Last week was the first ever, and much anticipated, St.Emlyn’s Conference. The programme was ram packed with talks, which left my head spinning a little as there was so much to take in. So, I am delighted to say that Dr Carrie Thomas has helped to compile some notes from the day. Many of the content has already been covered on the St.Emlyn’s blog, or will be in the next few weeks and links have been provided where available. Here is a little summary of what went on, along with both my and Carrie’s key take homes from the day.
“In pursuit of excellence” was a Keynote speech from Natalie May, where she asked us to consider what excellence means to us. Natalie described the pursuit of excellence as a journey – both for individuals, and also for our teams. She recommended that in order to guide us through the journey we need to know where we are to begin with. Reflection, in various guises, whether this be personal reflection, peer feedback or formal case reflection, can help us achieve this. She advised us all to think about what our fears are and to deliberately stretch ourselves, outside our “comfort zone”, in order to improve and to close the learning loop by following up patients.
Salim Rezaie’s talk “Beyond ALS” was probably my [KW] favourite talk of the day. He emphasised that “advanced life support” should not really be “advanced” for Emergency Department Practitioners – it is after all bread and butter stuff for us. What we need to be achieving is excellence and mastery.
Salim focused on five key points:
· CRP– talking through the evidence of the non-inferiority of mechanical CPR and its importance in small teams.
· Adrenaline– challenging the thinking around IV boluses – is there a place for continuous IV adrenaline (a “dirty epi bag”) in lower dose instead?
· Pulse checks(and why we shouldn’t do them)
· Ultrasound(POCUS) – how to limit time off the chest and yet get the info we want.
· Airway– should we be using supraglottic airways more?
Honestly, we feel we really can’t do this talk justice, so you’re just going to have to hop over to RebelEM and watch it!
Ashley Liebig’s talk about Performance Psychology started with the questions “where have you experienced fear?” and “what does stress look like?” Without doubt, we’ve all felt fear and seen the behaviour in ourselves, and those around us, when people are stressed. However, in the midst of that chaos there can be quiet and calm. Ashley gave a great description of being in “the zone” or “flow” – which resonated with me [CT] from my time in competitive sport. That time where you just know you’ve got this; a state where time stands still and everything happens as it should with ease. She talked about how this state can help our practice by increased happiness, reducing stress and making us better at what we do. Ashley encouraged us to consider everyone’s frame – different things will lead to fear in different people – and that techniques such as cognitive re-appraising or “re-framing” a situation can replace the distracting emotional and neuroendocrine responses that influence how people perceive threat. She encouraged us to identify potential threats in our practise using visualisation or mental rehearsal, then reframe them and rehears how to manage them – helping to find that state of flow.
“The Future of Diagnostics” was up next with Rick Body. To begin he took us back to the Greek origins of the word, explaining “dia” meaning apart; and “gnosis” to know – or more specifically a deep sense of knowing, rather than observational or logical knowledge.
So, how can we manage with uncertainty within medicine? Rick talked about the T-MACS score which, uses specific Troponin results as a continuous variable, rather than a binary positive or negative result. This personalised result can therefore be used to make shared decisions with patients and personalise decision making.
Back to more linguistics Rick then briefly touched on Theranostics – or precision medicine – discussing the future of diagnostic tests to select a treatment for a patient. For example, genetic testing is already being used to assess risk of developing deafness to antibiotics such as gentamicin. He challenged us to think about whether primary prevention and health advice could or should be in the remit of Emergency Medicine and how the use of technology in the future could help facilitate this.
Is there a way to make all of us better in resus? Without expense and fancy kit? No, there isn’t one way, there are at least five, and Simon Carley covered his top five in this next talk. Here they are in a nut shell:
· Zero Point Survey– this is really looking at the pre-resuscitation phase. More info here:
· 10 in 10– take 10 seconds every 10 mins to reassess, re-evaluate and update as a team;
· Peer review– observation and feedback on the shop floor to help you get better
· Have one person “fly the patient” (lead the arrest) whilst someone else takes on the heavier thinking tasks. The person who is leading the arrest doesn’t have to be a senior, and certainly doesn’t have to be a doctor, they just need to be competent at team leading and know their algorithm.
· Hot debriefs– these don’t have to take long, just 5mins, but do them often.
For a more thorough look at these, hop over to the St.Emlyn’s Blog:
George Willis spoke on aortic emergencies. I think this is one of those areas that scares quite a lot of us. Dissections seem to delight in being as difficult to diagnose as possible, and even once we have detected them I feel that “speak to vascular” is frequently the only management plan we put in place. George told us how to actually manage these patients (especially the sick ones) in our EDs.
· Good IV access– doesn’t have to be central, get two peripherals in if you can
· Arterial line– in the arm with the highest BP.
· Lower HR to 60bpm– with esmolol, or labetalol, or diltiazem if B-blocker CI.
· SBP 100-110– aim for as low as you can go, with nicardipine.
· Pain control
Worth noting is that if the BP drops suddenly it probably isn’tthe drugs! Think tamponade or cardiogenic shock instead.
Chris Gray spoke brilliantly about the management of patients with GI bleed. Despite us seeing them relatively frequently (1 in 350 admissions) in the ED, and them being associated with high mortality rates, management of GI bleeding doesn’t get that much attention – perhaps because it’s seen as less glamourous than other resus cases. As well as covering the clinical aspects of GI bleed management Chris spoke about the importance of teamworking, anticipation and planning. He recommended this link for learning about Sengstaken-Blackmore tube insertion:
The second speaker from Sydney HEMS, Clare Richmond, talked about patient transfers. She impressed on the audience the importance of preparing well regardless of the length of the transfer – even if it is just around the corner to the CT scanner. Sometimes when we’re “just” taking the patient to the ward, or on a short journey in the hospital it can be all too easy to forget that the reason these patients are in our care is because they are sick! Clare’s take-home points were to: admit what you don’t know – to your team on, or preferably before, a transfer, and also to yourself so you know what you need to learn, and to plan for all the possible things that might go wrong – in advance, so you’re always prepared.
The wellbeing session started with Liz Crowe being linked in by video. Liz reminded us that in order to solve the problem of burnout we need to look at the systemic factors not just the individual ones. Whilst we know that the NHS isn’t going to be fixed overnight, by making small changes we can still improve things. She advised us that when we feel burnt out and as though we “don’t want to do it anymore” then we need to change something – now this can be as dramatic as a complete change of career or as simple as reframing why we carry on: I come to work because I…. love going on holiday and this job enables me to do that, for example. Liz’s top tips for wellness were to laugh, remember than no one loves a martyr, and to exercise regularly (no excuses allowed).
Next Laura Howard spoke about setting up the ED Spa in the Emergency Department in Central Manchester, this is an amazing idea and achievement for her and her colleague, Kirstin Ballantyne. Laura has written a blog on it, and rather than reading my summary I’d really recommend reading this instead
The wellness session ended with a panel discussion about what the panellist do for self-care. In addition to the usual exercise comments the panel recommended finding and spending time in their “happy place”, joining societies (like a singing club) and the important support that our work families bring us.
Dan Horner explored the concept of a “UK Resuscitationist” and whether one person can, or indeed, should encompass all of this. He argued that a resuscitationist needs to:
· Extend the incision– broaden their approach, look at all the options and balance risk
· Keep their skills honed – relying on education and deliberate practice, supported by an expert, who may even be from a different speciality.
· Be academically sharp– keep up to date with resus science by reviewing and appraising the literature, and returning to basic principles where evidence is lacking
· Manage change and quality improvement– to ensure the level of resuscitation is constant even when you can’t be there all the time
· Know when not to do something
Stating that in summary a “resuscitationist” is not an individual role, but a system role, and that we, as individuals have a duty to ensure our systems are up to it.
Kat Evans of BadEM talked to us about “Resuscitation lessons from Cape Town”. Having never worked in South Africa, this was really eye opening. In UK Emergency Medicine we tend to think that we are horrendously under resourced, especially with the never ending “winter” pressures. The description of how Kat and her colleagues not only cope, but provide consistent, high complexity and frequently life-saving care with such little resources was beyond impressive. It made me really thankful for so many of the things we take for granted in the NHS and made me realise how much we can do for our patients by simply doing our best.
The final talk of the day, “Beyond ATLS” was delivered by Alan Grayson. The general consensus was that despite all it’s bad press ATLS is actually pretty good at doing what it advertises itself to do – give a universal approach to managing a trauma patient. However, even when we have a standardised approach, things, that we believe are basic, still seem to go awry. Rather than making things more complex, what we should be doing is making sure that we take ownership of doing the basics well. Tightening up on our communication skills, teamwork and supporting each other after the event.
Oh, there was so much content!
Our top tips from the day were:
1) We all need to keep striving forwards in order to improve and give the patients the best possible care we can.
2) Good team-working skills are key to everything we do in Emergency Medicine.
3) Don’t worry that you can’t change the big stuff, change the things you have and get those marginal gains in.
All in all, it was a great conference that covered an amazing amount! We’re already looking forward to what the St.Emlyn’s group might be up to next year….
Keep checking (or better still, subscribe to) the St.Emlyn’s blog so that you don’t miss out on the talks when the accompanying blogs and videos are released!