The PicPod: Recent Episodes
The PicPod
Nudge nudge…. a favourite of politicians and social commentators, but how can nudge technology help us in ventilation weaning? Lisa McIlmurray has been working on a pilot study of nudge technology attached to a ventilator. How does this help to move patients on?
What are the algorithms used in this technology? Are there unintended consequences? What is the user acceptability? How was the tool developed, and how was it improved to be worthwhile?
Alarms are annoyances which can distract from the patient, and therefore are often switched off. How is this different to an alarm, and how do we harness the interplay between machines and humans?
The future is coming. Listen about it now.
Change is hard….isn’t it? We spoke to Rebecca Lawton, a professor of Psychology from the University of Leeds, who is an expert in patient safety; behaviour change; improvement science; workforce engagement and wellbeing.
Why is change so difficult? Who is it most difficult for? And how do we convince individuals, and teams, to make changes? How do hierarchies interact with team changes?
The psychology of change is challenging, but we cannot progress with our practice without this. Is it harder to adopt a practice, or to remove them? And why does this matter?
And what do prehistoric cave dwellers have to do with this?
First, do no harm… How much of the things we do every day are worthwhile? We all do so many interventions, but are they actually worthwhile?
Some may be ineffective, some inefficient, and some may be harmful. But which is which? How do we find out whether we should, or shouldn’t do something?
What is an acceptable miss rate? What are the implications of getting this trending towards zero? Who will have our backs if something goes wrong, and how defensive should we be?
Benficience, and non malifience. Not two sides of the same coin: they are two ends of a seesaw.
Calum Semple is a respiratory and infectious disease professor in Liverpool. He has been part of the governmental advice team for pandemics since before COVID. We spoke to him in advance of his talk at the 2024 PCCS conference
What is the frequency of pandemics? Is the 2018 Spanish Flu pandemic the last “real” one, or do MARS, SERS, and H1N1 “count”?
What is a W shaped mortality, and why does this matter? Where will the next pandemic pathogen come from? What were the case fatality rates from previous pandemics?
We have heard of MPox: is this a problem?
How important are multi resistant bacteria, and of what relevance is chicken’s drinking water?
What can we do about all this? With novel vaccine technology (remember PicPod 52?), how long would it take to get a vaccine up and running? And then how do we convince the population to take the vaccine? Can we use social influencers and clinic patients?
How important are platform trials? How would digital NHS connectivity help? How useful is the COVID19 enquiry?
And when should we rebuild something which is broken?
Pandemics are not over. There will be more….
Nicola Disma, an anaesthetist in Genoa, Italy, is lead author on the European Society of Anaesthesiology and Intensive Care guidelines on airway management in neonates and infants, published in full text here.
We discussed all things airway. Video laryngoscopes: useful, mandatory, or deskilling? “Normal” video blade or hyperangulated?
Oxygen during intubation: does it work, is it useful, how should this be done?
Nasal or oral tubes, what is the evidence, and what are the risks?
Cuffed or uncuffed tubes, what are the risks and benefits, and why would anyone choose an uncuffed tube?
What does it feel like to perform an emergency cricothyroidotomy, and exactly how many years has this aged Harish?
Is ECMO a viable option for airway emergencies?
How can we improve our team workings, and what is safety in these situations?
So many questions asked, some have answers, some don’t (yet). But great to share the knowledge and opinions of Nicola and his excellent research.
What’s the point of evidence? It’s to gain knowledge, so that we can treat our patients better. But what happens when the data is wrong, faked, misleading, or simply made up?
Retraction Watch (www.retractionwatch.com, and @retractionwatch) collates retractions from journals around the world. Their database makes terrifying reading: tens of thousands of papers which have been retracted are all listed, including hundreds of COVID papers. Individual authors have a “leaderboard” (loserboard?) headed by someone with an incredible 194 retractions.
We were lucky enough to speak to Ivan Oransky, one of the leaders of Retraction Watch. It’s a terrifying conversation, where he lays bare the outright fraud in medical publishing.
However, all fraud has drivers and motivations. Why are people pushed towards these staggering opportunities for fraud? Where, or what are the solutions?
Anyone working in medicine can learn from this podcast. Thank you to the Retraction Watch team: please keep up the incredible work.
From the 2023 PediCritiCon conference in Pune, India, I was lucky enough to chat with Bala Ramachandran from Chennai. He gave a great talk on precision medicine, its implications, and what the future may hold.
What’s the difference between personalised medicine and precision medicine? How does it differ to “usual” medicine? What are the tools we can use? Is precision medicine all about the genomics (side note: what’s the difference between genomics and genetics?), or can we make our own practice more precise with the tools we have now?
What investigations can we use, and are they ready for roll out now? Is the future bright…. or is this an ongoing dream?
All this and lots more. Enjoy!
Much research is technical and esoteric. Some research is fundamental and answers questions we want to answer every day. Often the first is easy to do (just add a lab and equipment), but the second is really, really hard.
Mark Peters and team have just published the OxyPICU trial in the Lancet. It’s the world’s biggest ever individually randomised trial in PICU, and involved most of the PICUs in the UK to achieve almost 2000 randomisations.
The question posed is simple: is a goal of 88-92% oxygen saturations better than 94-98%?
We go through the methodology, the statistics (probabalistic index anyone? It’s really simple once it’s explained), the results, the implications, and the implementation.
This study has gone straight in to the Top Ten PICU Studies, and will be a cornerstone of practice for the foreseeable future. We have done the hard work for you, so listen and you’ll be able to quote the results, and even parts of the supplemental data.
PicPod went to the 2023 PediCritiCon conference in Pune, India. It was a superb conference full of content, learning, and Bollywood dancing…!
We sat down with Brenda Morrow, Professor of Paediatrics at the Red Cross Hospital in Cape Town, physiotherapist, and president of the World Federation of Paediatric Intensive and Critical Care. She gave the keynote lecture at the conference.
Brenda has unparalleled knowledge of the state of intensive care around her region. We discuss the incredible progress which has been made in Malawi, but also the context within intensive care operates. What is “critical care”? Where does it begin, and how is it defined? Could contraception be defined as critical care?
The challenges are vast but the solutions are coming. Brenda discusses the fellowship training programme and what impact this is having.
Finally we discuss the Cape Town Red Cross hospital, and some of the excellent work being done there past and present.
At the PCCS2023 conference Harish and I were delighted to be invited to be a part of the conference. We were interviewed on stage by Zoltan Gyorgyi and Peter Donnelly, who asked us about the birth of PicPod, the process, and some highlights and lowlights.
Unfortunately questions from the audience were not recorded, but thank you to everyone there, and honestly, we were humbled at your thanks. We don’t do this “for the likes”, (note this quote by Banksy), we do this because it’s interesting and fun, but stories of inspiration and learning through the PicPod mean a lot.
So PicPod75 is a little different, an interview with us. Back to normal next time!
At the PCCS2023 conference in Edinburgh, we were lucky enough to meet David Cooper from Cincinnati Children’s Hospital. He gave a great talk on high reliability teams, and afterwards we chatted to him about his programme.
We discuss hierarchies: when are hierarchies good, and when are they bad? Is democracy a good thing? What is a Democribus?
How did this team reduce cardiac arrests on their unit? How did they prepare for sudden deteriorations, by making the unexpected expected?
What is a flight plan, how do they work, and how does this team avoid group think?
A really, truly fascinating 50 minutes which will make every one of us think deeply about how we can improve our systems.
The link to the website discussed during this episode is Pediatric Cardiac Critical Care Consortium (PC⁴) (pc4quality.org)
One of the most entertaining talks at the 2023 Paediatric Critical Care Society Conference was by Roddy O’Kane, consultant neurosurgeon in Glasgow, on the management of ICP.
On the theme of the conference, he was very clear: proper management of ICP depends on excellent team work, and listening to all the members of the team.
He spoke also about the dangers of being in PICU: what damage does the deep sedation we use do? Is the primary goal to keep the patient flat, or to get out of PICU?
On decompressive craniectomies: what did Rescue ICP tell us, or did it just underline what we thought we knew already? If you’re going to do one, then how large should it be?
Link to the article discussed during the podcast: Managing raised intracranial pressure in paediatric brain injury – Paediatrics and Child Health (paediatricsandchildhealthjournal.co.uk)
At the 2023 PCCS conference in Edinburgh we chatted to Marie Spiers, Emergency Department consultant in Glasgow, about paediatric traumatic cardiac arrest.
How does traumatic cardiac arrest differ to medical cardiac arrest? Is the treatment different? What should we be focusing on?
What is the point in chest compressions, and when should they be the absolute priority, and when are they a side show? What can studies in pigs show us, and are they extrapolatable? And, crucially, is “unhose” a word? (it’s not, by the way. Apologies).
Every day we go round the patients, making clear, robust plans so that the day works like clockwork. However, do you know how much of this information sticks with the team? It’s a shockingly low percentage (even JUST AFTER the plan has been made).
Listen to Lindsey who spoke at the 2023 PCCS conference in Edinburgh. She goes through the systems which are in place in her unit in Cincinnati, meaning that team knowledge has increased hugely. How does protocolising a ward round help? How do we listen (no, really, really listen) to our team? How are team members empowered to be a part of the process? Which metrics should we use to monitor ward rounds?
No ward round is perfect, but listen to Lindsey to hear how we can make them better.
She references two papers: links are here.
Improving Communication During Cardiac ICU Multidisciplinary Rounds Through Visual Display of Patient Daily Goals
Improvement in Multidisciplinary Provider Rounding (Surgical Rounds) in the Pediatric Cardiac ICU: An Application of Lean Methodology
In conjunction with the 2023 Paediatric Critical Care Society Conference in Edinburgh, we have interviewed Cathy MacDonald, one of the keynote speakers.
Cathy has had a long career as a police hostage and crisis negotiator. What can she teach us about crisis negotiation? What are the parallels between her world and ours? What are the strategies which can help us when conflict arises? What are the four dimensions of need?
Cathy’s a truly inspiring listen, honestly we could have listened to her for hours. Sadly we have cut it down to just under 44 minutes, but every one of those is worth listening to.
Enjoy: she’s the opening speaker to the conference, and worth listening to either on the way there, travelling back, or any other time.
How many times have we discussed fluid balance on a ward round? What is our fluid goal? And why?
Offloading fluid is a “good thing”, but why? And when?
What does the evidence say: what balance should we be aiming at, and when? Does the evidence actually give a message which can be summarised in one soundbite, or, surprise surprise, is it actually more complicated than that? Does the truism that more fluid = higher mortality actually hold up to scrutiny?
And what is fluid overload? Is this a definable metric, or does the evidence use an easy to calculate number, which isn’t what we should be talking about? What is the ROSE concept, and how can it help us?
How do haemodynamic monitors work, and what parameters are useful to us?
Again loads to think about, enjoy this episode!
Liz Whittaker, consultant in Infectious diseases at St Mary’s Hospital in London, talks to us about Group A Strep in children.
Over the past month or so the UK has had a huge surge in invasive Group A Streptococcal infection in children. Trainees up and down the country have rapidly been able to sign off their chest drain competencies, due to the huge amount of normally fit and well children presenting with empyema.
Is this year’s outbreak unusual? Why has it happened: is this a post COVID phenomenon, or something else? Which viruses are involved in making this infection more likely? Who should have flu vaccine, and why is there controversy about the nasal vaccine?
Why do patients react as they do, and how should we treat it? Which antibiotics? Should we give IVIG (here we go again….)? Should we give steroids, and in which situation?
Are there long term complications? Are we going to go back to the bad old days with rheumatic fever being a common condition, rather than something only suitable for textbooks and clinical exams?
What is the future for mask wearing: how much of this is rational, how much is cultural, and how much is simply polite?
And what is the frankly terrifying Zombie Bacteria Hypothesis?
Happy Christmas from the PicPod.
We all “know” of the clear respiratory support escalator: air, oxygen, CPAP, BiPAP, Invasive ventilation. But where does High Flow fit in? What parameters should we use to determine when and how to use it? Ram from Imperial/St Mary’s in London led the two-armed First ABC trial, the largest and […]
Without statistics, studies are just words. We need some way of translating data in to messages. More and more we read about studies which are using the mysterious Bayesian approach. How does this compare to the standard “frequentist” approach? What are the differences in data collection, analysis, messaging, and interpretation? […]
Everyone has now heard of Cytokine Storms. It’s the thing with Covid: and why Covid was so severe in so many patients. However, what is a cytokine storm? What are the “good” cytokines, and what are the “bad” ones? How do we differentiate, and what can we do about it? […]
Our second podcast linked to the 2022 PCCS Conference in Leicester, September 2022, with Mike Farquhar, sleep consultant at Evelina Children’s Hospital, and Sapna Kudchadkar from Johns Hopkins. This podcast went live at the time of Mike’s talk at the conference. Take a walk around a paediatric intensive care unit. […]
Big Data. Artificial Intelligence. Machine Learning. All very 2022, all very trendy. But how can this help our practice in Paediatric Intensive Care? Heather Duncan, consultant intensivist in Birmingham, has been working for many years with AI and Machine Learning, including input from the MacLaren F1 team. What is Big […]
Coming this September: a proper face to face conference IS BACK! The 2022 Paediatric Critical Care Society Conference, held in Leicester on the 14-16th September 2022, will be packed full of mind-expanding workshops, cross cutting plenary topics, and focussed sessions on a breadth of PCC issues for all members of […]
Severe TBI is a difficult, frustrating condition to treat. The secondary injury process occurs despite our best efforts: and our monitoring tools are incredibly blunt. Physiological parameters change when it’s too late: ICP is a localised and at times unreliable measure. CPP is two steps away from cerebral blood flow. […]
For the June Paediatric Critical Care Society Hot Topics Webinar series, we have interviewed one of the the speakers Barney Scholefield from Birmingham, an expert in the field of Post Cardiac Arrest care. First of all: what is cardiac arrest? How do we define it, and how do we classify […]
We were invited to chair a session at the 2022 Paediatric Critical Care Society Study Group meeting at St Mary’s Hospital in London. This is a national meeting of research interested PIC clinicians. Two excellent speakers contributed. Chris Gale is a neonatologist who has led the WHEAT trial, in to […]
Paediatric Acute Respiratory Distress Syndrome (PARDS) is one of the very difficult situations which paediatric intensivists fear. As part of the UK Paediatric Critical Care Society Hot Topics series, this PicPod episode interviews Heidi Flori, Clinical Associate Professor at the University of Michigan, and PALICC member, who was a speaker […]
We are pleased to announce that in the coming weeks the UK Paediatric Critical Care Society (https://pccsociety.uk/, @PICSociety, soon to be @PCCSociety) is going to be joining up its educational resources run by its members. In this short podcast we explain the strategy. First we have Akash Deep, chair of […]
Some conditions are rare. Some conditions are difficult to understand. Some conditions are difficult to treat. ADEM is all 3. A sometimes devastating condition affecting completely normal children, ADEM is an upsetting and challenging condition. Treatment this aggressively is important. Mainstays of treatment are steroids, IVIG, and plasma exchange. But: […]
PicPod 55 was all about Lactate: this one’s about the opposite (in some ways): Oxygen. Mark Peters is a professor of Paediatric Intensive Care at Great Ormond St Hospital in London. He is leading the Oxy-PICU trial, looking at whether a targeted saturation of 88-92% is different to 94-98% in […]
Lactate, the intensivist’s friend and the athlete’s enemy. As intensivists we always ask about the lactate as it’s a great indicator of problems afoot. But where does it come from? What does it signify? Is lactate itself actually bad? Does it cause damage? Does CRRT reduce lactate (hint: yes, but […]
From the 8th to the 14th May 2021 the World Federation of Pediatric Intensive and Critical Care Societies (WFPICCS) organised a very impressive, continent by continent programme of events to celebrate, discuss, and share PIC around the world. To mark this we invited four really special guests to the PicPod: […]
The news has been full of pictures of the Covid situation in Brazil. In a huge and diverse country, control seemed to have been lost. We have interviewed Fatima Marinho and Ana Bierrenbach from Sao Paulo who work for a non governmental organisation (Vital Strategies) which is keeping track of […]
Extraordinary times need extraordinary solutions. The SARS-CoV2 pandemic has caused global health and economic devastation. But humanity is fighting back. It is an incredible effort of humankind to create vaccines in less than a year. But not only have we been able to create vaccines, we have created them in […]
Bronchiolitis (remember that condition) will come back, and it will again be the staple of the PICU winter. It’s our bread and butter: but are we doing the right thing? Becky Mitting from St Mary’s in London has just published experience from three centres in London, all very close together, […]
The PicPod project has hit 50 episodes, a milestone we never imagined we would reach. We hope you have found these podcasts informative and useful. Here’s to the next 50! For this special anniversary episode we have three very special guests: Deanna Behrens from Chicago, Sapna Kudchakar from Baltimore, and […]
One of the extraordinary aspects of the pathophysiology of COVID-19 is the so-called “Cytokine Storm”. This is implicated both in the adult type condition, and as part of the PIMTS-TS / MIS-C condition.
We were lucky to spend time talking with Prof Ram from Bristol, a paediatric rheumatologist with an interest in cytokines. What is the difference between biologics and small molecules? What is the future of cytokine blockade?
Specifically, which cytokines are involved in PIMS-TS / MIS-C? Should we blockade them? What is the difference between all the inflammatory conditions, eg PIMS-TS/ MIS-C, toxic shock syndrome, HLH, and even sepsis? When should we use IVIG, steroids, or a targeted biologic?
And, as an aside, why is the COVID mortality so high in certain high income countries, and so low in many low income countries?
Enjoy and learn!
COVID-19 has devastated the world, with millions of deaths and socio-economic disasters. Medicine has been fighting back hard, with some incredible examples of research answering the important questions at breakneck speed.
The RECOVERY trial is the one which has answered questions on Dexamethasone, Hydroxychloroquine, Azithromicin, Lopinavir-Ritonavir, and now convalescent plasma (works, harms, no effect, no effect, no effect).
To get high quality, properly randomised, trustworthy data so incredibly quickly is an amazing feat. RECOVERY has a paediatric arm, which was agile enough to have included a PIMS-TS / MIS-C arm as early as June.
Answers on the therapies on these important conditions are urgent, and at the time of recording 118 paediatric patient have been randomised. There are two arms: for respiratory COVID, and for PIMS-TS / MIS-C. IVIG, steroids, and Tociluzimab are all being randomised: soon Baricitinib will be joining the party.
Saul Faust leads the paediatric arm of RECOVERY. He talks about the history of the trial, how we got here, and what is next. What has been found so far? What are the implications for future studies?
Our only weapon in this situation is knowledge.