Ep 285 - Resuscitative Hysterotomy with Caroline Leech at BASICs 2025

Making decisions with incomplete information is part of everyday emergency and trauma care. But when the stakes are particularly high, how do you know when you have enough information to act? Waiting too long may cost lives. Acting too soon may put patients, colleagues or yourself at unnecessary risk. For our 300th St Emlyn’s podcast, Iain Beardsell revisits conversations he and Liz Crowe recorded at Tactical Trauma in Sweden. Drawing on interviews with Claire Park, Sean Brayford-Harris, Alice Hutin and Chris Bishop, he explores how clinicians and first responders make difficult decisions under pressure, from major incidents and mass casualty triage to prehospital eCPR and ECMO in trauma. In this podcast: How Claire Park uses the 40–70 rule to explore when we have enough information to act, while recognising the risks of entering potentially dangerous scenes. Lessons from the London Bridge terrorist attack about delayed treatment, casualty evacuation and the difficult balance between responder safety and patient survival. Why the Ten Second Triage tool was designed without physiological measurements, allowing non-clinical responders to prioritise casualties and deliver immediate lifesaving interventions. How simple, familiar frameworks can reduce cognitive load when responders are frightened, overwhelmed or working outside their usual clinical role. Why the availability of prehospital extracorporeal CPR (eCPR) does not mean every patient should receive it, and the challenges of explaining decisions not to proceed. The value of discussing decisions aloud, seeking colleagues' views and debriefing after difficult cases. Why veno-arterial ECMO remains controversial after major trauma, particularly because of anticoagulation and bleeding risks, and how multidisciplinary decision-making can help identify potential candidates.

Chest pain that sounds like indigestion, feels mild or seems “atypical” can still be myocardial infarction. The difficult question is not whether troponin is useful, but which patients actually need testing — and how much weight we should give symptoms, cardiovascular risk factors and clinical judgement. Professor Rick Body looks at the evidence behind those decisions, drawing on his own research and other studies of patients with suspected acute coronary syndromes. He explores which clinical features genuinely change the probability of myocardial infarction, which are less useful than we might think, and how to balance the risks of missing MI against unnecessary investigation. In this podcast: Why “heavy” or “crushing” chest pain only modestly increased the probability of myocardial infarction in Rick’s study population. Why indigestion-like pain should not automatically reassure us, and why apparently “atypical” symptoms cannot safely exclude acute coronary syndrome. The diagnostic significance of associated features such as vomiting and, particularly, sweating observed by the clinician. Why dividing chest pain into “typical” and “atypical” presentations has limited discriminatory value. Why having no recognised hypertension, hyperlipidaemia, diabetes, smoking history or family history does not rule out acute myocardial infarction. How clinician gestalt does track with risk, but is not sufficiently reliable on its own to rule myocardial infarction in or out. Why none of this means testing everyone: Rick’s practical approach is to seek a convincing alternative explanation and use troponin when MI remains a plausible diagnosis that has not otherwise been adequately explained.

Traumatic cardiac arrest demands rapid treatment, but one of the hardest decisions is whether a resuscitative thoracotomy is likely to help. Can the location of a penetrating injury and the rhythm on the monitor give us better information than an uncertain history of when the patient arrested? Recorded at Trauma 2030 at the Royal College of Surgeons of England, Iain Beardsell speaks with Laura Kocierz about a data-driven approach developed from London’s Air Ambulance experience. They discuss distinguishing cardiac tamponade from exsanguination, using ECG rhythm as a surrogate for arrest duration, and why thoracotomy should target the underlying pathology rather than simply the diagnosis of traumatic cardiac arrest. In this podcast: Why traumatic cardiac arrest is better thought of as a clinical low-output state rather than relying on a simple binary definition. How the surface location of a penetrating injury can help estimate whether cardiac tamponade or exsanguination is the more likely cause. Why a wound within the cardiac box or epigastrium was associated with more than a 30% chance of isolated tamponade in the London data. Why treating presumed exsanguination should not stop the team actively looking for concurrent tamponade, including with ultrasound. How the presenting ECG rhythm may provide useful physiological information when the reported duration of traumatic cardiac arrest is uncertain. The observed progression from organised sinus rhythm through bradycardia and agonal complexes to asystole as arrest duration increases — and why these are population-derived timings rather than precise clocks for an individual patient. Why an organised rhythm in a patient with suspected tamponade may support immediate resuscitative thoracotomy even when the reported arrest time appears prolonged. Why resuscitative thoracotomy is not, in itself, a treatment for exsanguination, where haemorrhage control, blood transfusion and rapid movement towards definitive care may need to take priority.

The Fifth Universal Definition of Myocardial Infarction changes some familiar language around MI and puts new emphasis on how we interpret troponin, myocardial injury and imaging. For emergency clinicians, these changes affect both how we describe what is happening and how confidently we can make the diagnosis. Iain Beardsell introduces Rick Body, Professor of Emergency Medicine at the University of Manchester, who works through what has changed and what it means in practice. In this podcast: Why the familiar type 1–5 classification has been replaced by primary, secondary and procedure-related myocardial infarction. How conditions including plaque rupture, spontaneous coronary artery dissection, coronary vasospasm and embolism now fit within primary MI. Why the definition now supports sex-specific 99th percentile high-sensitivity troponin thresholds, and what this may mean for commonly used assays. How coronary or cardiac imaging has become more important when moving from a likely MI diagnosis towards confirmation and defining the underlying mechanism. Why a raised troponin is not synonymous with myocardial infarction, and how acute myocardial injury may result from inflammation, haemodynamic stress, physiological stress, catecholamine excess, toxicity or trauma. The challenge of diagnosing chronic myocardial injury in the emergency department when the definition describes assessment in a stable clinical setting. Why interpreting a troponin delta remains nuanced: absolute versus relative change, time from symptom onset and the interval between samples all matter. Where occlusive myocardial infarction (OMI) now sits: the terminology has not replaced STEMI/NSTEMI, but recognised occlusion patterns including de Winter T waves, Wellens syndrome, Sgarbossa criteria and posterior MI are explicitly discussed.

Small decisions in the resus room can save minutes; badly designed systems can waste thousands of hours. In the April 2026 St Emlyn’s round-up, Iain Beardsell and Simon Carley move between both ends of that spectrum, from external haemorrhage control and chest drains before CT to ED crowding, clinician productivity and the reflex to solve safety problems with more mandatory training. There is also new evidence on smoking cessation in the emergency department and HI-PEITHO, a randomised trial of catheter-directed thrombolysis for higher-risk pulmonary embolism. In this podcast: A practical escalation approach to external haemorrhage control: why accurate direct pressure still matters, when to escalate, and why a tourniquet should not automatically be the first intervention. Chest drains before trauma CT: when physiological compromise makes drainage necessary and when inserting one first may simply delay definitive imaging. How Stevan Bruijns’ idea of a cognitive bridge can help clinicians explain ED crowding to colleagues who do not experience the problem themselves. Why asking how many patients per hour a clinician sees can be misleading if staffing, crowding, IT, physical environment and workflow are ignored. Jesse Spurr’s challenge to healthcare’s instinct to respond to errors with another training module, and why systems thinking may identify more useful solutions. What a systematic review tells us about smoking cessation interventions in the ED, including the difference between behavioural advice alone and interventions incorporating nicotine replacement therapy. The HI-PEITHO trial of ultrasound-facilitated catheter-directed fibrinolysis plus anticoagulation for intermediate-high-risk pulmonary embolism, and why the composite outcome and balance of benefit and harm need careful interpretation. Why putting a major trauma patient straight onto a portable monitor, checking transfer oxygen and preparing equipment early can remove avoidable delays on the way to CT or theatre.