April 2026; papers of the month

Welcome to the Recess Room Podcast. 5, 4, 3, 2, 1, Fire! So hi and welcome back to the Recess Room Podcast. I'm Simon Lang and I'm Rob Fenwick and this is April 2026's Papers of the Month. Yes, Bishbashbosh straight into April at Easter Bunny and more importantly of course it is my birthday month. Send all your gifts via the Recess Room HQ please be bold. And well actually I won't make you buy me anything because as an early birthday treat to myself I've decided to read these three wonderful papers that are coming on and what are these papers we've got to eat this month. It's true that I get excited by reading papers it's weird isn't it? Yes so first up we are going to be looking at how good we are at identifying traumatic pneumothoruses that need early decompression. Next I'm going to be taking us through the Swift trial so whole blood versus blood components which is better for our patients. And finally community emergency medicine specifically a review of head injury cases. Can we could we should we be delivering that care closer to the patient's home well you are about to find out very good and yeah it's absolutely garden as season now isn't it? Spring is upon us the grass is growing the blossom is out it literally couldn't be any better. So we need to crack through this so I can get back on the lawn before we do that though. A huge thanks to Zole Medical Corporation for collaborating with us on the podcast and making this all free open access and available to you. And after you've done that why not go to the website do a few of the MCQs that are there and get a CPD certificate for listening to this. Or even more if you've forgotten to buy your loved one any strike why not take a look at the courses we've got there. We've got some on critical appraisal our assigned intubation or else we got bit of sedation a bit of cut of arrest master class a bit of extrication. I mean to be completely honest you did and better to have bought a course rather than the egg in the first place but there we go. I would tell you what that knowledge will last longer than that egg will I can tell you that for nothing. None of that a moment on the lips like time of the hips. Well like a moment in the air life time of more knowledge rolls off the tongue. Rolls off the tongue. Absolutely. So without further ado let's actually get into something useful let's crack into the papers. So I love this paper it follows on really nicely from our decision making episode where we were thinking about the importance of making a diagnosis, the risk of missing it and also the consequence when a diagnosis is made or very high suspicion of a diagnosis about whether or not we need to intervene with that patient because this paper looks at how easy or difficult it is to identify a blunt traumatic new mythorax which Rob has mentioned requires early decompression and we've seen over the last few years practices evolved into more conservative management for new mythoracies appreciating the risks and the benefits of decompression of drainage but there are still clearly some new mythoracies that cause physiological insults that without decompression can lead to real harm or death the patients. And you therefore want to be pretty confident in where that point is where intervention tips into being more beneficial than harmful to the patient. So the title of this paper pre hospital diagnostic performance of emergency physicians in identifying blunt traumatic new mythorax requiring early decompression lead author is obviously published in BMC emergency medicine this year. So what about the paper? Well, this is a retrospective observational study in a French level one trauma center over an eight year period from January 2015 and they look at all patients with a CT confirmed new mythorax managed by pre hospital emergency physicians the primary point the bit that they were really focusing on was the diagnostic performance of pre hospital clinical assessment to identify new mythorax that resulted in early decompression which they deemed to be a decompression pre hospital or within four hours of admission. The statistical analysis that they did was focused on the predictive performance of three clinical signs that will all be used to looking out for so the bits that you might hang your hat on with the diagnosis being present or absent and those were asymmetric lung sounds thoracic expansion asymmetry and subcutaneous emphysema. So what did they find? Well, they are the total of 280 patients with 41% of them getting early thoracic decompression and pre hospital clinicians suspected new mythorax in 63% of these cases altogether. So they were suspecting new mythorax was present in more patients than they decompressed which makes sense when you consider the risk and harms of decompression. So those patients were getting pre hospital early decompression from an in hospital perspective in the ones that hadn't already been decompressed early drainage of new mythorax was to occur when the new mythorax thickness was higher than 20 millimeters or associated with large subcutaneous emphysema. With regards to those signs that they found pre hospital and they looked at the notes to identify this asymmetric lung hospital had the highest sensitivity for these new mythoraxes requiring early decompression at 74% but poor specificity at 46%. Subcutaneous emphysema had a sensitivity of only 40% but a higher specificity at around 79% and thoracic expansion asymmetry had a sensitivity of 34% and a specificity of 77%. So basically that means that none of the signs alone was particularly reliable at rolling in or rolling out the need for decompression but if you saw thoracic expansion asymmetry or subcutaneous emphysema you should probably take note. The authors then created a simple composite score using the three signs combined together with each sign scoring one point. Now increasing scores improved specificity substantially and a score of three had a specificity of 99% and a positive predictive value of 83%. But sensitivity remained extremely low. So, snow time fuse come in Rob the authors conclusion pre hospital clinical assessment alone had limited diagnostic performance for detecting blunt traumatic new mythorax requiring early decompression. A simple clinical composite score offers higher specificity but remains insufficiently sensitive to be used as a standalone diagnostic tool. It may support field decision making as a risk stratification aid but pre hospital clinical signs alone are not sufficient to rule out a new mythorax requiring early decompression. So some really interesting stuff in here I thought Rob what did you make of this paper? Yeah it was an interesting paper and I think it does give you a useful feel for the sort of frequency of those signs but I wasn't 100% sure what to take from this if I'm perfectly honest because I think the inference here is that we are missing I guess clinically important new mythorax or new mythoracies and that we need to find ways to improve this but I'm not entirely sure I fully agree with that as a statement which is sort of where my pondering comes from I guess. And I think that because of the retrospective nature of this study it means it's really tricky to understand fully what's going on and it's impossible to know whether the clinical suspicion of those new mythories was under represented as of course it relies on that documentation which we know might not always be as accurate as it could be particularly for those things that you're just suspecting rather necessarily treating. So I think there are some clinical signs three in particular which they've used to sort of determine whether a new mythorax was suspected by these physicians but these are you know clinical signs which might only be there in a small proportion of cases or obviously they are more likely to be present in those cases where you have for example a massive new mythorax but then what they've done is they have used the CT scan performed in the hospital to determine a number of cases in which a new mythorax might have been. Well I think that's okay I guess but it's a very big step to say that based on a CT the patient should have undergone decompression earlier potentially in the pre hospital environment as the timing of when that decompression happens and whether it's actually performed at all isn't binary is it and you do see that in the results tables that are presented within there. You might have a patient that you suspect has got a new mythorax but because they've got relatively normal physiology so say for example a normal heart rate blood pressure and sat you might actually get a CT to confirm the underlying pathology and the extent of it before you intervene and at that point it might be direct to a chest rate if you're seeing them in an ED and I think that's actually a really good strategy and that has got absolutely nothing to do with the pre hospital care that has been delivered. So are we sort of retrospectively applying a completely different standard and I guess it's this assumption that a new mythorax that's decompressed within four hours should have been diagnosed in the pre hospital environment and I'm not sure I definitely agree with that and I think there are clearly within this patient. but groups of patients who add an early decompression pre-hospitaly, so around 10% and I think, for me, I'm thinking, "Well great, that means that that patient cohort, they identified and treated promptly." And I wonder whether the other 90% that are out there are still getting reasonable care. It's just happening a bit further down the line after imaging, which to me, I think is just good practice. If they're not human, they're not really unstable, crushingly unwell, then what's the point in doing it in the pre-hospital environment when you can get more advanced imaging? And I guess that's my sort of problem. I think the other thing to bring up is the idea of this composite score. So I think it makes sense that, you know, when you've got all three of those elements present, you are more likely to have a pneumothorax because it goes relatively hand in hand, doesn't it, with a diagnosis, and a specificity of 99% that makes total sense. But it's also a fairly obvious conclusion to reach, I think. But what I found most interesting was the sensitivity for those. So the sensitivity for those three elements was 4%. So this has gone like completely full circle. So, you've reported that pre-hospital suspicion of a pneumothorax only occurred in 46% of patients. But then you put forward a case for a composite score that's got a sensitivity of 4%, which it's a bit baffling to me. So in summary, I think nice hypothesis generating paper from that perspective. But I think to actually answer this, you probably need to use a different methodology, probably something prospective if you want to understand more about this. And we really need to understand, importantly for me, about whether these perceived delays actually make any difference to a patient's outcome because I'm not sure this study definitely says that delayed recognition causes harm. I think it just applies it retrospectively as a diagnosis. So I'd be interested to get your thoughts though, because obviously this was paper you were super keen on off the back of our last roadside to recess episode, wasn't it? Yeah, so I agree with you about that need for early decompression. And it is totally different, isn't it? Decompressing a patient in a pre-hospital environment as opposed to the relative sterility of doing that in hospital and that is apples and oranges. But I do understand why they've done that into trying to identify a pneumothorax, which is of reasonable size. And so therefore you may expect to have some clinical findings because ultimately we don't really care about a pneumothorax that's good, you know, a couple of millimeters wide just at the apex and isn't causing the patient any problems whatsoever and shouldn't be intervened with. So I can see why they've done this. The reason that I like it is because I think it's a really useful paper in terms of giving us a feel for how accurate our clinical findings are and it's that thing, isn't it? It would be very easy with the same patient to have completely different interpretation, especially when thinking about lung off-scultation, about whether or not there are discrepancies between both sides of the chest. And I think what it does for me is it really highlights the fact that we need to look at these aspects of the clinical assessment, but we do need to appreciate the fact that none of them on their own are that accurate. Combining them with the mechanism of injury is really powerful and also doing a primary survey in a really detailed accurate way, feeling every really feeling the soft tissue for any surgical lymphsema. I use the finding of surgical lymphsema. I give a lot of weight to that and it's interesting to see in this paper that that does actually tease out to be quite an important part of the examination. The other thing to mention is that ultrasound was being used on some of these patients and if you're thinking about how you might be biased when you're documenting in your notes or I couldn't appreciate lung sounds quite as much on the right hand side as the left. And actually you've already done an ultrasound and you found that that lung looks like it's down on the right. Well then I think you might hear things slightly differently with that, but totally take what you're saying. There are some questions about methodology here, but I think from a clinical practice perspective and improving the care that we're giving, I think this still goes some way to that. Nice, yeah, I agree. I think it's always useful to revisit these papers that examine the weight or how the tests perform, I guess, with regard to specific clinical signs and symptoms, isn't it? I think it's fascinating when you read them listed in a book, say for example, one of the ALS books or whatever it might be, but then actually when you go and look into the frequency, the sensitivity, the specificity of them, you realise which ones are more bang for buck, so to speak. So yeah, lovely to see it there. Yeah, basically it just justifies when I can't hear a pneumothoraxis present, but you can, it justifies the fact that I'm well seated with a normal population. Anyway, you no longer know how to use the stuff, let's go. But anyway, we'll move on. Right, we're on to paper number two. Yes, what a massive paper this one is this month. So as we know, bit of background here, hemorrhage remains one of the leading causes of preventable death, astertrauma and a lot of that happens before the patient ever reaches hospital. Now, because of that, there's been a real push over the last few years to get blood products to patients earlier, particularly in that pre-hospital phase. And whole blood has become increasingly attractive on paper at least, because it gives you everything in that one bag. So the red cells, the plasma, the platelets, much, much simpler logistics and faster administration. But I think, you know, although whole blood has been gaining favor, robust trial evidence, particularly in the civilian pre-hospital trauma setting has been pretty limited. So this month, the paper I've got used trying to answer exactly that question does giving whole blood pre-hospital actually improve outcomes. So the paper title was pre-hospital whole blood intromatic hemorrhage, a randomized controlled trial. It was published in the new England Journal of Medicine and the lead author was Jason Smith and colleagues for the Swift trial group. So what did they do? Well, this was a pragmatic phase three multi-center open label randomized superiority trial across 10 air ambulance services in England with patients then going on to one of 19 different hospitals. Now, they included patients of any age with traumatic injury leading to pre-hospital transfusion for major hemorrhage. The decision to transfuse was a pragmatic one and based on clinician judgment and local air ambulance criteria. Now, they excluded those patients where IV or IO access couldn't be established, patients with a known objection to blood transfusion and those who had already received blood products before the air ambulance arrived. Now, they also pre-specified that patients in traumatic cardiac arrest at the time of the air ambulance arrival would be enrolled but would then actually be excluded from that primary analysis. And patients were randomized then to receive up to two units of whole blood or standard care, so up to two units of red cells and two units of plasma pre-hospital. Now, in total, 942 patients were randomized and after excluding those with non-traumatic hemorrhage and traumatic cardiac arrest, this modified intention to treat population was 641 and 616 had primary outcome data available. So that was 314 in the whole blood group and 302 in the standard care group. And just a bit about those groups, I guess, well, the median age was mid to late 30s, about 75% of them were male, just over 70% had blunt trauma and the median injury severity score was 33. So this is a seriously injured bunch of patients. And one of the elements that also had a little bit of discussion online was the on-scene times. So they was a median of 67 minutes from the air ambulance team arrival on-scene to the patient arriving in the ED. So just over one hour. So what were they actually looking at then? Well, the primary outcome they were looking for was a composite that was composed of death from any cause or massive transfusion. And that had to occur within 24 hours of randomization. And what did they find? Well, the primary outcome, well, that occurred in 48.7% of patients in the whole blood group and 47.7% in the standard care group. So that gave a relative risk of 1.02 with confidence intervals that crossed one. So absolutely no difference in terms of statistical differences there. So when you look back at the secondary outcomes, well, death at 6 hours, 24 hours, 30 days and 90 days, massive transfusion on its own, days free from organ support, hospital length of stay, again, no difference between those groups. And from a safety perspective, well, there was no obvious safety problems with the whole blood. So serious adverse events are actually a little bit more frequent in the standard care group. So 37 versus 31 and thrombotic events looked exactly the same as well. So before Simon comes in with his credibly useful thoughts on this. The author's conclusion was that in patients with life threatening traumatic hemorrhage, pre-hospital transfusion of up to two units of whole blood was not superior to standard care in reducing death or massive transfusion within 24 hours. So Simon, really big paper, loads of coverage on the socials as they say out there. The socials. Socials. Socials. No, I'm sorry. You are so street. I know I'm down with the kids, kids with a zad, obviously. What did you think of this, mate? What did you think? Come on, big paper, big journal as well. Yeah, I mean, this has been talked about a lot online, hasn't it? Yeah. And the first thing is this is a phenomenal undertaking. Another great bit of pre-hospital research and brilliant to see these being, I mean, churned out would make it sound like it's an easy undertaking, it clearly isn't, but it is good to see these keep coming. I think there's a lot of debate isn't there about what the right strategies for these patients in terms of giving blood products. And I think this is really useful because I think it informs it and that there was no real difference seen here with a caveat that this is clearly a composite outcome that they're looking at here, which makes it slightly more complicated to interpret. But I think the other thing is that it's really interesting that we've got these trials on going and these on going debates off the back of the refill trial where we were looking at the benefits of blood products in resuscitation these sorts of patients and there wasn't any benefit seen with that trial, but actually practice has evolved in a way to go into further depth over this. And I think from my personal perspective, I wouldn't have expected to see a big difference here. Clearly there are a lot of more intelligent minds that are working on this and know an awful lot more. But I wouldn't have expected to see a huge amount of difference because of the result and the refill trial and teasing out the exact patient that is going to benefit from these strategies. I think that's going to be a lot less. It's a lot more of a specific patient and specific to the environment and the service within which that patient is being seen. It depends on transfer time to hospital, time from the onset of injury to you arriving. But I think this empowers teams to make a much more nuanced decision over how they want to approach things specific to their patients that they serve and their geography and their service. So it's really valuable, but I'm not surprised by the outcome. Yeah, I think that's a really sensible take home. I think keep it for me. I think it is basically a comparing whole blood against what is already pretty good standard care if you were to compare it through that lens. If that makes sense, you're not comparing two vastly different things. It's that one bit. But I think for me, it's that idea that actually what it does is what it doesn't show that whole blood's the answer to everything clearly. But what it does do is it allows you to have some nuance to your practice. And also it overcomes potentially some of those logistical barriers which you might have, which clearly, you know, it's easier to administer one single blood product rather than multiple single products from a logistic perspective. So it does give more options out there. I thought it was a fantastic undertaking though. You know, any pre-hospital care research is amazing to see. The fact that it's come from the UK, the fact that it's been done so well and from a, you know, a study design perspective, I think it's great. There's so much detail in there. I mean, if you go and look at the supplementary material online, which is about, I can't remember, it's 25 or 30 pages, but you can get lost in that for an afternoon if you want to go and do some reading. But it's an amazing undertaking. I think it really shows, you know, that high quality research can be done out there. But yeah, from this perspective, I think, you know, with the caveats that we've mentioned is a pragmatic trial. The primary outcome is a composite. The fact that massive transfusion can be altered by local practice and individual clinicians decision making. I think it's really good evidence, you know, I think it just says out there that quite right, if we're looking at patient groups that may well benefit from whole blood, it's going to have to be more nuanced than everyone, isn't it? So Langas, time for paper number three this month, I believe you're going to take us through some community emergency medicine. Oh, yeah. Yeah, had to find a way to get it in, didn't I? Right. This is a really interesting paper, actually, because all of us that work in emergency care will know that it doesn't take an awful lot to fall, hit your head and end up in emergency department with a CT scan, especially if you're on an anti-crackulent. Now at times, this can be a really useful test and the nice guidance in the UK support reasonably liberal scanning, although some aspects have changed in the latest guidance, including in the anti-crackulated group that are neurologically intact, to consider rather than to perform a CT head on everybody in this cohort, as long as there are no further indications for a scan. But if you take those cases back to their original point of injury before they get to the emergency department and consider where these head injuries might happen, the risks of conveyance for some multi-morbid patients, maybe with a package of care that's already in place and the consequences of going to hospital for that scan, maybe we should be scanning less patients in order to work in the best interests of patients. Now there are also an increasing number of community emergency medicine services setting up, showing the benefit of collaboration between pre-hospital clinicians and emergency medicine clinicians with the learning that happens between those crews and also sharing the scaper practice and taking that senior emergency medicine decision making to the patient at the very start before the cascade of further care happens. And the conflict of interest here, I may have invested interest in the Bristol Community Emergency Medicine Service, so it might be a bit of a fan of this approach. So I just happened to stumble across this paper and thought we might talk about it. So the paper title is Community Emergency Medicine, a service review of patients that sustained head injuries in the community. An early intervention by a senior clinical decision maker provide care closer to home. So the lead author for this is Davies and it's a letter published in the emergency medicine journal this year. So this paper, as we've said, looks at whether bringing senior emergency medicine decision makers directly to the patient in the community can reduce, convince to the emergency department after head injury in a safe and effective way. Now this study comes for the Ann year in Bevan, that's only take number 27, University's Health Board Physicians Response Unit in South East Wales. So this is a physician paramedic team responding to 999 calls designed to deliver consultant or senior registrar level emergency medicine decision making at the patient's home. And the team operates across a mixed rural and urban population of around 600,000 people and often attends older patients with falls and head injuries. Now what the author has done here is conducted a retrospective service review of adult patients seen by this P.I.U. between December 2022 and December 2023. First up they identified patients with presentations likely to represent head injuries, so that included falls, head injuries, collapse and then they reviewed the notes to confirm that a head injury had occurred. Now the key outcome was where the patients discharged at scene subsequently reattended the ED required further P.I.U. reassessment or died within seven days. And this was a pragmatic marker for potentially missed significant injury. They also looked at the anti-corregulated patients and included the anti-plaitlets other than aspirin monotherapy in this subgroup. So over the study period, this Physicians Response Unit saw nearly one and a half thousand patients of whom around 200 sustained a head injury. The mean age of patients was 84 years and nearly half were anti-corregulated. So of the 203 patients that they got with this head injury, 74% were discharged at scene and 26% were conveyed to the emergency department and nearly half of this cohort were anti-corregulated. Amongst those discharged at scene, 10% reattended either the emergency department or were reassessed by the service within seven days and importantly none of these reattended patients were found to have an intranial hemorrhage or fracture on CT related to the original injury. Now they also mentioned within their work that the reattendence rate is pretty consistent with the general English ED reattendence rate in the middle of this period which was at 11%. Only two patients represented with deterioration thought likely to represent pathology that had been present but not recognised at the first assessment from the service and many reattentances were related to other medical conditions including infection, dehydration, cardiac disease or further falls. So the conclusions from the authors, this study suggests that bringing senior decision-making directly to the patient can benefit selected patients who have suffered from head injuries. So probably no prizes for guessing what I think about this piece of work. What did you make of yourself? That's like Mark in your own homework isn't it? Well done. No, I mean in summary we've charted about this lots of times off and stuff and what I love about things like this is well we'll talk about chems in general and we'll talk a little bit just about the paper we'll work it out from there. So I think that when you see emergency care under such pressure at the moment you have to try and do things differently, rather than turn up expecting the same results by doing the same process every day and that's exactly what I think for me chems is about. It's about doing something differently especially now that we've got this growing body of evidence that it might well be very beneficial for patients not only the system that are within there and that's essentially what I think this paper is doing. This is exactly the sort of cohort of patients that traditionally ends up in a needy, you know they're older, they're more frail, they're often anti-correlated, they're not infrequently miserable about being brought into hospital to be perfectly honest with you. So the fact that you know you've got 150 so 74% of these that were discharged in the community with no subsequent intracranial bleeds identified on seven day re-attendances, massively reassuring but also just goes to demonstrate where we might be able to benefit these patients. Now I do think there's a few bits that we need to be careful with so clearly this is a service review not any form of comparative effectiveness study so we haven't really shown that this model is better than standard pathways what we've done is shown that within this one service, within this one team it appears to have worked really well. Secondly I think you know the outcome they've chosen is pragmatic. but it's still a surrogate isn't it you know an ED attendance or repeat chem's review or death within seven days well that's fine but it doesn't fully exclude the possibility of mispethology if patients presented to other hospitals or they deteriorated say after day eight or simply didn't represent and I also think for me if you want to add a bit more granular detail within that it would have been really nice to have seen a breakdown of what number of these cases were crew requests because I think that gives a little bit more understanding behind which patients crews knew didn't need to go to an ED but were essentially made to take them there versus those patients who genuinely it was the decision-making rather than just the bypassing of protocols that maybe were a little bit outdated or whatever but for me yeah I think it reinforces senior decision-makers can you know avoid unnecessary conveyance of some groups of patient I think it's great to see that anti-curricular stone doesn't necessarily always need to mean an automatic ED attendance and I think bringing that patient's care closer home to avoid an ED attendance is just superb but you know to get it closer to home I think to understand that I think a big thing for me is that it needs to be someone that is based in or based around an emergency department setting so you know I think there's a role for these schemes everywhere in the UK it's my summary of it I think there's clearly a nice piece of work here and it's really encouraging and what I do wonder now is I wonder how much more evidence is going to be needed for regions without them to encourage them to consider different ways of working when we're under so much pressure and patients are often having a bad experience when they do arrive at an ED because they're having to wait so yeah obviously this is right up your street though I mean what did you think of it? Yeah I mean thanks very much reading the scripts that I asked you to work off there I put some longer words in there mate yeah but you know so clearly I am a massive fan of this sort of practice and you really do see the benefit in bringing forward that senior decision making to the patient's home and to the community and you're absolutely right this isn't about the fact that a paramedic couldn't have made that decision this is very often about the paramedic recognising that risk benefit but then guidelines or scope of practice not enabling them to deliver that management strategy that they want to employ so I think there is a risk isn't there with the community emergency medicine services that it's perceived that the doctor is going to come out and then make all the right decisions it absolutely isn't that this is about empowering excellent pre-hospital clinicians to deliver the care that they have already identified so I could go on about this ad nauseam in fact Rob will attest to the fact that I could go on about this ad nauseam but this is a really good example of how chem's also allows you to really interrogate what you're doing and then try and refine their practice as well because it's really diligent isn't it to go through this in a way that we may not have the opportunity or may not be seeing so much in the emergency department as well so a really interesting paper if anyone wants to talk about this for 24 hours or more a bit absolutely delighted to have the longest coffee ever well maybe we'll just cover it on a brief episode in future but yeah go and have a look at this this is clearly only one part of what that service does amongst an awful lot of other community emergency medicine care so that is it for April 2026 is PAPES OF THE MONTH three really interesting papers make sure you can take a look at themselves come to your own conclusion but I think some really interesting things to think about in terms of our own personal practice and in terms of system design a huge thanks once again to Zoll Medical Corporation for collaborating with us on the podcast and making this all free open access and available to you and if you like what you've heard here then make sure you go to the website and you check out the online courses that we've got available there on the website so have a fantastic Easter if you haven't had it already take care of yourselves and we'll speak to you soon speak to you soon