Last week I had the chance to attend the inaugural St. Emlyn's Live day in Manchester (#StEmlynsLive). The day proved (as expected) to be a fantastic collection of talks and ideas on Emergency medicine, critical care, medical education, and the surrounding factors involved in being part of this profession. With a wealth of learning points to take away, I wanted to put a few of them together in a blog post. Many of the topics will be covered (or are already covered), both better articulated and in more detail at their own blog and other sites, but there were a few parts that were my favourite. When looking back ad considering the bits that I took away, I would probably break them down into a few key themes:
- Striving for excellence
- Innovative thinking
- Clinical pearls
Excellence
The topic of striving towards excellence was a common theme throughout the day, with many of the speakers covering different aspects of it - unsurprising with it being the first of St. Emlyn’s philosophical pillars. Natalie May (@_NMay) opened the day, bringing back pearls of wisdom from her work in Sydney HEMS, something that Clare Richards (@drclarebear) revisited later in the day. They both covered features of the setup at Sydney HEMS that allows excellence to really flourish. One of the standout parts for me was the normalisation of debrief that was so fully integrated into the way that they conducted their service. Cases, even more ‘mundane’ ones, were routinely discussed to identify learning points. All of this as part of striving towards delivering a better service for patient.
Within this nebulous term of ‘excellence’ though, there was repeated reference to the components that were the more tangible components in day-to-day practice. The aforementioned morbidity and mortality (M&M) meetings, the contrasting discussion of ‘excellent practice’, the leg-work of audit and governance structures, and of course the training, were all highlighted as the very achievable components of a system that is working towards excellence. For me, this reiterated the fact that much of this talk of ‘striving toward excellence’ is far more than just aspirational thinking. I think that these are all components of our normal clinical practice that we may partake in less fully, or see as lower down the hierarchy of importance when we are at the clinical coalface, but which may be the building blocks of a better system. Now I can see that the criticism may be that it is all very nice talking about these ideas over coffee at a nice conference, or even delivering them in a system with a predictable degree of down-time, but how can I fit in a weekly M&M session when system is as stretched as it is currently? Well I think that the next clinical theme gave me hope.
Within this nebulous term of ‘excellence’ though, there was repeated reference to the components that were the more tangible components in day-to-day practice. The aforementioned morbidity and mortality (M&M) meetings, the contrasting discussion of ‘excellent practice’, the leg-work of audit and governance structures, and of course the training, were all highlighted as the very achievable components of a system that is working towards excellence. For me, this reiterated the fact that much of this talk of ‘striving toward excellence’ is far more than just aspirational thinking. I think that these are all components of our normal clinical practice that we may partake in less fully, or see as lower down the hierarchy of importance when we are at the clinical coalface, but which may be the building blocks of a better system. Now I can see that the criticism may be that it is all very nice talking about these ideas over coffee at a nice conference, or even delivering them in a system with a predictable degree of down-time, but how can I fit in a weekly M&M session when system is as stretched as it is currently? Well I think that the next clinical theme gave me hope.
Innovative Thinking
Simon Carley (@EMManchester) opened his talk with pretty much a summation of this concern. It’s nice to hear about these ideas, and in many ways it is inspirational, but it is hard to the make the translational step when you go back to the clinical job the next day. As such, his talk, as well as facets of several others, were about the ‘low hanging fruit’ of improvement. The life-hacks and tweaks that can be implemented with little or no funding, planning, or even that much effort. The particular topic that he was covering was around resuscitation practice, and he presented his ‘top 5 tips’ for streamlining and optimising your clinical care, without needing to learn how to deliver REBOA or getting a departmental ECMO machine. He has written an excellent blog on the presentation here and goes into more detail about the zero point survey here. The concept of ‘hot debriefs’ was an idea that particularly caught my eye, as debrief is still a practice that I struggle to complete with any degree of regularity. All simple, easily implementable strategies that any one of us could bring into our workplace the next day.
In a slightly different vein, but just as inspiring, was the fascinating talk from Kat Evans (@Kat_Evans). She delivered an eye-opening account of the challenges faced by her and her team working at her hospital in South Africa. What was perhaps most inspiring was the adaptations that they had innovated to meet these challenges. Faced with a high number of thoracic stabbing wounds and limited resources, she described their triage system for coping with such large numbers: top off at the door, ultrasound/echo, the chest drain room for those with pleural injury, thoracotomy in the ED for those that needed a hole in the heart fixing. And the speed of the turn-around was just as amazing. No languishing in hospital beds, but instead kept mobile and active (including an exercise bike in the ‘chest drain lounge’). Even the enhanced recovery programme physios aren’t quite achieving this level yet. Now I know that these are all (mostly) fit young men, but along with some of the perioperative medicine stuff at the moment (the enhanced recovery programme being an example of how ‘normal’ care has progressed), it does make you wonder which aspects of our own practice are actually superfluous, and even unconsciously harmful. Innovative responses to challenges like this suggest that different models might not necessarily be what they first appear.
In another contrasting direction, Rick Body (@richardbody) gave a fascinating talk on what may be in store for the future of diagnostics. He covered questions that continue to challenge me - how can we use what information we have to make the right decisions? Whilst not completely handing medical care over to AI just yet, he described how we may soon be able to use big data, user friendly apps and point of care (POC) testing to navigate the branching paths of diagnostics. There is even a fancy new term; theranostics, precision medicine where the diagnostic test can guide treatment. Whilst the old challenge of chest pain was the central narrative of his talk, there was even a reference to POC genetic testing in the ED! If ever there was a talk to get you more excited about involvement in research, I think this one would take some beating. Some of the themes from his talk are covered a bit more one his blog post from earlier this year (here).
In a slightly different vein, but just as inspiring, was the fascinating talk from Kat Evans (@Kat_Evans). She delivered an eye-opening account of the challenges faced by her and her team working at her hospital in South Africa. What was perhaps most inspiring was the adaptations that they had innovated to meet these challenges. Faced with a high number of thoracic stabbing wounds and limited resources, she described their triage system for coping with such large numbers: top off at the door, ultrasound/echo, the chest drain room for those with pleural injury, thoracotomy in the ED for those that needed a hole in the heart fixing. And the speed of the turn-around was just as amazing. No languishing in hospital beds, but instead kept mobile and active (including an exercise bike in the ‘chest drain lounge’). Even the enhanced recovery programme physios aren’t quite achieving this level yet. Now I know that these are all (mostly) fit young men, but along with some of the perioperative medicine stuff at the moment (the enhanced recovery programme being an example of how ‘normal’ care has progressed), it does make you wonder which aspects of our own practice are actually superfluous, and even unconsciously harmful. Innovative responses to challenges like this suggest that different models might not necessarily be what they first appear.
In another contrasting direction, Rick Body (@richardbody) gave a fascinating talk on what may be in store for the future of diagnostics. He covered questions that continue to challenge me - how can we use what information we have to make the right decisions? Whilst not completely handing medical care over to AI just yet, he described how we may soon be able to use big data, user friendly apps and point of care (POC) testing to navigate the branching paths of diagnostics. There is even a fancy new term; theranostics, precision medicine where the diagnostic test can guide treatment. Whilst the old challenge of chest pain was the central narrative of his talk, there was even a reference to POC genetic testing in the ED! If ever there was a talk to get you more excited about involvement in research, I think this one would take some beating. Some of the themes from his talk are covered a bit more one his blog post from earlier this year (here).
Clinical Pearls
Whilst we await these technological changes, and think about some higher level strategies to improve our care and the way it is delivered, there were also a few talks on some clinical challenges that we may face. George Willis had some great points on managing aortic nightmares, including tips on the best way to perform pericardiocentesis (!) - the tip is to not take too much blood off at a time. Similarly, Salim Rezaie (@srrezaie) did an excellent talk on going beyond Advanced Life Support (ALS) to improve our resuscitation care. Key point included considering using mechanical CPR devices where available (not worse and can allow cognitive offloading), the quality of human delivered CPR is very important (how often are we actually assessing this during an arrest?), and thinking about how ultrasound scanning can be implemented into identifying reversible causes of arrest, but without negatively impacting on CPR. There is a lot more of what Salim talked about available here: http://rebelem.com/beyond-acls-cognitively-offloading-cardiac-arrest/
Now I feel that I have barely scratched the surface of the topics of the day, but in the interest of attention spans I think I will finish this blog post here. I strongly recommend having a look at some of the other references from the day which I have listed below and will try and add to. I hope this post has served as a bit of a taster for these topics, and at the very least directed you towards some interesting ideas and resources. In the spirit of the day, I will now need to think how I can implement all these ideas.
Thanks for reading.
Tom Heaton
Thanks for reading.
Tom Heaton
Further Reading
St Emlyn’s Blog - The home of it all - https://www.stemlynsblog.org/
SMACC - Social Media and Critical Care - https://www.smacc.net.au/
Bad EM blog - Brave African Discussion in Emergency Medicine - https://badem.co.za/
R.E.B.E.L. EM - http://rebelem.com/
ED Educate - a nice summary of the day - https://www.ededucate.co.uk/blog/st-emlyn-s-live
SMACC - Social Media and Critical Care - https://www.smacc.net.au/
Bad EM blog - Brave African Discussion in Emergency Medicine - https://badem.co.za/
R.E.B.E.L. EM - http://rebelem.com/
ED Educate - a nice summary of the day - https://www.ededucate.co.uk/blog/st-emlyn-s-live
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