC2014.   Iain and Nat take you through the day.  vb  S

Old, young, pregnant, social, airways, cricoid and dogmalysis. There is loads to catch up on from #LTC2014. Iain and Nat take you through the day. vb S

Ep 30 - London Trauma Conference: Day two round up.

Iain and Simon talk through the practicalities of in situ sim in the ED. How do we make it happen in a way that works and helps individuals, teams and departments learn together. Much of the work in this podcast should be attributed to John Gatward from Sydney Australia who inspired us to start and to Kirten Walthall our new Sim Fellow who introduced records and departmental learning processes to our systems.  There are a couple of errors on the podcast. Firstly it's roughly 18 months that we have been doing in situ sim, time must fly so much that I said 9 months! Secondly, on reflection we average 2-4 sim sessions per week, but that includes some sessions that are not in situ, held in a separate area when training other groups of docs in the hospital. The ED in situ frequency is 2-3 sessions per week. As ever we stand on the shoulders of these giants who support what we all hope to achieve. vb S

Iain and Simon talk through the practicalities of in situ sim in the ED. How do we make it happen in a way that works and helps individuals, teams and departments learn together. Much of the work in this podcast should be attributed to John Gatward from Sydney Australia who inspired us to start and to Kirten Walthall our new Sim Fellow who introduced records and departmental learning processes to our systems.  There are a couple of errors on the podcast. Firstly it's roughly 18 months that we have been doing in situ sim, time must fly so much that I said 9 months! Secondly, on reflection we average 2-4 sim sessions per week, but that includes some sessions that are not in situ, held in a separate area when training other groups of docs in the hospital. The ED in situ frequency is 2-3 sessions per week. As ever we stand on the shoulders of these giants who support what we all hope to achieve. vb S

Ep19 - In Situ and Guerrilla Sim in the ED

The Challenge and Value of Research in Emergency Medicine: at DGINA 2014  Rick Body's talk from DGINA on the need for research in EM.  Check out the associated blog post at http://stemlynsblog.org

The Challenge and Value of Research in Emergency Medicine: at DGINA 2014 Rick Body's talk from DGINA on the need for research in EM. Check out the associated blog post at <a href="http://stemlynsblog.org" rel="nofollow" target="_blank">http://stemlynsblog.org</a>

Ep 24 - Getting started in Emergency Medicine Research

Whilst I remain in Virchester healing the sick and injured, Nat and Iain are sharing the #FOAMed love at the London Trauma Conference. This is the first round up from day 1 with many highlights and a few tasters for some more podcasts to come.  vb  S

Whilst I remain in Virchester healing the sick and injured, Nat and Iain are sharing the #FOAMed love at the London Trauma Conference. This is the first round up from day 1 with many highlights and a few tasters for some more podcasts to come. vb S

Ep 29 - London Trauma Conference: Day one round up.

Next week Iain and Nat will be in London for the best trauma conference in the world. Join them in person, online, on the podcast and on twitter.  Check out the program here, it's amazing.  http://www.londontraumaconference.com/  Have fun :-)  S

Next week Iain and Nat will be in London for the best trauma conference in the world. Join them in person, online, on the podcast and on twitter. Check out the program here, it's amazing. <a href="http://www.londontraumaconference.com/" rel="nofollow" target="_blank">http://www.londontraumaconference.com/</a> Have fun :-) S

Ep 28 - Iain and Nat preview the amazing London Trauma Conference.

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