RCEM Conference 2025: Reflections from Day 2

By Joey Godfrey | Shared with permission on St Emlyn’s Blog

Day 2 of RCEM Conference 2025 took us into the heart of complexity—of patients, practice, people and culture. From frailty in older adults to the nuance of syncope and the real-world impact of neurodiversity, the sessions built on Day 1’s energy with practical insight, human stories, and big-picture thinking.

Frailty, Pragmatism and Patient-Centred EDs

We started with a panel discussion featuring three EM/Frailty consultants tackled one of the ED’s greatest balancing acts: the risk of doing too much versus doing too little. A case was shared that resonated with many in the room—a care home resident with dementia and on anticoagulation presents after a fall. A head injury prompts a CT, but the patient can’t tolerate it without sedation. The CT is normal—but the patient is now too drowsy to return home and ends up disoriented, falling on the ward. The cascade is familiar. Could we have made a better, earlier decision?

The panel encouraged clinicians to adopt early, pragmatic, risk–benefit decision-making. They reminded us that NICE guidance advises clinicians to “consider” CT for head injuries in anticoagulated patients [1]—but in many areas, there is no one in the community with the skills or authority to make that call. Some areas have addressed this with GP or ACP-led services. Others reported success with “fast-track CT” pathways, where patients go directly from ambulance trolley to scan and then return to their place of origin. Neurosurgeons in some regions have made blanket statements that they will not operate on patients with Clinical Frailty Scores above seven, which has further shifted decision-making.

There was also a plea for creativity in ED discharge planning, working with OPAL teams and services like Same Day Emergency Care and Hospital at Home. Deprescribing anticoagulation should be a shared decision, ideally involving families or next of kin. Evidence shows that patients would have to fall multiple times a day before the bleeding risk of anticoagulation outweighs stroke prevention benefits. That said, trial data often comes from younger, healthier populations—so caution is warranted.

One stand-out innovation is Plymouth’s “X-ray car”—a service that brings portable X-ray machines to patients in their own homes, requested by GPs or 111. Only 11 of 115 patients required transfer to ED on the day of their imaging, and a few more had planned follow-ups. POPs and slings were applied by community staff. The service is (allegedly) inexpensive to run and has led to a significant reduction in ED attendances.

The panel closed by urging departments to job-plan ED frailty leads, work closely with allied services, and view Comprehensive Geriatric Assessment (CGA) as an evolving process—not a one-time ED checklist [2,3]. Ideally, it begins in the ED and continues at home with follow-up by appropriately skilled clinicians.

Syncope, Chest pain and Paediatric cardiology

Professor Matt Read, opened the session with a structured approach to a commonly encountered but often anxiety-provoking presentation: syncope. He reminded us that syncope is not a diagnosis but a symptom—and recognising its subtleties is key.

The ESC data shows nearly half of patients presenting with syncope are admitted, but the mortality remains low, at under 1% [4]. Many clinical decision rules exist—San Francisco, ROSE, Canadian Syncope Risk Score—but the consensus was that none trump good clinical judgement.

Matt Read emphasised that syncope should be distinguished clearly from seizures, presyncope, and dizziness. Collateral and bystander history is crucial. Syncope during exertion is especially concerning and warrants a higher suspicion of cardiac causes. When a diagnosis is not immediately clear, key components of assessment include a thorough history, an ECG, and consideration of family history of sudden cardiac death. Lab tests and imaging rarely add value unless clinically indicated. NICE guidance on transient loss of consciousness (TLOC) remains a preferred tool for many [5]. Looking ahead, the ASPIRED Study is investigating the role of early ambulatory ECG monitoring, and early results are eagerly anticipated [6]. Don’t forget to review DVLA rules regarding fitness to drive post-syncope [7].

Samantha McDonnell’s chest pain session was a practical reminder of how much the field continues to evolve. She encouraged appropriate referrals for CT coronary angiography, particularly through risk stratification pathways like TMACS, though uptake has varied across institutions. The session touched on the sometimes-debated use of antiplatelets and anticoagulants in NSTEMI patients and highlighted the importance of revisiting key ECG patterns—particularly Wellens, de Winter’s, and the revised Sgarbossa criteria. Conduction system pacing, including His bundle and left bundle branch pacing, presents new challenges for ECG interpretation, as complexes can appear deceptively normal [8].

Dr. Anjum Gandhi delivered a great session on recognising cardiac disease in unwell neonates. Using vivid case studies, he reminded us that sick babies don’t always follow classic patterns—and cardiac causes should be on our radar for any sick looking neonate.

Duct-dependent congenital heart diseases like coarctation of the aorta and pulmonary atresia may present subtly, often mislabelled as sepsis. The key is in the details: hepatomegaly, differential pulses or saturations between limbs, and a lack of improvement despite fluids and antibiotics. When in doubt, start prostaglandins. The risk of causing harm is low if the baby is ventilated, and the potential benefit is lifesaving [9].

Neurodiversity

Trainees and consultants shared powerful personal accounts of navigating Emergency Medicine as neurodivergent professionals. Dr. Tess Dick spoke about her experience as a dyslexic ST5 who also manages diabetes and depression. Dr. Paul Robinson discussed life with ADHD—describing a fast-moving, complex mental landscape that sometimes clashes with traditional training and assessment structures.

What emerged was a picture of a system still catching up with the needs of its clinicians. Adjustments are often limited to exam accommodations, like extra time, when what’s needed may be far more fundamental—changes in rotas, interview formats, feedback delivery, and induction design.

April McKay brought a broader workforce perspective. Neurodivergent professionals can be exceptionally productive when properly supported [10], yet high unemployment rates persist. Failing to offer reasonable adjustments can cost Trusts significantly [11], both financially and in lost talent. Culturally, there’s still work to do. Encouragingly, up to 50% of one UK medical school’s intake now identify as neurodiverse—so the shift is happening. But systems must adapt accordingly.

Culture in the EM Workplace

The final session of the day addressed something less clinical but just as vital—culture. A multi-disciplinary panel tackled workplace behaviours, incivility, and the hidden costs of toxic environments.

Culture, they said, is like the weather—hard to define, but impossible to ignore. Poor culture impacts complaints, referrals, productivity and morale. Many staff feel unable to speak up. Data from the GMC shows that microaggressions and bullying remain prevalent. Some groups are more likely to speak up than others—paradoxically, those working in the worst environments may be the least likely to voice concerns.

The panel suggested several practical ways to make a difference: attending bed meetings to advocate for flow, integrating small positive rituals into handovers, and ensuring staff undertake Active Bystander Training [15]. Monitoring applications to consultant posts, reviewing GMC survey data, and challenging inter-specialty behaviour were also recommended as more objective measures as to how your workplace is viewed. If no-one applies for your consultant posts…… there might be a message there.

They acknowledged the legacy of a “suck it up” mentality, fuelled by survivorship bias. The shift toward a more inclusive and supportive culture must be deliberate, strategic, and values-driven. But it’s within reach [12–14].

Final Thoughts

Day 2 built on the momentum of Day 1 with real-world ideas and honest conversations—from the clinical grey zones to the unseen pressures shaping how we work. Frailty, syncope, sick neonates, neurodiversity, and culture—each session gave us tools to do better, and be better.

Thanks again to all who spoke, shared, and reflected—and to Joey Godfrey for capturing it all so clearly.

Joey Godfrey

Simon Carley