Decision making sounds like a slightly academic, niche topic… but in reality, it sits underneath every single thing we do in emergency and pre-hospital care. Every patient contact, every test we order, every treatment we start and every one we choose not to – is a decision made in an environment that is time critical, information-light and full of uncertainty.

In this episode we take a step back and look at how we actually make decisions at the front door and on the roadside. We talk about why the importance of the decision really matters, not just whether a diagnosis is possible, but how severe it is, how common it is, and whether finding it will genuinely change what we do for the patient. We explore pre-test probability and prevalence, and why knowing how often a condition really occurs in the group of patients in front of you is one of the most powerful tools in emergency medicine.

We then move into testing. What actually counts as a test? It's not just bloods, scans and ECGs. It's how someone looks, how they move, what hurts when you examine them and how the story fits together. From there, we build into likelihood ratios and Bayesian thinking; how a piece of information should genuinely shift your estimate of risk, rather than just making you feel more or less comfortable.

We also tackle test and treatment thresholds; the idea that there are times when we should stop chasing a diagnosis, and times when the probability is high enough that we should treat without waiting for more tests. Finally, we bring all of this back to real life, with human factors, competing priorities and the reality that sometimes the technically "correct" decision isn't the best decision in that moment.

This one is all about becoming more comfortable with uncertainty and making better decisions because of it.

Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon, Rob & James

March's Papers of the Month is here and we've got three absolute crackers to get stuck into.

First up, we head prehospital to explore pseudo-pulseless electrical activity. This review challenges us to rethink how we approach organised electrical activity without a pulse. We discuss the role of POCUS, the concept of treating profound shock rather than "arrest," and what this means for decision-making and management.

Next, we move to cardiac arrest physiology with a systematic review examining intra-arrest diastolic blood pressure and coronary perfusion pressure. We take a look at the proposed thresholds, the heterogeneity in the evidence, and whether haemodynamic-guided resuscitation is ready for prime time.

Finally, we dive into airway nuance with a brand new taxonomy of performance errors in hyperangulated video laryngoscopy. We've covered a very similar paper before on standard geometry VL which was incredibly useful and this looks to do just the same for the alternative technique required with a hyperangulated device. We explore the microskills, the common errors, and what this means for how we train, feedback and improve our emergency intubations.

Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob

This episode is an absolute cracker! And we can say that as we've got outsider help...

We've all been involved with patients where securing the airway with a prehospital anaesthetic feels intuitively right; the patient with a severe head injury after a fall from height, the unrestrained driver in a high-speed collision with devastating chest injuries, or the patient with significant maxillofacial trauma following assault. In these situations, advanced airway management appears clearly beneficial.

What remains a bit ambiguous is the effect of that intervention. Does it play out into a mortality benefit and if so how should we redesign systems to meet a 24 hour need for this (with many prehospital critical care services not being available fully around the clock), bearing in mind competing financial priorities for optimum health care. Maybe it's okay that for some patients the anaesthetic is delayed to the Emergency Department?

Worldwide, trauma accounts for an estimated 4.4 million deaths annually and carries a substantial economic burden. Despite decades of improvements in trauma systems, medications such as tranexamic acid, and the development of prehospital critical care teams, some key aspects of trauma care remain really difficult to study well.

Prehospital emergency anaesthesia is a prime example. It is time-critical, ethically complex, highly operator dependent and almost impossible to study using conventional randomised trial designs. As a result, clinicians have largely been forced to rely on observational studies, despite the well-recognised problems of bias and confounding that accompany them.

In this episode, we explore the existing evidence base and then focus on a landmark new study published in The Lancet Respiratory Medicine. This paper applies machine-learning techniques to a large UK trauma dataset to address the question; does prehospital intubation improve survival in patients who are predicted to need early airway intervention?

We walk through how the authors developed a predictive model to identify high-risk patients, how doubly robust estimation was used to move beyond simple association, and how survival and health-economic outcomes were assessed. The results suggest a clinically meaningful reduction in 30-day mortality for selected high-risk trauma patients who receive prehospital intubation. And we're then joined by two of the study's authors, Amy Nelson and Julian Thompson.

Together, we explore what these findings may mean for the future of prehospital emergency anaesthesia, how we should think about evidence in complex emergency care environments, and whether this type of analytical approach could reshape trauma research more broadly.

Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon & Rob