August 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 August 2026's Papers of the Month. Yes, Simon Lang it certainly is and I am pretty much recording this as I'm packing my suitcase or that's what I'm planning to do when you're speaking anyway, rolling up them t-shirts nice and tight and I am looking forward to that Recess Room summer break. But I think before we go any further it would be remiss of me not to mention about our new mediocre videos that are live on social media, wouldn't it? Incredibly, instantly forgettable in many cases unless of course you're looking to get your eyes on James Yates in which case always a pleasure never a chore. And I mean. I certainly think that you particularly Simon have taken to them like a duck to water haven't you even though obviously you've definitely got a face for the radio. Wow, wow. I mean it's so much to say about this Rob. Very kind of you to hype it up as mediocre already. It's definitely been a steep learning curve but yeah we've been putting on new educational content which practically you can't really deliver on a podcast format so if you want to see that then take a look at Instagram and TikTok. We are so down with the kids. And there it is. It's actually a risk that we might be recording a little bit of this to go on there as well so you can see just how polished it is in the background. Oh my goodness. But thankfully if you don't want to get involved in that you can just listen to the podcast which is great and that's why we're here because we've got a job to do and that job is to look at three papers isn't it Simon? So first up, what is the impact of advanced pre-hospital interventions on on-scene time? Spoiler alert, it doesn't go down but there is some real impact. There is some really good discussion here and I think this is a great paper to have us go through. Then I'm going to be taking us through a paper looking at restrictive versus liberal oxygen strategies for post-cardiac arrest patients. What a topic that is. And then finally, oh my goodness me, necrotising fasciitis. What the heck should we be using to diagnose it? So there is some proper, proper content in here dude isn't there? There absolutely is and a huge thanks to Zol. Medical Corporation for collaborating with us on the podcast and making this all free open access and available to you in their pursuit of excellent patient care. And before we get into it, we should probably mention that not only have we been doing 52 takes per TikTok, we've also been working for the last few months on our Recess Room Academy and I'm very, very excited to deliver that to you in the next few weeks. So you'll have to take a look at the website when it comes out. But essentially, we're going to be doing a lot of work on that. But essentially, that is an academy based on all of our content. It's got thousands of MCQs, SBAs, exam simulator. It's got the most phenomenal patient simulator. You can talk to that patient and work out what's going on. I mean, when I get bored of chatting to Rob, I often just have a chat to this patient simulator instead. If you want a quick recap, there's a daily brief, which can be emailed through to your inbox. There are flashcards, deep dives into any of the episodes on the podcast, and it's got a new cutting edge CPD. Diary that automatically logs all of the activity along with access to our online courses. I can tell how excited you are listening to this. Go and take a look at it. We'll clearly pop something on social media when it's all out along with a refresh on the website. So that's enough of a preamble. Let's crack into the episode. Well, as Rob mentioned, this first paper gets right to the heart of one of those recurring tensions in pre-hospital trauma care. Do we stay and deliver advanced intervention or do we get moving to definitive care? And this is definitely a topic that I know that many of us involved in that emergency care pathways discuss a lot. And the issue is that as time's gone on, we've had more and more access to kit and interventions and can therefore bring forward a load of stuff that would previously be done in the emergency department. So thinking about things like pre-hospital, emergency anaesthesia, blood products, thoracostomy, thoracotomy, advanced vascular access, and in a few patients in a few services, maybe even REBOA. Now, the tension is that these interventions could, could prevent death before hospital or by time to definitive hemorrhage control, neurosurgical interventions or other definitive treatment is available, but none of them are free and one of their costs may be a additional seam time. So just because we can, does that mean we should? So this first paper is really interesting because it looks at something that all of us working in that pre-hospital trauma system wrestle with. Every time we add capability, are we actually improving care or just spending longer on scene and delaying the bits that really matter? So this paper, the title of the paper is the impact of advanced pre-hospital interventions on scene time. The lead author is Gandolfi and published. Just recently in SJTREM. So the authors use data from the London's air ambulance, as we know, a physician paramedic trauma service that operate in a very busy urban area. And they compared patients treated during July 2005, 2010, and then from 2017 to 2021. And that gap is important because the number of additional interventions like blood transfusion, REBOA, arterial cannulation, central venous cannulation were introduced. Between those periods. Now, this is a retrospective observational study using prospectively collected data. And they included primary trauma missions where the team reached and treated the patient and excluded non-trauma patients, patients that were dead at scene and cases where scene time couldn't be calculated. And the primary focus was the association between advanced interventions and scene time. So how much difference does it make on that scene time to perform? In order to work that out, they defined eight interventions that are advanced. So blood transfusion, pre-hospital emergency anesthesia, central venous cannulation, arterial cannulation, thoracotomy, thoracotomy, REBOA, and advanced life support for traumatic cardiac arrest. And they calculated that scene time from the team's arrival at the patient until departure from scene. So in total, there were nearly 1,400 patients included. 228 in the earlier group and 629 in the later group. And about 26% of those received at least one advanced intervention. And that's interesting, actually, because I thought this would be higher, but we'll come back to that later. Now, the proportion receiving an advanced intervention rose from 23.6% to 29.4%. So the service was doing more advanced procedures in that later period. But there was another major change in the case mix. Sadly, penetrating trauma increased from. around 24% to 34% over that time period. And penetrating trauma patients have dramatically shorter scene times than blunt trauma patients, a median of 10 minutes compared with 25 minutes. So a phenomenal difference. Now, despite the increase in advanced capability, the overall median scene time did not significantly change between the two periods, 22 minutes in the early cohort and 20 minutes in the later cohort. However. When we look at the individual patients, the picture becomes a bit clearer. Patients receiving no advanced intervention had a median scene time of 17 minutes. And as the number of interventions increased, so did that scene time, reaching a median of 57 minutes in the small group receiving five interventions. Now, they also did an adjusted analysis with each advanced intervention associated with a 41% increase in scene time. Pre-hospital emergency anaesthesia was the most common advanced intervention undertaken in over 300 patients with a median scene time of 37 minutes and Raboa had the longest median scene time at 61 minutes. So an awful lot to take out this paper, and we haven't been able to cover all of the results here. So go and have a look at the paper. It is free and open access. So the author's conclusion was the availability and uptake of advanced pre-hospital interventions has increased over the past year. And in the last two decades, overall scene times have not changed. However, this is likely explained by the shift towards more penetrating trauma and a continued majority of patients receiving no advanced interventions. Among patients who do receive advanced interventions, scene times increase with each additional procedure, highlighting the importance of operational efficiency and careful triage in deciding when these time-costly interventions are appropriate. We suggest further work is needed. If you have any questions or comments, please feel free to ask them in the comments section. So Rob, pretty standard, I've taken far too long running through that paper, but this is a classic, isn't it? Is it a stay and play or load and go? I mean, I wouldn't suggest that would be a better title of the paper, but that is essentially what's at the core of what we're looking at here. What did you make of this paper? Well, I don't know, I think they framed it slightly differently to that and I think the you know it's another brilliant paper from the team at London Air and it says you'd expect and I mean I'm constantly impressed you know these HEMS services you know they're definitely asking some really interesting questions of their patient databases and it's certainly helping to inform the literature isn't it and I think you know this one that you've just covered is another great example it's asking the question that constantly adds a bit of tension doesn't it on scene and you know when you're in training rooms and you're having discussions around it you know so what should we do here versus what should be done in hospital and you know if you look at the evidence there is stuff out there that it clearly says penetrating non-compressible hemorrhage are two things that really do benefit from shorter on scene time or less delays to definitive care depending on which way you think of it and I like that this paper frames it slightly differently though and it presents this more balanced view so it's not saying in any way shape or form that advanced interventions are bad because they take time it's just it quantifies that risks and to clinicians and teams that perform it so it says hey you know you you you can do an advanced intervention sure but it is going to add time and in fact if you look at this paper it's going to increase your on-scene time by 41 percent for every intervention you perform so I mean for me that's really super useful so it's not saying do less interventions it doesn't tell us whether those extra minutes are worthwhile as there are no patient outcomes here in this paper and if giving that blood performing that anaesthetic changes survival then those extra minutes are completely justified aren't they but this paper doesn't tell us that bit of the puzzle so I think if you take the caveats that are within this paper so it's London which is clearly a very mature trauma system they also excluded patients who died on scene so there's going to be some survivor bias and those who get these interventions are clearly going to be the sickest patients that you're going to see out there well if you take all those caveats I think what you've got is a a super clear message that you know these interventions have an opportunity cost so everything you do on scene buys you something potentially beneficial for that patient but it also costs us and the patient time to definitive care so actually as clinicians our job is to make sure that trade-off is worth it for that patient in front of us and you can only make those decisions based on evidence and based on information like you've got here so I think for me it's incredibly useful I think the next question for me though is what's the clinical value of these extra minutes for the individual interventions and ultimately for different patients so I think that's a really good question and that is a really really difficult research question to answer but ultimately the bit that we all want to know but I think this is one of those things that really informs and make sure that you can you know balance your decision making on scene far better knowing that this information is there and available to us to inform our practice that was my thoughts long and rambling what about yours mate so I agree with all of that I think what I would find really useful and it wasn't within the scope of what I was trying to look at here but to know what the comparator is time-wise of these interventions happening in hospital because I think one of the privileges of pre-hospital critical care is having the opportunity to go through data like this and really assess how your performance impacts the patient but if you knew that it was going to take longer for some of these aspects to happen in hospital or possibly even shorter then you can start to make a really balanced risk assessment of whether you should be performing these on scene or in hospital taking into account the travel time as well and lining up the further steps as well so I would be fascinated to see that and it would be great to have the opportunity to look at the data from an in-hospital perspective as well but this is useful by itself and I think this is something that a lot of other services will go and have a look at as a result of reading this paper so really informative I think it's difficult to generalize this isn't it to your service and say that this is going to make 40% of the time that you're going to be doing this 20% difference to our scene time by doing an advanced intervention but it might provide that spark of inspiration to then go and have a look at yours and then translate that into even an improvement or informing your practice so it's great yeah a really good piece of work and I guess with that we should crack into paper number two yes we should someone turn his mic off so one of the really interesting things about post-cardiac I said turn it off oh okay you can keep it on but just don't interrupt me uh so one of the interesting things about post-cardiac arrest care is that we've gradually moved away from this idea that more oxygen must be better and for years you know the default after return of spontaneous circulation was often you know stick the patients on 100% oxygen and the thinking was simple enough you know they've just had a cardiac arrest they're critically unwell so why would you risk hypoxia but I think over the last decade we've started to understand that physiology a little better and we know that whilst ischemic encephalopathy is really common after cardiac arrest the really important bit here is that the injury doesn't just result from oxygen deprivation during cardiac arrest but actually it also occurs because of reperfusion injury after we get ROSC now the evidence we currently have suggests that high oxygen exposure after reperfusion can actually contribute to oxidative injury leading to neuronal death really bad so it therefore makes clearly good sense that by limiting exposure to hyperoxygen you can actually reduce the impact of hypoglycemia a conservative oxygen strategy might reduce this effect and of course downstream then could improve outcomes so I guess the question is should we actually be targeting normal oxygen levels rather than giving as much oxygen as possible and my paper this month I know what's in the guidelines out there but my paper this month looks to answer that question in what I think is probably the largest trial that we've seen to date so the paper title was conservative oxygen for unresponsive patients after cardiac arrest and this was published in no less than the New England Journal of Medicine now it was completed this study by a group and I will give you the name of them so it was the logical investigators and the Australian and New Zealand intensive care society clinical trials group so that is a bit of a mouthful it's such a coincidence this always works out of the word isn't it it is yeah I mean who would have thought it would come to be the logical group absolutely phenomenal chance absolutely incredible isn't it yeah the logical investigators I will let them off that mouthful of a title though because this is awesome work so what did they do well this was a large multi-center randomized controlled trial conducted across 53 that's right 53 intensive care units in Australia New Zealand and Ireland and they recruited 1840 patients who remained unconscious and mechanically ventilated after achieving a ROSC following either an out-of-hospital or an in-hospital cardiac arrest now once recruited patients were randomized to one of two strategies so either a conservative or a liberal oxygen strategy so a little bit more detail on that as clearly you know the numbers here are going to be important so in both groups the lowest acceptable oxygen saturations was 90 percent so never lower than 90 percent now in the conservative group they set an alarm at 90 percent and they were 95 percent oxygen sats with the idea that the fraction of inspired oxygen was reduced to its lowest level to get that patient with peripheral oxygen sats between 90 and 94 percent and ideally the patient would not be receiving any supplementary oxygen now in the liberal oxygen group the patients were mandated to receive a fraction of inspired oxygen so an FIO2 of at least 0.3 and there were no upper alarm limits set for the oxygen sats then both sets of patients were treated according to this strategy until either discharged from the intensive care unit or until 90 days after randomization okay so those are the groups then but what did they find well as we said they recruited those 1840 patients between 2021 and 2024 i mean just ridiculously massive numbers that isn't it and about three quarters of those included had out-of-hospital cardiac arrests and the other quarter were in-hospital cases now the median time from ROSC to randomization was around seven hours in both groups so that's definitely worth bearing in mind but the headline result well the primary outcome they were looking at was a favorable neurological outcome at 180 days measured using the extended glasgow outcome scale and that result was give me a drum roll simon lang was that there was a favorable neurological recovery in 38.2 percent of patients in the conservative group and 39.7 percent of patients in the liberal group so absolute and relative risks both exactly the same so no statistically significant difference between those two groups so did conservative oxygen improve outcomes well no it didn't in a word and it was exactly the same story for those secondary outcomes so no difference in overall survival in ITU length of stay in hospital stay etc etc so the author's conclusions before i let you in in this trial involving ICU patients who are unresponsive after a cardiac arrest conservative oxygen therapy did not result in a higher likelihood of survival with a favorable functional outcome at 180 days than liberal oxygen therapy so simon absolutely massive trial admittedly based in the ITU but a huge undertaking what does this mean for us in emergency care what does this mean for us immediately following a return of spontaneous circulation give me your thoughts buddy yeah well it is a phenomenal undertaking isn't it this is a very impressive research group so yeah i think that's the first thing to say it's confusing this area i think and when you read the paper they nicely outline the reason and the context for this study there's been conflicting results from trials in this area and i think we need to bear in mind don't we the precision that your oxygen strategy can be undertaken at depending on your environment and depending on the phase of care it is important isn't it here to know how long how many hours it took to recruit these patients into it i think you said that that was seven hours so this isn't directly generalizable into our pre-hospital and our ed population but it's informative about what will then go on after that i think from a methodological perspective it's important to recognize that this is powered to see i think it was nearly a nine percent difference in favorable neurological outcome and that would be amazing if they could find that but that was always going to be a bit ambitious and probably reflects the fact that doing a study on the scale that would be needed to pick up a one or two percent difference would be totally unfundable yes so i understand why that's there but this is trying to tease out something which would need huge numbers so that's relevant to know i haven't really got anything else to say about the methodology that could be negative i think it's really good one thing i would jump in there so there was an overlap between the two groups again just methodologically thinking about how big that difference was that they were shooting for so about a quarter of the patients in the conservative arm had protocol deviations where the oxygen amount wasn't reduced as much as intended and some patients in the liberal arm also received lower oxygen amounts than specified so even then what that does is it narrows the separation between these two strategies even more doesn't it and that's why i think it's important to know that which i think again reduces the chance of being able to find a statistically significant difference but sorry i stepped on your toes there but these are a good methodological considerations no you it's good it's good to add some actual informed opinion to the paper so thanks very much um although you say that that then does make it a more pragmatic trial doesn't it it does you can have a strategy but we know that delivering strategy to the letter is also quite difficult so i would argue converse to that that actually that probably increases the validity of it i think what this means for practice that essentially there is a risk isn't there when you're trying to be really tight early on in your practice in that initial rosk phase in the pre-hospital phase and in the ed phase when lots of things are going on when there's lots of movements and when there's lots of activity then being so precise can be difficult and allowing a more conservative strategy could be more challenging because you're at more risk of then having hypoxia and then you're at more risk of then having hypoxia so i think yeah for me there are different phases where you can bring in different precision i think early on for me my practice is going to be ensure that they're not hypoxic to start with then as more capacity and availability comes into it and you get further down the line then we can then start to sort of aim towards normoxia but i don't think that a conservative strategy that's talked about here fits in with my pre-hospital and emergency department practice but it's fascinating to read and really impressive that the authors have done it so i have a bit of anxiety i've noticed anxiety is the right word but like but like you know when you read this stuff in like the guidelines as in you want to titrate them to a certain level you want to avoid hyperoxy well what that does is it creates this sort of momentum whereby you know you get the rosk and immediately you go from one management strategy onto another and at that stage you might not have a reliable oxygen saturation stress and you know and what you're basically doing is you're writing a guideline which i agree with avoid that hyperoxia but it's at that point where you've got a stable patient and you've got reliable monitoring and you can understand and you can titrate and you've got devices and kits that you can do that with and i think that what this paper has done for me is it's reassured me a little bit that in those early stages after you've got a rosk you can probably chill out a little bit and actually you know i don't think i need to be quite as focused on getting that oxygen down as quickly as maybe i have been or had that anxiety around the need to want to do it but then i think what you do is as you've built your team around you and that patient becomes more stable and you've got more kit more equipment more monitoring then actually you've moved into the next phase haven't you of that post-arrest care and actually then you can be targeting the guideline recommended saturations which is great but i think this paper has reassured me of that that actually i've got a lot of people who are it has informed my practice so you know the next arrest i'm dealing with in my ed i will have this knowledge in the back of my mind and i think that's super useful so massive thanks to the authors for producing it huge undertaking but simon in the interest of time i think we should move on to paper number three yeah so you mentioned it earlier this is about necrotizing fasciitis because it is one of those genuinely time critical emergencies in emergency medicine and it's uncommon but delayed diagnosis is consistently associated with increased mortality because definitive treatment is surgical debridement rather than antibiotics alone but the challenge is that when these present early it often disguises itself as uncomplicated cellulitis with the classic examination findings only developing later on in the disease current uk practice mirrors international guidance where we should maintain a high index of suspicion involve the surgeons early commence the treatment and then we can move on to the next stage of the disease broad spectrum antibiotics and resuscitate promptly and appropriately with the use of investigations to support rather than replace clinical judgment now ct has become the imaging modality of choice when uncertainty remains while the larynx score that's l-r-i-n-e-c in case i said it wrong has gained widespread popularity despite increasing concerns regarding its ability to safely exclude disease and this is a very important part of the disease and it's a very important part of the disease this paper is really interesting because it revisits the evidence behind physical examination imaging and that score larynx asking whether any are accurate enough to confidently rule in or rule out necrotizing soft tissue infections just for all of you non-larynx experts out there obviously i am an expert in this score that's calculated using a white cell count a haemoglobin a sodium a glucose a creatinine and a crp so uh yeah just if you're interested in learning more about if you want to go and have a look at that it gives you a score and you're able to tot it up we'll tell you about how relevant it is in just a second though yeah thank you to our resident larynx expert now traditionally with that as rob will know a score of six or more is considered highly suspicious for necrotizing soft tissue infections whilst a score of eight or more is regarded as strongly suggestive for the diagnosis sounds appealing if you don't have access to ct but let's go into this paper so published this year in concise reviews of published evidence in academic emergency medicine and the lead author is jihari so this short paper summarizes a systematic review meta-analysis of 23 studies involving nearly 6 000 adult patients with the suspected diagnosis surgical findings or histopathology were used as a reference standard so this is a brief overview paper rather than a full write-up of a systematic review meta-analysis but there's some stuff in here that's definitely worth discussion to inform our practice on the is how poor the classic examination findings are in excluding the disease fever had a sensitivity of only 46 and a specificity of 77 so those likelihood ratios are pretty bad hemorrhagic bully were more specific so that's good at 96 but only there in a quarter of patients hypotension was similarly highly specific at 98 but only had a sensitivity of 21 so you're getting the feel for these that when you spot them they're really useful but they're not that commonly present and plain radiography demonstrated a sensitivity of only 49 and a specificity of 94 so can't be used to rule it out but ct what we're using more frequently how good is it well if you're looking for fascial gas on ct that achieved a sensitivity of around 89 and a specificity of 93 so a likelihood ratio of over 10 13 and a negative likelihood ratio which is nearly a rule out at 0.12 but if you expand that ct criteria to look at fascial edema enhancing or fluid tracking that increased the sensitivity to 94 so gave a rule out of the diagnosis even so the authors stress that ct should not delay surgical consultation or theater when clinical suspicion is high and on to rob's favorite score is probably where this review challenges established practice most using the conventional cutoff of six or more had a sensitivity of 68 and a specificity of 85 oh i know disappointing isn't it very no point you being an expert in it now really rob never mind years wasted but if you increase that threshold to eight or more that did improve it to 95 specificity but the sensitivity dropped to only 41 so in other words your score supports the diagnosis but a low score absolutely does not exclude it so the author's conclusion about this really tricky diagnosis both to make or to rule out out necrotizing soft tissue infections remain primarily a clinical diagnosis no single physical examination finding imaging motility or larynx score is sufficiently sensitive to rule out necrotizing soft tissue infections diagnosis remains primarily clinical so rob what did you make of this paper yeah langers i mean i guess for me it's not a huge surprise i don't think in terms of the headline result as i'm sure you know if there was something was with amazing test characteristics we would have probably heard of it by now but actually you know reading this to reinforce that there aren't any is probably just as useful really but i mean i do think it's important to carry out with some critical appraisal points not least that essentially we're looking at a shortcut review here similar to a best bets that we'd have in the uk i think they call it brass track in this one or something like that it's an interesting name anyway but most of the studies here are retrospective and most of them include the studies that i've done in the past and i've patients that were already considered to be high risk for neck fash so they're not the all comers that we might need to make a call on if that makes sense but it's definitely useful you know i mean the classical signs as we've said they looked at it's a really useful reminder that they're often late and that the absence of them shouldn't allow us to drop our guard i think the lorin lorinic come on expert the lorinic score well i i will surprise you i'd never heard of it prior to reading this and thank you wow good i know i will yeah and thank goodness really you know that i don't need to remember it now because of what this paper sound plus i also think you know i really think that waiting two hours to get the lab values for a patient who you suspect necrotizing fasciitis in is a massive window to miss for those patients and as soon as you get stuff like this so these scores as soon as they start becoming widely utilized in my experience you could guarantee that getting a surgical seam to see them will be an absolute nightmare so i can hear that phone call now in my ears it's going to be ring me back when you've got a lorinic score and like it's just grown isn't it you know so i mean the imaging's interesting though i think you know that might have a role to support decision making i mean even in plain films actually you know it can be quite specific if you actually see gas i mean the flip side is you can't use them to reassure yourself if they're normal but if it's there then actually that could be quite useful and with all of this though you know i think you need to remember the biggest risk is delaying your life and being surgical involvement you need to be able to quantify and qualify to those teams why you're concerned about neck fash because you know if you're ringing a surgeon at three o'clock in the morning saying i think this might be neck fash then quite rightly they're going to ask why what is making you worried and this paper i think doesn't remove that need for clinical judgment it just reinforces that you need to be able to articulate what it is that's concerning you so yeah i think for me you know neck fash it's clinical diagnosis there are some tests that might be able to support that but i think it's going to be quite useful and i think it's going to support you which can increase or decrease your suspicion but none of them replaces that moment whereas an experienced clinician if you look at a patient and think this just isn't right and if that's what you're thinking that's the point to pick up the phone to whichever surgical specialty is going to have the absolute pleasure of accepting your referral without any follow-up questions would be my take absolutely agree with that i think one thing that people use quite a yeah yeah yeah yeah i could think back to a case i saw recently where i did base my decision making around that as well but i guess the fact that it's not here you wonder whether the evidence doesn't exist there but i think that's something that i would definitely factor into my decision making but this isn't going to be practice changing as a paper is it but it is really useful i think to shine a spotlight back on the potential diagnosis and just make sure that we do a really thorough clinical examination and assessment of these patients so worth the read go and take a look so that is it for august 2026's papers of the month three great papers go and check them out we will be off for our little podcast hiatus over the summer but look out for that recess room academy really excited to launch that make sure you have a look at our social media channels the absolute cringe that is on there to be able to spot when that is coming up and if you want to grab a hold of us on our social media channels we'll be there for you space on the cadaver course come and refine your advanced airway interventions and your surgical skills there are still a couple of spots left on the 18th of november so go over to the website and click onto it there so that is it from us a huge thanks to zoll medical corporation for collaborating with us on the podcast and making this all free open access and available to you have a great summer and we will speak to you soon speak to you soon you