Coda Change: Recent Episodes
Coda Change
Coda Conference: Clinical Knowledge, Advocacy and Community. Melbourne: 11-14 Sept 2022 codachange.org
Sonia Chanchlani shares how Doctors for the Environment Australia developed toolkits for educators and clinicians to enable practical action at the front line to work towards net zero models of healthcare.
This session was recorded at the Sustainable Healthcare Workshop workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
Sharon Desmond, Group Manager for Caring for People & Planet at Mercy Health, discusses Mercy Health's strategy for developing sustainable models of clinical care.
This session was recorded at the Sustainable Healthcare Workshop workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
In this discussion Ramsey Awad shares how the Hunter New England Health Service is moving towards net zero infrastructure to provide high quality healthcare today without harming future generations.
This session was recorded at the Sustainable Healthcare Workshop workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
In this discussion Nick Watts answers questions from the CODA22 audience to bust some common myths about implementing systems of sustainable healthcare.
This session was recorded at the Sustainable Healthcare Workshop workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
In this discussion Michelle Fox, Corporate Vice President at Teleflex shares an industry perspective on how medtech companies are working towards a model of sustainable healthcare
This session was recorded at the Sustainable Healthcare Workshop workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
In this discussion Kate Charlesworth talks about the Climate Risk and Net Zero Unit at NSW Health and the macro actions we can take.
This session was recorded at the Sustainable Healthcare Workshop workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
In this discussion Eugenie Kayak talks about why we need a national sustainable healthcare unit.
This session was recorded at the Sustainable Healthcare Workshop workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
In this discussion Clare Arnott talks about decarbonising health and medical research institutions.
This session was recorded at the Sustainable Healthcare Workshop workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
In this #Codapodcast, Ben McDonald Country President of AstraZeneca talks about decarbonising the pharmacy supply chain.
This session was recorded at the Sustainable Healthcare Workshop workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
In this discussion, Kate Charlesworth and Eugenie Kayak answer questions from the audience of the Sustainable Healthcare Workshop, which took place at Coda22 in Melbourne, September 2022.
For more information about the CODA Project go to: https://codachange.org/
In this discussion, Nick Watts, Ramsey Awad, Sharon Desmond, Michelle Fox, & Ben McDonald answer questions from the audience of the Sustainable Healthcare Workshop, which took place at Coda22 in Melbourne, September 2022.
For more information about the CODA Project go to: https://codachange.org/
In this discussion, Amy Freeman-Sanderson, Wade Stedman, & Simon Finfer answer questions from the audience of the Sepsis Leaving Nothing & No one behind Workshop, which took place at Coda22 in Melbourne, September 2022. This discussion also features a first person account from Cherie, a sepsis survivor.
For more information about the CODA Project go to: https://codachange.org/
In this discussion, Simon Finfer & Michelle Patson answer questions from the audience of the Sepsis Leaving Nothing & No one behind Workshop, which took place at Coda22 in Melbourne, September 2022.
For more information about the CODA Project go to: https://codachange.org/
In this discussion, David Anderson and Gladis Kabil answer questions from the audience of the Sepsis Leaving Nothing & No one behind Workshop, which took place at Coda22 in Melbourne, September 2022.
For more information about the CODA Project go to: https://codachange.org/
Matthew Humar presents 4 case studies which discuss unrecognised oesophagael intubation.
This session was recorded at the SAS workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
Tim Cook uses individual cases and analysis of the systems, processes and human factors involved in unrecognised oesophageal intubation to investigate why this tragic occurrence is still a problem around the world. He offers us some tools and advice to prevent unregognised oesophageal intubation from happening in our practice.
This session was recorded at the SAS workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
Nicholas Chrimes, Andy Higgs and Tim Cook - three of the authors of the recently published PUMA guidelines - outline their key recommendations for the prevention of unrecognised oesophagael intubation.
As a component of PUMA, these guidelines are intended for airway practitioners of all disciplines working in any context and have been endorsed by the world’s major airway societies.
This session was recorded at the SAS workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
The mission of the Project for Universal Management of Airways (PUMA) is to create a single set of airway guidelines that provide consistent guidance for airway practitioners of any discipline, in any country, in any context. Following years of development these guidelines will be released in six separate papers over the rest of 2022. In this session, two of the authors, Nicholas Chrimes and Andy Higgs, will present highlights of the papers published so far.
This session was recorded at the SAS workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
David Anderson describes the current state of play with airway management in the prehospital setting.
There are important differences between airway management in the prehospital environment and airway management in hospital. Prehospital intubation has been practiced for over 50 years and continues to evolve, with many techniques and procedures devised from prehospital use finding their way into ED and ICU practice. The main indications for prehospital intubation are cardiac arrest and severe TBI. 3 large studies show no evidence to support prehospital intubation in cardiac arrest and this practice should probably be reserved for specific cases. Prehospital RSI for TBI remains controversial as the evidence available to date is conflicting and isn’t high quality. While scene time if often commented on, there is no evidence available prehospital RSI increases time to CT or OR for patients with a severe TBI. There is no evidence that any one craft group is better at intubation than any other. In order to make prehospital airway management as safe as possible, innovations such as checklists, kit dumps and pre-drawn syringes are common. Many prehospital services invest much more heavily in the training and maintenance of airway skills than in-hospital specialties.
This session was recorded at the SAS workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
Adam Rehak and Gerri Khong walk through the good, the bad and the ugly of human factors in airway management. Using video footage of a highly realistic (tachycardia inducing) simulated airway emergency, the multi-stage case discussion canvases both audience responses and the input of a panel of human factors experts: David Brewster, Brooke Dench, Ben Meadley and Ian Summers, to illustrate that airway management is far more than just a technical skill. Instead, it will become clear that success is equally dependent on careful preparation, coordinated teamwork, precise communication and effective cognitive tools.
This session was recorded at the SAS workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
David Brewster describes the current state of play with airway management in the critical care setting, including a summary of the INTUBE study and the Safe Airway Society guidelines for airway management in COVID-19 patients.
This session was recorded at the SAS workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This discussion discusses the use of ketamine in fibre-optic intubation.
This session was recorded at the SAS workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
Adam Rehak addresses confusion and lack of awareness around these combined techniques that are making their way into the armament of airway operators.
This session was recorded at the SAS workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
ENT surgeon Georgie Harris and anaesthetist Drew Heffernan describe how they use high flow nasal oxygen to achieve tubeless airway surgery.
This session was recorded at the SAS workshop at CODA22 which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This panel features Jo Simpson, Forbes McGain, Andy Shrimpton and Tim Cook and took place during the SAS Workshop at CODA22, which took place in Melbourne in September 2022. This is Part 2 of this discussion.
For more information about the CODA Project go to: https://codachange.org/
Panel Description
Are we safe when we intubate COVID-19 patients? Are CPAP, high-flow oxygen, and intubation AGPs? Two years into this pandemic, what should we be doing at work to keep ourselves safe? An international panel of experts presents their research, emerging evidence and review current practice. Andy Shrimpton presents the game-changing AERATOR studies, Forbes McGain presents his experience with the ventilation hood and Jo Simpson reviews the historical evidence regarding AGPs and her work on aerosol containment devices.
Finally, Tim Cook, who was awarded an OBE for services to anaesthesia during COVID-19, brings the session together with his take on the evidence surrounding healthcare worker safety during the pandemic.
This panel features Jo Simpson, Forbes McGain, Andy Shrimpton and Tim Cook and took place during the SAS Workshop at CODA22, which took place in Melbourne in September 2022. This is Part 1 of this discussion.
For more information about the CODA Project go to: https://codachange.org/
Panel Description
Are we safe when we intubate COVID-19 patients? Are CPAP, high-flow oxygen, and intubation AGPs? Two years into this pandemic, what should we be doing at work to keep ourselves safe? An international panel of experts presents their research, emerging evidence and review current practice. Andy Shrimpton presents the game-changing AERATOR studies, Forbes McGain presents his experience with the ventilation hood and Jo Simpson reviews the historical evidence regarding AGPs and her work on aerosol containment devices.
Finally, Tim Cook, who was awarded an OBE for services to anaesthesia during COVID-19, brings the session together with his take on the evidence surrounding healthcare worker safety during the pandemic.
This panel discussion features features Eve Purdy, Casey Parker, Sarah Yong, Jeremy Pallas, and Chris Hicks and took place during the Clinical stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation features Ben Dunne and took place during the Earth stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation features Victoria Brazil and took place during the Clinical stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This panel discussion features Dr Sarah Yong, Associate Professor Nada Hamad, Professor Zoe Wainer, Dr Jessica Stokes-Parish, Dr Ian Summers, and Chris Bowles and took place during the Ethics stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by David Anderson as part of the Clinical stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Tanya Selak as part of the Clinical stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Eric Levi as part of the Clinical stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Karen Price as part of the Clinical stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Alex Psirides as part of the Clinical Care stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
Gemma Figtree, Mya Cubitt, and Greg Kelly answer questions from the audience during the Clinical stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Greg Kelly as part of the Clinical stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
Mya Cubitt and Jeremy Pallas answer questions from the audience at the Trauma Updates Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
Ben Medley and Luke McDonald answer questions from the audience at the Trauma Updates Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
Yolanda Coleman and Nilru Vitharana discuss a paediatric trauma case study. This Panel took part at the Trauma Updates Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Virginia Newcombe as part of the Trauma Updates Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Kate Jordinson & Loren Gallagher as part of the Trauma Updates Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Nilru Vitharana as part of the Trauma Updates Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This Q&A features Dr David McCreary, Dr Jennifer Jamieson, and Associate Professor Joseph Matthews. It took place as part of the Trauma Updates Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
Oli Flower sits down to talk with Penny Stewart, an intensivist working in Alice Springs, to discuss the upcoming "Together Outback: Hearing the Outback Voices in Healthcare" conference.
Music credits: Spinifex Gum - The Children Came Back. Listen to the full track.
Together Outback: Hearing the Outback Voices in Healthcare
20-21 June, 2024 | Alice Springs Limited free tickets available. Book now to confirm your place!
Together Outback: Hearing the Outback Voices in Healthcare is a unique conference looking at the challenges of critical care in the rural and remote setting. The need to adapt to the environment, the resources and our patients. How adaption drives the need for innovation and advocacy to build strong critical care in remote Australia.
Get ready to be inspired as renowned journalist and Indigenous affairs expert, Stan Grant, takes the stage to share his unique insights on healthcare disparities and the importance of hearing marginalized voices. With his thought-provoking perspectives, Stan Grant will challenge the audience to think critically about the current state of healthcare and its impact on First Nation communities.
But that’s not all. “Together Outback” goes beyond one speaker, providing a platform for numerous respected doctors and healthcare professionals to share their experiences and expertise. These esteemed individuals will shed light on the challenges faced by clinicians delivering critical care in regional and remote Australia, as well as the unique challenges faced by Indigenous communities, and discuss innovative approaches to bridging the healthcare gaps.
This event is a must-attend for anyone in the healthcare industry who wants to gain a deeper understanding of the issues faced by First Nation Peoples. The insights shared by the speakers will provide valuable knowledge and tools that can be applied to improve health care practices.
Through a professional and compelling tone, this event aims to raise awareness and spark meaningful discussions about healthcare inequalities. Attendees will have the opportunity to engage with like-minded professionals, exchange ideas, and contribute to the ongoing dialogue on improving healthcare for all.
Prepare to be captivated by the stories, ideas, and solutions presented at “Together Outback: Hearing the Voices in Healthcare.” By attending, you’ll be part of a transformative event that will leave a lasting impact on your understanding of healthcare disparities and the importance of inclusivity in the field. Don’t miss out on this unique opportunity to be part of the conversation.
*This event is funded by the Commonwealth Department of Health’s Specialist Training Program (STP)
For more information, go to: https://intensivecarenetwork.com/together-outback-the-free-conference-you-must-attend/
This presentation was delivered by Yolanda Coleman as part of the Trauma Updates Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Luke McDonald as part of the Trauma Updates Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Ben Medley as part of the Trauma Updates Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Mya Cubitt as part of the Trauma Updates Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Dinesh Palipana as part of the Trauma Updates Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Jeremy Pallas as part of the Trauma Updates Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Karin Thursky as part of the Cure stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Fiona Gray as part of the Cure stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Simon Finfer as part of the Cure stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Madiha Hashmi as part of the Cure stream at CODA22, which took place in Melbourne in September 2022. Features introduction from Naomi Hammond and Brett Abbenbroek.
For more information about the CODA Project go to: https://codachange.org/
This Q&A is moderated by Greg Kelly and features Dinesh Palipana, Marnee Shay, Jess Stokes Parish, Clara Tuck Meng Soo, Maya Newell, and Eve Purdy. It took place as part of the Educate stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This presentation was delivered by Maya Newell as part of the Educate stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Marnee Shay as part of the Educate stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Clara Tuck Meng Soo as part of the Educate stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Jess Stokes Parish as part of the Educate stream at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Dinesh Palipana as part of the Educate stream at CODA22, which took place in Melbourne in September 2022.
This podcast features an introduction by Greg Kelly.
For more information about the CODA Project go to: https://codachange.org/
This Q&A features Emily See, Carol Hodgson, and Caleb Fisher, and took place at the Critical Care Update Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This Q&A features Chaturi Dissanayake and took place at the Critical Care Update Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This Q&A features Panka Jain and took place at the Critical Care Update Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This Q&A occured between various speakers from the Critical Care Update Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This presentation was delivered by Caleb Fisher as part of the Critical Care Update Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This presentation was delivered by Carol Hodgson as part of the Critical Care Update Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This presentation was delivered by Chaturi Dissanayake as part of the Critical Care Update Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This presentation was delivered by Toby Jeffcote as part of the Critical Care Update Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This presentation was delivered by Panka Jain as part of the Critical Care Update Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project go to: https://codachange.org/
This presentation was delivered by Luke Torre as part of the Critical Care Update Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This presentation was delivered by Emily See as part of the Critical Care Update Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This presentation was delivered by Charlotte Harper as part of the Acute Paediatrics Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This presentation was delivered by Elliot Long as part of the Acute Paediatrics Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This presentation was delivered by Warwick Teague as part of the Acute Paediatrics Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This Q&A was part of the the Acute Paediatrics Workshop at CODA22, which took place in Melbourne in September 2022. It features Fran Lockie, Jackie Schultz, Alison Boast, and Tony Norris
For more information about the CODA Project, go to: https://codachange.org/
This presentation was delivered by Tony Norris as part of the Acute Paediatrics Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This presentation was delivered by Alison Boast as part of the Acute Paediatrics Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This presentation was delivered by Jackie Schultz as part of the Acute Paediatrics Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
This presentation was presented by Fran Lockie as part of the Acute Paediatrics Workshop at CODA22, which took place in Melbourne in September 2022.
For more information about the CODA Project, go to: https://codachange.org/
You may have noticed that the last couple of podcasts we've published were neuro-related talks that were recorded at the BRAIN Symposium which took place earlier this year.
If you want more neurocritical care podcasts make sure to head over to the NeuroResus channel. Over the coming months we’ll be publishing more talks from the BRAIN Symposium around neurocritical care, neuro resuscitation, and neuro emergencies.
Subscribe to Neuroresus in your preferred podcast app, or sign up to the Neuroresus newsletter to receive updates directly in your inbox.
Mark Weedon takes us through the increasingly utilised concept of an optimal cerebral perfusion pressure (CPPopt) for each unique patient.
This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com.
Social Worker Victoria Whitfield and Bereavement councilor Louise Sayers discuss the power of words when health professionals are communicating topics around of death and serious injury with relatives and patients in critical care. They use role plays to bring theories to life.
This podcast was recorded at the Brain Symposium which took place in March 2023. For more talks and content like this, visit neuroresus.com.
Ambulance Victoria has committed to become a more sustainable ambulance service. This includes achieving net zero emissions five years prior to the Victorian State Government commitment of 2050 with additional emissions reduction targets for 2025 and 2030. By fulfilling these targets, the carbon footprint for each patient cared for by Ambulance Victoria will be halved by 2030. It is apparent that to meet these emission reduction targets, Ambulance Victoria's current model of care needs perpetual refinement. Reducing emissions from electricity and fleet start to look easy in comparison to reducing low value care. Delivering better care to a patients according to their particular healthcare needs suggests that our pre-hospital service needs to be reimagined to start prior to any patient picking up the phone to dial Triple 000. Ambulance Victoria are discovering new ways to offer best care for particular patient cohorts via new technologies such as telehealth and the Virtual ED and by partnering across our communities primary and secondary healthcare networks, to offer timely support to those for whom an ambulance doesn't offer the greatest benefit. In 2021, Ambulance Victoria undertook a study to map the carbon pollution associated with its Triage Services and measure changes in carbon pollution resulting from the use of alternate patient care pathways. The analysis revealed interesting results that have implications for pre-hospital service design in the future. We hope that this study offers insight into new ways of thinking for decision makers and enables a triple bottom line approach to assessing the benefit of programs and keeping an awareness of how to serve the community in more environmentally sustainable ways. Using a multipronged approach to improving healthcare sustainability at Ambulance Victoria can reduce the environmental impact of pre-hospital healthcare services and thereby minimise the health impacts from the sector that are associated with dangerous climate change.
CODA Change and Sustainable Healthcare. Climate change is a pernicious environmental and health threat to humanity. Yet, healthcare itself pollutes, contributing to approximately 5% of total global anthropogenic emissions. What can be done to avoid this harm? Forbes McGain has spent 15 years undertaking research with colleagues to discover healthcare’s environmental footprint, with a particular emphasis upon practical efforts to reduce this environmental and economic burden. In this discussion we will hear of a series of micro, meso, and macro actions that each can contribute to reducing our carbon and other environmental footprints at work. Mico: all clinicians have agency to avoid, reduce, reuse, and if none of these are possible, recycle. Further, efforts to provide excellent primary care such as preventing obesity, diabetes, and drug harms, and delivering vaccinations are integral to ameliorating healthcare’s environmental footprint. From titrating oxygen on the hospital wards to deliver enough, but no more for patients, to undertaking antibiotic stewardship (and switching from i.v. to oral preparations) there are actually many daily activities in healthcare that could reduce our environmental footprint whilst delivering ongoing safe patient care. Meso: Collaboration is the key here! There are many low carbon healthcare activities that cannot be ameliorated without teamwork, for example at the GP clinic, hospital ward, or operating theatre level. A good example within hospitals are efforts to convert single use to reusable equipment. Although evidence is presented of the economic and environmental benefits of reusable anaesthesia equipment such information (and publications) has not lead to widespread adoption of such approaches. The importance of champions in each hospital and collaborating with clinical and non-clinical colleagues in hospitals is emphasized. Forming hospital environmental sustainability committees, and alliances with hospital executives and the board is vital. Macro: Advocacy at the medical and nursing societal and colleges level to incorporate environmentally sustainable healthcare into routine clinical education, examinations, and research agendas is the work of concerted groups of clinicians. Influencing the various state, territory and national governments to develop/extend sustainable healthcare units will likewise form part of macro efforts. Joining the Doctors for the Environment, Australia (DEA), activating the ANMF and AMA to get involved in environmentally sustainable healthcare will augment such efforts. Full Sails on Our Journey!
Climate change is now our lived experience. With no vaccine to reduce its impact on health, the only preventative strategy we have is to reduce emissions, including healthcare delivery. The greatest portion of healthcare’s emissions profile comes from the stuff we use, so we have to change what we do. But how?
Decarbonisation on the clinical floor is a look at every day work activities. It is bridging the gap between abstract concept and service delivery. It comes with triple bottom line wins – people, planet, and profit.
The future isn’t written yet. The things we do now are what make it. We have choices to make that matter. We need visionaries to show us the direction. We need practical examples that bridge the gap between ambition and action. We need to tell the climate story in a way that draws people in, that empowers them to take action and enables us to be part of the solutions.
Nick Watts
In today’s podcast, Nick Watts - chief sustainability officer at the NHS speaks about why - when the NHS says there are three things they want to implement over the next decade - their response to climate change is number two.
Watts explains that they understand the health implications of a rise in temperatures, they understand that it means a doubling of the number of high risk health facilities in flood zones, and a tripling of the average duration of fatal heatwaves and notes that they saw what that looks like for our healthcare system.
He talks about how while the average across a summer the UK face 2200-2400 excess deaths from heatwaves; the recent six-day heatwave saw 12800 deaths – six times the usual amount. That’s why the NHS cares deeply about this.
If the climate crisis is a healthcare crisis, Watts says that it’s important to face it head on. Principally, he says, acute care is responsible for the NHS’s emissions, while primary care also comes in strong due to its prescriptions and medicines.
He discusses how in order to cultivate real change, you don’t just run at one small part – turning off the lights and turning the temperature down simply isn’t enough - you need look at every single emission you can possibly think of. For the NHS it means net zero by 2045.
NHS reports publicly to both their board and 1.4million NHS professionals every single year. Watts says that it hit first year emissions target; he promises they’re going to hit their second. It will, however, start getting hard to hit their targets from year 5 onwards.
Transparency is critical. Milestones and scope need to be clear.
Watts explains that from 2027 onwards the NHS will no longer purchase from anyone that does not meet or exceed their commitments to net zero.
He says that while the NHS will do absolutely everything in their power, they can’t run at this alone. The challenge is too big, medicine is too complex. Thankfully the NHS isn’t alone. 14 other countries followed suit in committing to reaching net zero.
To end, Watts insists that it’s when other people take note, start taking this seriously, and when other healthcare systems start to engage that net zero stops becoming possible, and starts to become inevitable.
Sepsis in other words ‘life-threatening organ dysfunction’ in response to infection is a leading cause of death worldwide and a global health priority recognised by the World Health Organisation. In Australia, for adults with sepsis admitted to the intensive care unit, the in-hospital mortality is estimated as 18–27%. Early recognition of sepsis, prompt administration of antibiotics and resuscitation with intravenous fluids for those with features of hypoperfusion or shock are the mainstays of initial treatment. Emergency departments often being the first point of contact for patients presenting with sepsis, are required to prioritise sepsis as a medical emergency. The “Sepsis Kills” program implemented across the nation aims to reduce unwarranted clinical practice variation in management of sepsis.
In a recent Australian based study conducted across four emergency departments in Western Sydney Local Health District, among 7533 patients with suspected infection, a reduction in risk of in-hospital mortality was observed for each 1000 mL increase in intravenous fluids administered in patients with septic shock or admitted to ICU. However, despite evidence showing mortality benefits, not all aspects of sepsis care have been given the needed attention. In the same setting, out of 4146 patients with sepsis, 45% of them did not receive intravenous fluids in the emergency departments within the first 24 hours. Younger patients with greater severity of illness and presented to smaller hospitals were more likely to receive fluids.
The unanswered questions regarding the facilitators and barriers influencing intravenous fluid administration in sepsis are being explored using qualitative methods. Several emergency physicians and nurses have provided insight into aspects that influence their ability to provide appropriate fluid resuscitation such as constantly overcrowded emergency departments with chronic staff shortages of skilled health professional, failure to recognise sepsis early, the complexity of the presentations and lack of resources. Awareness of these challenges among stakeholders is the need of the hour. Leaving no one behind and not disregarding the critical aspects of sepsis care are crucial. Recognition of these factors and sustainable interventions are necessary to improve clinical outcomes for patients.
For more head to our podcast page #CodaPodcast
Physiotherapists form a key part of the multi-disciplinary team in the Intensive Care, focusing on both respiratory care and optimisation of function. This talk will discuss the role of physiotherapy across the continuum specifically in the management of an acutely unwell septic patient. I will discuss the focus of a physiotherapy assessment, main treatment aims, some of the barriers for the implementation of physiotherapy in ICU, while identifying strategies to enable appropriate application of physiotherapy techniques.
For more head to our podcast page #CodaPodcast
Sepsis is a common presentation in the prehospital and retrieval environment, with most cases having a respiratory, urinary or soft tissue origin. However the best practice for identifying and management sepsis in the prehospital environment remains unclear. Despite sepsis having been a priority for in hospital guidelines and protocols for decades now, relatively little attention has been paid to prehospital sepsis management. Traditional teaching is that early antibiotics in sepsis save lives, however trials examining this are observational and confounded by outdated ICU care. An appropriately sensitive and specific tool for the prehospital identification of sepsis remains elusive. NEWS2 is common and lactate-modified QSOFA emerging (although prehospital lactate measurement remains difficult). The role of prehospital antibiotics, and the most appropriate one are also unclear. Most ambulance services that carry antibiotics use ceftriaxone. The retrieval environment is similar, with sepsis probably being the single commonest reason to call a retrieval service.
For more head to our podcast page #CodaPodcast
As part of the Sepsis Workshop, this presentation will briefly touch on the challenges that patients and their families face on discharge from hospital after an admission for sepsis.
For more head to our podcast page #CodaPodcast
As an ICU registrar you meet septic patients at different points in time: as the first responder, asking ‘could this be sepsis?’; as the second responder, admitting the patient to the ICU; or the third responder, having to consider adjuncts in the deteriorating patient. Each of these presents different challenges and learning experiences, making the reality of managing sepsis more complex than one might first expect.
For more head to our podcast page #CodaPodcast
As with everything else, ICU management of sepsis should ideally the evidence based. Evidence based practice combines the best scientific knowledge (evidence) with patient preferences and clinical assessment and judgement.
While the pursuit of specific pharmaceutical agents to treat Sepsis has resulted in the expenditure of billions of dollars without producing a single effective agent, much of what we do in the treatment of patience with Sepsis can be evidence based. Clinicians make literally hundreds of decisions day on the management of an individual patient in the ICU, often these decisions are made routinely without a great deal of thought about the reasoning behind them. Every decision made about the treatment of a critically ill patient should be based on evidence or the belief that the action resulting from that decision will improve a patient centred outcome for that particular patient. A patient centred outcome is an outcome that affects how the patient feels, functions or survives meaning we should question every decision we make to ask whether it is going to improve one of those outcomes.
The best evidence on which to base of such decisions comes from large robust randomised controlled trials conducted by unbiased investigators. The last 20 years has seen the emergence and maturing of regional and national clinical trials groups who conduct such studies and increasingly collaborate with each other. (2) Such collaboration is often essential to perform studies large enough to provide evidence to guide clinical practice such collaboration is often essential to perform studies large enough to provide evidence to guide clinical practice. As someone who designs and contacts clinical trials I am well aware that they provide evidence on a population basis. Each trial result is the net of harm and benefit resulting from the treatment being studied and even when a treatment is proven to have a net benefit there may be some patients who are harmed by the use of that treatment. A graphic example of this is someone who suffers a massive intracranial haemorrhage when treated with thrombolysis. Causing visible harm to a patient may shake a clinician's faith in an effective treatment making it important that we accept such tragic events without changing our practice to deny that effective treatment to future patients.
Research, like clinical practice, has inherent imperfections. Researchers, like clinicians, need to recognise this and be prepared to put their hand up and admit when they have been wrong. Conducting robust studies of appropriate size in an effective collaborative research group is the best way to avoid being wrong too often!
For more head to our podcast page #CodaPodcast
Sepsis causes organ and tissue dysfunction in response to severe infection, resulting in significant physical and cognitive morbidities. For patients diagnosed with severe sepsis, admission to an intensive care unit and use of an artificial airway are often required. The sequalae of severe sepsis necessitating critical care can result in significant changes to a patient’s swallowing and communication function. These negative changes and impacts to function can occur during and after a diagnosis of sepsis, and ultimately impact a patient’s health and functional status. The nature and long-term recovery of swallowing and communication function is still to be completely understood; however evidence affirms recovery continues well beyond hospital discharge.
This presentation will focus on tasks we do daily – eating, drinking and speaking. Specifically, the nature of swallow impairments will be described, and the impact of this new disability will be explored from the perspective of the patient’s body structure, function and activities. Core components of swallowing safety and efficiency will be described, alongside the role of assessment and management within and beyond the ICU. Changes to communication including altered voice, speech and language function will be described. Outcomes of altered communication function over the continuum of care during, and after hospital will be explored. The evidence base and the lived experience of sepsis and patient stories will underpin the content delivered in this presentation.
The final aim of the presentation will be to describe and highlight the role of speech pathology, an allied health profession, in the management of swallowing and communication function. Following the workshop attendees will be able to (1) describe the characteristics of swallowing and communication disorders; (2) have knowledge of the impact of these new disabilities; and (3) will be able to describe the role of speech pathology in the healthcare team for the patient with sepsis.
For more head to our podcast page #CodaPodcast
Dr Greg Kelly – a paediatric intensivist at Westmead Children’s Hospital – is today’s guest, on the #Coda22 podcast, during which he discusses a little girl called Abbie, who has lived in ICU for almost two years, and how she represents a very important group of patients – who are a tiny fraction of admissions, but a huge proportion of the workload at Westmead Children’s Hospital. Such patients are complex in such a way that no-one knows exactly what to do with them; nor how to respond to them. He goes on to discuss the problems they see every day at Westmead Children’s Hospital, and what the practitioners can do about them.
This session presents a series of medical cases with important clinical caveats. Additionally, a contextual discussion follows, focussing on the social determinants of health and their integral importance in delivering high quality care. The practice of acute medicine requires many skills to ensure the delivery of the highest quality care. Clinical knowledge and skill are essential, but equally communication, empathy, social/cultural awareness and advocacy are also vital. Knowing our patients and understanding their circumstances provides a foundation on which clinical practice can then be contextually applied. Without context raw facts can be misleading and even result in misdirected treatment plans.
In this week’s episode of the #CodaPodcast, Gemma Figtree – a Cardiologist and Professor discusses the profound inequality of gender issues.
In this week’s episode of the #CodaPodcast, Dr Daniel Nour – who founded Street Side Medics a not-for-profit, GP-led mobile medical service for people experiencing homelessness - in August 2020 talks about his grave concern for the homeless who have gone untreated for years. He talks about how it was seeing the inequality in healthcare among the homeless that made him want to do something about it and how we often think about their need for shelter and food, but not for suitable healthcare.
He also discusses the barriers that face homeless people and what it was that led him to launch Street Side Medics.
There is a moment that regularly occurs in the life of a clinician working at a major trauma service - where a rotating registrar, a keen sponge - appears, and a discussion about learning goals for the rotation is had. Its always about trauma, I'm here to learn procedures, intercostal catheter insertion, thoracotomies etc etc and if there is a trauma call, I'd love to be involved. But when I point to an older woman in the corner who has fallen from standing height, suggesting that perhaps we start our trauma education there, there are looks of confusion, annoyance even. This patient doesn't fit their expectation of what trauma physician needs to learn. But a trauma physician's paradigm, must evolve.
Healthcare Saves!
Healthcare Pollutes!
Healthcare is responsible for 7% of Australia's carbon emissions, consumes 10% of Australia's GDP, and has numerous other adverse environmental effects.
In this talk, Forbes McGain, an anaesthetist and intensive care physician, introduces healthcare's polluting ways, and how clinicians can mitigate their own carbon footprint. Action is the Antidote to Anxiety!
For more head to our podcast page #CodaPodcast
The chair, Kate Charlesworth opens by explaining that the healthcare system has a big problem – we are, in effect, producing our own patients. We use huge amounts of resources; produce vast amounts of waste and have a big carbon footprint. Globally, if the healthcare system was a country, it would be the fifth biggest polluter on the planet. The irony is then of course that we’re therefore contributing towards the climate crisis which is harming human health. We’ve seen that with storms, fires, floods, and all the associated impact they’re having on our health.
We have a huge job ahead of us – to decarbonise or to get to a net zero health system.
Nick Watts, doctor, and chief sustainability office for the National Health Service in England says that he wants to discuss three things: why the NHS cares about climate change, what we can do about it and exactly what that change needs to looks like. He then goes on to explain the steps that the NHS is taking to reach net zero by 2045, and the exact steps that we need to take in order to do the same.
His three key messages are:
The climate crisis is a health care crisis.
The time for talking about stuff is over, the only thing that matters is what we are going to do about it.
Don’t listen to anyone that tells you that it can’t be done.
For more head to our podcast page #CodaPodcast
Beyond Zero Emissions is an independent think tank that shows through research and innovative solutions how Australia can prosper in a zero-emissions economy. Over the past 10 years we have published research on how to decarbonise sectors of the economy such as energy, transport, buildings and heavy industry.
Healthcare is a significant energy consumer - around 7% of national emissions come from healthcare facilities and services. Within this important sector, energy use holds the most emissions reduction potential, while manufacturing has the strongest ‘multiplier effect’ - the ability to deliver widespread benefits from decarbonisation.
We can power our healthcare sector on 100% renewable energy right now.
Energy is used in health facilities for heating water, air, running medical equipment and keeping the lights on. It is also used in vehicles transporting supplies, patients and staff. With clean technologies available now, e.g. heat pumps and electric vehicles, there are readily-available means to run our healthcare system with renewable energy.
We can power our manufacturing sector on 100% renewable energy right now.
We know what happens when global supply chains are disrupted. A strong onshore manufacturing sector is not only important for a zero-emissions economy, but for all Australian industries - including healthcare. Today, imports meet approximately 80% of domestic demand for medical devices and diagnostics, while nearly all medical technology products manufactured in Australia are exported.
When our healthcare system can source more of its construction materials, products and equipment from local suppliers, we shorten supply links, speed up transport time and provide more onshore jobs supporting this sector.
Beyond Zero Emissions is working with partner organisations around Australia to revitalise our manufacturing sector with 100% renewable energy. We’re building alliances of industry, government and community to support the decarbonisation of local manufacturing and supply chains in regional hubs where it’s needed most.
Resilience for healthcare depends on resilient energy and manufacturing supply chains - and achieving that means more renewable energy powering our economy.
For more head to our podcast page #CodaPodcast
Each speaker delivers a short high impact clinical case from practice ranging from conflict zones to 2 week boarding in the emergency department in India. These cases have been chosen because of the profound personal impact upon the clinician. Following the clinical cases, Ben will facilitate a debrief to explore how these clinicians prepared for, performed in, or recovered from the situations.
Ankur Verma opens the podcast by telling his listeners that he’s going to share with them something that happened during the time that Delta was in its dreadful stages in both Australia and India.
He goes on to talk about a case that took place during the Delta wave, when minutes matter. He recounts a patient - Mrs P - who had come in gasping and immediately went into cardiac arrest, and notes that – as is often the case – she immediately became part of the ward’s family. After testing positive for Covid, they then gave her a CT scan to see if she had pneumonia and subsequently put her on various experimental medications, including steroids.
She got better over the next four or five days and was weaned off the ventilator and over the next couple of days we removed her TPI (trigger point injection) but then her sugars went up. Ankur explains that just when he thought she was becoming much better, she started becoming hypoxic again and he then found out her left lung had collapsed.
She then went on to improve – and, understandably – her family were thrilled, especially her son. After a two-week rollercoaster ride, she was discharged, much to the joy of everyone involved.
At a time of great distress, Ankur explains that Mrs P reminded him and his co-workers of the power of determination and motivation, and it was through a combination of compassion and great determination and motivation that she survived.
He notes that Mrs P gave the hospital staff a ray of hope and a much-needed silver lining during what was an otherwise hellish Covid wave, and notes that he owed her more than she owed him for saving her life.
But, continues Ankur, she had other plans. She had been a ray of hope during the dreadful delta in India and the world and sadly, she died.
But Ankur says that he and his co-workers didn’t lose sight of the vision and the hope that she gave them and that they continued to support each other. He concludes the podcast with an important lesson learnt: take care of yourself and those around you because when the dark times come, those people will be the ones surrounding you.
For more head to our podcast page #CodaPodcast
Bec Szabo – an obstetrician, gynaecologist, and medical educator – begins the podcast by asking the audience to go back to Melbourne with her on a journey through the looking glass. She notes that while taking her listeners to Wonderland might be a bit quirky, but that it’s essential for the point of the story. Bec also wants to preface the talk with a trigger warning; and acknowledges that the subject matter of her talk might be triggering – so please do bear in mind that this talk covers Covid, ICU and pregnancy before listening.
As per the notion of taking her readers through the looking glass, Bec wants to take listeners back to spring 2021 – a time that Melbourne was looking down the barrel of a sixth lockdown. Known as having had one of the longest – and strictest – lockdowns in the world - people in Melbourne were tired and had done a lot. Many were already vaccinated.
Bec then goes on to say that she wants to talk about Covid and pregnancy and, explains to listeners that she wants to paint a picture of inequality and sexism.
She runs through a case of what happened shortly after the Delta strain had arrived in Melbourne – it was a time when things were changing rapidly during covid with delta things came thick and fast. A pregnant woman was admitted to hospital; it was her third child, and her two toddlers, partner and parents were all sick with Covid; and despite concerns over a post-partum haemorrhage, a healthy baby was delivered, and the woman went back to the ICU.
Except, says Bec, this wasn’t what actually happened; what she described was a simulation, carried out in order to ensure they had everything prepared in the case that something similar happened.
She goes on to say that teamwork and communication are everything, but so too is listening to the voice of the patient. And that while we’ve heard that belonging and community and connection are important, having those values and shared goals to keep us doing what we’re doing.
Bec closes the podcast by that we need to remember we’re the captains of our soul. And that if we can be human and kind, we can deal with emotionally fraught situations.
For more head to our podcast page #CodaPodcast
In this week’s podcast Liz Crowe – an advanced clinician social worker who has worked in Brisbane’s major children’s hospitals in intensive care, emergency departments and cancer wards - begins the podcast with the question – is all this talk of burn out, actually making us burnt out?
In this podcast, Liz goes on to address exactly what the term burn out actually means and discusses how the literature on burnout in healthcare workers is prolific. She discusses how healthcare presents as an occupation of high risk, distress, and despair, with an escalation of risk post pandemic. Yet, she says, burnout is not the whole story even though it is the only story being told. Liz speaks about the extensive research into burnout and what it reveals, and the risk factors for burnout, which include excessive workload, lack of control or recognition, mismatch of values, lack of meaning and emotional contagion. However, she notes that none of these are individual deficits and says that it is concerning that ‘wellbeing’ in healthcare is never discussed in terms of meaning making, purpose, contribution, community, stimulating work or growth and development.
Yet, she goes on to say, for many critical care staff these positive factors for wellbeing are found in abundance.
Liz also states that her research shows that people want to believe that the bad stuff happens on one side of life; the good on the other, and people want to know how they get to the other side. Whereas, she says, in reality, life is a crappy mess that sits somewhere in the middle.
The podcast concludes with Liz stating that purpose and community are everything, that life is messy, but some days - despite how awful we feel - we soar because of the opportunities we have. She encourages listeners to savour life, and to remember that even on the worst day of their working life, their patients are doing it tougher.
For more head to our podcast page #CodaPodcast
"Death is not the enemy but occasionally needs help with timing." Peter Josef Safar (1924 – 2003) 'The Father of Modern CPR'
In this week’s episode of the Coda podcast, former flight paramedic Gary Berkowitz – who previously worked in Afghanistan and now works for Queensland Ambulance Service - explores how when death is inevitable, the way of dying matters.
To open the discussion, he addresses the fact that out of hospital emergency care practitioners are often faced with time critical decisions. He notes that fortunately, most of these situations often have clear guidelines because – generally speaking - they follow pathways with expected outcomes.
When it comes to ethics in healthcare, however, it can be a nuanced topic. For example, the decision to not commence resuscitation, or to withdraw life saving measures in a patient who appears to have no meaningful prospect of recovery, can be a difficult one. Gary goes on to note that in this environment, it’s impossible to design a guideline that could encompass all the elements of such a complex decision.
In this talk Gary examines providing care to patients rather than always trying to fight death. By way of example, Gary tells listeners how he was working closely with the various western military forces, when one day they asked a favour – a young Afghani soldier had been badly burnt fighting against the Taliban, and while his treatment had begun in a military hospital, it was decided it shouldn’t be continued there.
Gary was asked if he could assist transporting the soldier to a hospital in the city, and he goes on to talk about the fact that he had two options – to take the easy choice, which would have involved giving the soldier enough medication that he wouldn’t have to see him suffer; or the brave choice – which would have been to give him enough medication so he wouldn’t be suffering at all.
He discusses the ethics around each alternative – and how he came to sit with his final choice. Gary notes that the decision he made that day has remained with him ever since, and continues to influence his decisions in his everyday practice.
For more head to our podcast page #CodaPodcast
Working in medicine presents truly testing challenges for anyone. Adding the uncertainty that comes with autism can take these challenges to new heights. So how do those with autism break down the barriers of their diagnoses to become effective members of the healthcare community? And are there benefits to having such a unique mental approach to tasks?
HEALTH & WELLBEING SPECIALIST LIZ CROWE SITS DOWN WITH CANDICE CARLISLE – A NURSE IN THE ACUTE PAIN SPECIALTY TEAM WHO ALSO HAS AUTISM. CANDICE ADDRESSES THE ASSUMPTIONS, CHALLENGES & UNEXPECTED BENEFITS OF BEING AN AUTISTIC MEMBER OF THE HEALTHCARE WORKFORCE.
Candice begins by recognising the key role that autism plays in her shaping identity, and the importance of not shying away from her diagnosis. In saying this, she also affirms that having autism does not define who she is. Having two children with autism, Candice also ensures that they embrace the condition and see it as a good thing.
CANDICE GOES ON TO EXPLAIN HOW THOSE WITHOUT AUTISM CAN “DO THE RIGHT THING” WHEN ADDRESSING THOSE WITH THE CONDITION.
“For me, just knowing that people have the knowledge,” “…that’s fantastic.” Candice states that recognising autism within conversations and acknowledging the differences in a positive, open-minded light is helpful.
LIZ DIRECTS THE CONVERSATION TO CANDICE’S CAREER AS A NURSE AND HOW HER AUTISM AFFECTS HER WORK.
Candice concedes that the changes brought about by Covid were very difficult to deal with due to her reliance on routine. Different autism-specific anxieties make accepting change very difficult. Despite this, Candice explains that there are unexpected benefits to having autism in her line of work – the standout ones being attention-to-detail and situational awareness. She also explains how mechanisms like mimicry & masking can help autistic people cope in many areas of work and life.
THE PAIR CONCLUDE BY DISCUSSING THE IMPORTANCE OF SUPPORT FROM THOSE WHO DON’T HAVE AUTISM, PARTICULARLY IN THE WORKFORCE.
Tune in to this unique, insightful take on autism with Liz Crowe & Candice Carlisle.
Breaking Barriers: Working in Healthcare with Autism
For more like this, head to our podcast page. #CodaPodcast
Health care constitutes 7% of Australians domestic carbon footprint with hospitals and pharmaceuticals being responsible for almost 2/3rd of these emissions.
We can reduce this carbon burden by addressing our practice habits, taking emissions into account, while achieving best practice care.
Three areas where we can really make a difference are in pathology ordering, asthma management and anaesthetic gases. In each of these, low carbon practice also constitutes good clinical practice, making climate action a win for emissions and a win for our patients.
In this recorded After Hours Webinar presented by Kate Wylie, Dr Roger Harris presents the excellent work that Coda Change is doing to address these three climate actions.
Dr Harris is a co-founder of Coda and a senior staff specialist in the intensive care unit at the Royal North Shore hospital and the Sydney Adventist hospital (SAN). He is dual qualified in Emergency Medicine and Intensive Care and is passionate about education and climate change.
This is a recorded version of an After Hours webinar.
For more like this, head to our podcast page. #CodaPodcast
“5 THINGS YOU CAN DO TO SAVE THE PLANET” with Hugh Montgomery (w. Liz Crowe)
SCIENTIST & CLIMATE EXPERT HUGH MONTGOMERY DISCUSSES THE CONCERNING STATE OF THE PLANET & OUTLINES WHY WE NEED TO BEGIN TAKING REAL, IMMEDIATE ACTION TO SAVE IT.
In this chat with wellbeing specialist Liz Crowe, Hugh begins by addressing the satirical Netflix film “Don’t Look Up” and pointing out that it may not be as far from reality as people think. We’ve been sitting on our hands & ignoring warnings in terms of greenhouse gases for too long, and Hugh warns that the “asteroid is about to strike”.
HUGH CITES REPORTS WHICH CLAIM WE HAVE JUST A FEW YEARS TO TURN AROUND THE CLIMATE CRISIS. HE DETAILS WHAT COULD HAPPEN IF THINGS DON’T CHANGE.
Extreme weather will be one of the most notable signs. Global sea levels will also rise noticeably and temperatures across the world will reach record highs. These will be “colossal changes” according to Hugh. This will lead to up to 2/3 of the world’s population needing to move to try and escape these extreme changes. There is a “rapidly closing window to secure a liveable future”.
BUT WHAT CAN WE DO? HUGH SAYS WE NEED TO BEGIN TAKING RADICAL ACTION.
For those wanting to take greater steps toward saving the planet, Hugh recommends starting with the following ways:
- Buddy up with like-minded people who want to make a change
- Exert your influence to get family & friends to also begin taking action
- Find a good carbon calculator to measure your personal footprint
- Make improvements in whichever areas you can, with emphasis on the more damaging areas like heating, food & transport.
- After making personal changes, shift your focus to your workplace
To finish on a lighter note, Hugh states that “we are the only generation that has ever had the chance to save humanity” and reminds us that yes, we CAN do it.
Tune in to this eye-opening assessment of our ever-changing climate with Hugh Montgomery & Liz Crowe.
For more like this, head to our podcast page
#CodaPodcast
James Anstey provides his thoughts on the recent developments in delayed cerebral ischaemia following a subarachnoid haemorrhage (SAH). Unlike TBI, where outcomes have plateaued after 20 years, outcomes have steadily improved for aneurysmal SAH. Early intervention, with an increasing amount of coiling as opposed to clipping as well as ICU all likely playing a part.
However, there is still a subsection of patients who deteriorate three days or more post their event. This is likely due to delayed cerebral ischaemia (as opposed to pure vasospasm). This is a diagnosis of exclusion in a patient who deteriorates after three days post bleed and without hydrocephalus, seizures, infection or another identifiable causal pathology.
There are several pathophysiological factors at play. Firstly, microcirculatory problems, including vasoconstriction in capillary beds and clumping with endothelial damage. This is perhaps why treatments to improve perfusion have had little success. Next, a combination of cortical spreading ischaemia and angiographic vasospasm.
Gold standard diagnosis of vasospasm remains the catheters angiography. Transcranial Doppler and CT angiography are both being used more and more and certainly have a role to play. CT angiography in particular stacks up reasonably well to catheter angiography and has a negative predictive value approaching 100%. One potential problem is overcalling the narrowing at times and has occasional artefacts. Transcranial Doppler is used occasionally however has challenges with reliable operators, is user dependent and only visualises a part of the cerebral circulation.
Patients deteriorate, and we of course want to make sense of it. But what do we do thereafter? Hypertensive therapy with the aim to improve cerebral perfusion is often the go to method. James shares his thoughts on this technique, with reference to the current literature. Similarly, we diagnose vessel narrowing as the problem, however therapies that reverses this does not seem to confer good clinical outcomes. There is a large list of failed therapies because of this fact.
This raises lots of questions about this patient group. Jame’s main messages are to not become obsessive with vasospasm, use CT angiography as a good substitute for catheter angiography and be cautious of vasodilator therapies as they generally do not seem to affect long term prognosis.
This #CodaPodcast was recorded in November 2018 as part of Brain, a CICM Neuro Special Interest Group meeting.
For more like this, head to our podcast page. #CodaPodcast
Peter Brindley joins you again to bring you The Great Re-Engagement, alongside Pelesa Motshabi Chakane, Silvia Perez-Protto and Andrew Shaw.
This episode explores the future of healthcare, and the ways to utilise the global community, research, and technology to enable greater contentment for clinicians to enable excellent healthcare at a global level.
What will successful medicine look like in 10 years’ time if we get it right? It is a daunting prospect to consider. Palesa hopes that the positivity that has been borne out of the Covid-19 pandemic continues. She believes it will be the capacity for the healthcare system to utilise the unity that has been exhibited over the last two years will be the driving force for ongoing positive change. Ideally, this leads to healthcare for everyone, prevention of sickness and disease and exceptional care for the whole person. Silvia speaks of her dream of the abolition of healthcare disparity and universal access for all.
Andrew hopes that the medical community will engage both science and art to make these dreams reality. Andrew speaks about the integration of technology into the practise of medicine and explores the potential benefits and disadvantages. Further he speaks to the changing nature of healthcare to be servicing customers as opposed to patients. This comes with greater choice for individuals accessing healthcare. He sees this “relationship based” healthcare as key to ensuring technology does not become all consuming.
Prevention, rather than cure, is a key tenant to the development of healthcare in Andrew’s opinion. This sentiment is founded on an agreement to a moral contract by the medical community. The moral contract contains within it a right to affordable and accessible healthcare for all.
Silvia feels poor data collection, especially in terms of underrepresented groups, is hindering the design and implementation of health care systems. The way forward is meaningful engagement with all patients to better design systems. Palesa provides a viewpoint from a system in lower income countries. Whilst the medium and high-income countries are faced with challenges surrounded by the rising use of technology and perhaps patient disengagement, Palesa makes the point that for most of the world, burden of disease is still the major challenge to be faced. Utilising technology in an appropriate way to bridge the gap between low- and high-income countries is the way forward
Balancing education, research and clinical care is another challenge that is becoming more and more apparent. Andrew thinks that clinical care is, and must be, at the forefront of medical practise. It is what the patients hold most highly and for good reason. Whilst education and research are important, these pursuits may be best to be left to those who are legitimately good at them. The team discuss the best ways to balance being pulled in multiple directions whilst keeping the patients at the forefront.
For more like this, head to our podcast page. #CodaPodcast
Climate change is a real and accelerating existential danger. Urgent action is required to halt its progression, and everyone can contribute. Pollution mitigation represents an important opportunity for much needed leadership from the health community, addressing a threat that will directly and seriously impact the health and well-being of current and future generations.
Inhalational anaesthetics are a significant contributor to healthcare-related greenhouse gas emissions and minimising their climate impact represents a meaningful and achievable intervention. A challenge exists in translating well-established knowledge about inhalational anaesthetic pollution into practical action.
This new guideline is designed to provide a platform that engages health professionals as an active learning community, and invites sharing of success stories and evolving solutions across varied global practice settings.
For this podcast, @GongGasGirl interviews @jessahegedus about how they did it and why it is important.
This podcast was recorded for the Anaesthesia Journal.
For more like this, head to our podcast page. #CodaPodcast
In this episode of the #CodaEarth podcast about reducing harmful gases in anaesthesia, host Laura Raiti is joined by Jessica Hegedus - an anaesthetist working in Wollongong, New South Wales, who is also a member of Doctors for the Environment.
As someone passionate about environmental sustainability within anaesthesia, Jessica starts by telling Laura that the one thing that motivates her the most when it comes to the climate crisis is the fact that it’s an emergency that will end up impacting us all; as both citizens living in the community, and professionally as healthcare workers responding to its impacts. This puts many of us in the unique position in that we’re contributing to a crisis inadvertently as healthcare professionals, that we’ll also be on the frontline responding to.
They talk about the importance of reframing climate change as a health problem, and how as healthcare professionals we have the responsibility to protect and preserve health.
Jessica notes that while reducing healthcare admissions won’t resolve the climate crisis, that our leadership is essential, and that healthcare professionals are an important and trusted voice for action. She believes that we can send a powerful signal by getting our own house in order and that all contributions towards a low carbon society are important, however small.
Focus then shifts to the #CodaEarth Action – reducing harmful volatile agents used in anaesthesia - which not only make a significant contribution to CO2 healthcare emissions, but whose use is also directly within our control. Collective attention to reducing the impact is both meaningful and achievable opportunity for healthcare providers to demonstrate their leadership.
Laura and Jess also discuss six evidence-based actions to reduce anaesthetic gas usage that are practical and don’t compromise patient care. The actions include removing Desflurane from clinical use, de-commissioning Nitrous oxide piping, rationalizing Nitrous oxide where possible, advocating that healthcare workers use the lowest possible fresh gas flow, prioritising alternatives that have less environmental impact, and tracking progress, sharing results, and engaging with others.
Jess was inspired due to frustrations with slow progress on climate change, combined with increasingly visible effects of the crisis on the community and her practice, and has found that it can be both empowering and rewarding to exercise advocacy and effect change within her patch.
Jess also tells Laura that she believes there are meaningful actions we can all take that will contribute to a greater whole, and that the potential for healthcare providers to do this is immense. Jess believes that all contributions are meaningful and all roles are important, and that people shouldn’t be deterred by how big the problem is; perfect is the enemy of good and something is better than nothing.
Join Coda Earth now to safely reduce pMDI usage in your own practice.
In this episode of the #CodaEarth podcast, host Laura Raiti speaks to Brett Montgomery, a Perth-based GP & senior lecturer at the University of Western Australia. As someone who is passionate about the climate emergency and the role each of us play in reducing the carbon footprint of healthcare, Brett is also the lead author of our Coda action plan to reduce usage of metered dose inhalers (pMDIs).
To kick off the podcast, Brett touches upon the fact that while much of society sees climate change as a political or environmental issue more commonly associated with polar bears and icebergs melting, he believes it’s important that we begin to see it as a huge public health issue to cultivate real change. Brett believes that by reframing it as an issue that has real and serious health consequences, it will ensure people who aren’t currently concerned by its effect are motivated to act when it comes to both climate change and their own health.
Brett then goes on to discuss in further detail his particular point of focus, which is the overuse of inhalers in healthcare. They discuss that while inhalers may appear to be a minor contribution to our impact as a whole when compared to the likes of aeroplanes and cars, in actual fact they have a disproportionate effect on health system’s carbon footprint.
In fact, the healthcare system in Australia contributes about 7% of our entire national footprint – so not an insignificant number - and within the 7% about a quarter is down to prescriptions, of which, a fair chunk can be attributed to these inhalers.
Laura and Brett then go on to talk about ways in which the Coda community can get involved, and Brett highlights that it’s important that everyone is more mindful about prescribing inhalers and that they employ critical thinking when it comes to ensuring that an inhaler is the right choice for both the patient and the environment.
They explore alternatives such as dry mist or powder inhalers, and consider a study that shows that between a third and a half of people who are prescribed these inhalers struggle to find evidence of the diagnoses.
Finally, they look at what the future could look like for Australia, should we work towards a collective movement against climate change, and discuss leading countries such as the UK and Sweden, both of whom are working towards eradicating overall health emissions.
To close, Brett shares his key piece of advice for those wanting to make change: the best climate action is what you’re good at, what you enjoy and what the world needs.
Join Coda Earth now to safely reduce pMDI usage in your own practice.
In this special podcast focused on the ‘Reduce Pathology Test Ordering’ step of the Coda Earth Action Agenda, host Laura Rati is joined by Forbes McGain. Forbes is an antitheist and intensive care physician who works at Western Health Melbourne and is also an associate professor of medicine at the University of both Sydney and Melbourne. He is passionate about making seemingly small, environmental financial and social sustainability changes to how we practise medicine, and is currently examining ways in which we can make hospitals more sustainable.
To open the podcast, Forbes and Laura discuss exactly what it is that makes Forbes most passionate about championing change when it comes to the environment.
Forbes credits two main driving factors – the first being that he is a strong believer that nature truly is extraordinary and delicate, and thanks to his childhood spent growing up on a farm - he’s really been close to nature, and he believes that loosing that would be deeply sad for people the world over. He also cites that as the father of two children, it’s really important that they get the chance to experience the things he has experienced in his life.
Forbes also touches upon the fact that climate change is just a single example of our overwhelming use of resources on the earth.
Forbes is a passionate advocate of Coda, and believes the global community of healthcare professionals are fantastic in exploring and taking the next step beyond research. He speaks to Coda’s ability to translate medical evidence and data to influence beyond the work practise of just one person.
When discussing how the Coda community can work collectively to make a huge impact on the environment, Forbes states that pathology testing – and the frequent overuse of these tests - is something everyone can be involved in; highlighting that millions of tests around the world can be reduced to lessen the environmental impact.
Laura and Forbes explore the unnecessary amount of atrial blood gas tests (ABG) that are done each year. They examine a hospital case which saw a third of over 65k blood gases performed annually ultimately deemed unnecessary. They consider the fact that everything healthcare professionals do has a carbon footprint, from a single pathology test right through to a new MRI scanner; meaning that reducing these tests has an impact on patients, finances and carbon footprint.
Finally, Forbes offers his advice to those who haven’t yet made climate change a priority, simply stating that educating oneself is the first step, and that while there are certain things you can do alone; there’s a lot more that can be done by collaborating with others.
Join Coda Earth now to reduce unnecessary pathology testing in your own practice.
In part 2 of this episode of the Coda podcast, Coda co-founder Roger Harris is again joined by Sydney-based Chris Anderson and Lausanne-based Frederic Michard, as they discuss how we can do better when it comes to deteriorating patients.
In part 1, the three intensive care specialists explored precisely what a deteriorating patient is, how big a problem they are and exactly why we should care – in this episode Harris, Anderson and Michard now look at ways in which the problem can be resolved.
Hosted by Roger Harris, he is joined by guests Frederic Michard - a Critical Care MD, PhD and Chris Anderson - a fellow intensive care specialist. Roger speaks to Frederic and Chris about ways in which healthcare professionals can recognise deteriorating patients sooner, and how they should be responded to, as well as discussing both solutions and how deteriorating patients can be better detected.
By way of a resolution, the three experts explore the idea of wearable, mobile solutions and – imagining the future of patient monitoring – they discuss what said solutions might look like, and how they will help nurses monitor deteriorating patients.
They also address the question that arises regarding which patients are most in need of monitoring, concluding that it’s those at the greatest risk of clinical deterioration.
Harris, Anderson and Michard also agree that there is reason to believe that new, future techniques will be able to ensure accurate detection of deteriorating patients, and that smarter software will make such a task more streamlined.
Michard finishes by noting the importance that healthcare professionals focus on individualising not only the monitoring that is on offer, but – equally important - precisely who is going to be monitored and when.
For more like this, head to our podcast page. #CodaPodcast
This podcast is sponsored by GE Healthcare.
In this episode of the Coda podcast, Coda co-founder Roger Harris is joined by Sydney-based Chris Anderson and Lausanne-based Frederic Michard, as they explore precisely what a deteriorating patient is, how big a problem they are and exactly why we should care.
Hosted by Roger Harris, guest Frederic Michard is a Critical Care MD, PhD, based in Lausanne, Switzerland, who trained in Paris University Hospitals and in Boston and is well known for his research work and publications, while Chris Anderson is a fellow intensive care specialist, also based in Sydney. Roger speaks to Frederic and Chris about why it is that many patients who are admitted to hospital for surgery end up staying due to complications, and the implications this has on both hospitals and nurses as a whole.
Also touched upon within the podcast is failure to rescue – or FTR – which is the failure or delay in recognizing and responding to a hospitalized patient experiencing complications from a disease process or medical intervention. They discuss the two main components – the failure to detect deterioration at an early stage and the failure to react appropriately and in a timely manner and the impact this can have on patients.
Addressing startling statistics – which suggest an alarming number of patients will die within 30 days of surgery - the three intensive care specialists pose the question: how do we better detect and monitor deteriorating patients?
They discuss everything from the unreliable recordings of respiratory rates to other inaccuracies that can impact both the treatment and detection of deteriorating patients, to the effect older patients on hospital wards are having on the complexity of cases and conclude that there is absolutely room for improvement regarding how patients are monitored.
Reflecting on the influence that Covid has had on hospitals, the three experts note that many health care systems are under strain in the post-pandemic world, and that the subsequent nurse shortages are a huge issue, particularly on hospital wards. They conclude that this too, is a reason to upgrade the way in which our patients are monitored.
For more like this, head to our podcast page. #CodaPodcast
This podcast is sponsored by GE Healthcare.
Following on from the Commit step episode, in which the Coda team discussed turning anxiety into action as a way to start bringing about change, host Dr Laura Raiti - who is both a paediatric oncology fellow, and a Coda team member – speaks to Dr Fintan Hughes, an anaesthesiology resident, about the next step we should be taking as a collective Coda community.
In this episode, Laura and Fintan start by discussing the urgent need to come together to bring about necessary change, which forms the basis for this step – which is to examine our behaviours and the impact they’re having on our own carbon footprint. They touch upon how using a carbon footprint calculator (such as the one on our website) is the first step when it comes to identifying areas in which we can do better by looking at our own personal footprint, and the importance of doing so, without feeling guilty.
From committing to change to examining where that change should start, the podcast explores the idea of flipping the script, and using the calculator to cultivate change and co-ordinated action.
Fintan also talks about how completing a fellowship at University College London inspired him to get involved with Coda; and how he thinks the entire Coda community can get involved to bring about maximum change.
From taking measures to becoming a more ethical shopper, to paying more attention to where you bank, Fintan examines seemingly small and easily accessible steps that every listener can take to make a huge impact on our carbon footprint.
Fintan also shares with listeners his key piece of advice for those who haven’t yet started taking climate action but want to help contribute to bringing about change, and explains how it’s the small things that can make a big difference.
For more head to our podcast page.
In the first episode of Coda Earth’s unmissable new podcast, listeners will hear Coda co-founders Roger Harris and Oli Flower discuss a wide range of topics from exactly how and why Coda came to be, to how each and every one of us can make small, simple, and actionable changes that will make a real difference to the planet.
Hosted by Dr Laura Raiti - who is both a paediatric oncology fellow, and a Coda team member - she speaks to Roger and Oli about just how easy it is to commit to change – and why it’s the first step toward more sustainable healthcare delivery. The three of them discuss everything from the pandemic, to the bigger issue of climate crisis, and exactly why it’s the biggest threat to global health.
They also touch on the fact that while many of us feel helpless as individuals, and that there is a real sense of anxiety in the community, that together, we can turn that anxiety into action.
From committing to adding your voice to the movement, to acting together as a community to have a real impact on our collective carbon footprint, the podcast explores the climate change actions heath care professionals can get involved with, on both a macro and micro level.
Coda is all about taking action wherever possible, and about making such action fun and enjoyable for the whole community, and ensuring both action and advocacy are accessible to as many people as possible. And so, in this podcast you can expect to hear practical pointers on exactly where to start, templates for each action which are very simple to follow, and a selection of simplified tips that really will make a difference. Designed for people at all stages of life, the tips will draw on expertise from all over the world and will give listeners the best possible starting point to make meaningful change.
For more head to our podcast page.
Catalina Sokoloff presents Milrinone for treatment of post-aneurysmal subarachnoid haemorrhage vasospasm (delayed cerebral ischaemia.)
Catalina firsts explains the pathophysiology of delayed cerebral ischaemia. She makes the point that there is still much we do not know. Probable mechanisms at the microcirculation level include release of free radicals, lipid peroxidation, cortical depression spreading and microthrombi formation.
The ideal treatment once delayed cerebral ischaemia is present is therefore unknown. Mechanical angioplasty seems to be favourable in some instances however has its shortcomings. As such it is often reserved as a rescue option. ‘Triple H’ therapy is intended to improve blood flow beyond constricted vessels; however, each component is flawed as Catalina explains. Intraarterial drugs have been tried however similarly, the evidence is lacking.
This brings Catalina to Milrinone. This drug is a phosphodiesterase 3 inhibitor that has vasodilating and inotropic properties. Relevantly, the cerebrovascular smooth muscle contains large amounts of phosphodiesterase 3, making Milrinone promising. The combination of increased cardiac output, alongside decreased afterload theoretically should increase cerebral blood flow and subsequently brain perfusion.
Milrinone has also been shown to be a potent anti-platelet aggregator as well as possessing anti-inflammatory properties. Both processes are likely involved in the pathophysiology of delayed cerebral ischaemia.
Catalina continues to discuss the trials (both animal and human studies) that look at the effect of this drug. Whilst there are still no randomised control trials (at the time of the talk) looking at Milrinone, the early retrospective trial data is promising.
There are of course still obstacles surrounding the drugs Namely, no standard dose, no guidelines regarding titration and concerns surrounding the vasodilating properties.
Catalina concludes by proposing the pros of this treatment as she sees it. She argues that the apparent improvement in mortality, the non-invasive nature, and the lack of haemodynamic compromise are all indicators of the potential future of the treatment.
Please note this episode was recorded in November 2018 as part of Brain, a CICM Neuro Special Interest Group meeting click here for more info.
For more like this, head to our podcast page #CodaPodcast
Communicating Science In A Pandemic (Pt. 2)
The power & presence that social media has in healthcare communication cannot be ignored. However, many are still reluctant to embrace its usefulness as a tool which can enhance education and patient connections.
IN PART 2 OF THIS PODCAST, DR JESSICA STOKES-PARISH CONTINUES TO DISSECT THE ROLE OF SOCIAL MEDIA IN SCIENCE COMMUNICATION, ALONGSIDE REGISTERED NURSES PENNY BLUNDEN (@sick.happens) & PATRICK MCMURRAY (@patmacrn).
The trio begin by addressing the negative tone that accompanies the topic of social media in the nursing community. Patrick explains how this perception should be abandoned and social media should instead be seen & used as an educational tool. Patrick integrates social media into his own role as a clinical educator and knows first-hand how effective it can be when used correctly.
The focus then turns to the importance on educating the educators. Patrick & Penny outline how medical educators must learn how to use social media to expand practice and connect with people. They can then demonstrate to their students how to use the social media tool responsibly, the same way they teach responsible use of stethoscopes or syringes.
Penny goes on to say that there is a need for greater support for nurses online, particularly with regulation. If online regulation guidelines are unclear, nurses can often become un-registered and simply give away unregulated information under the guise of being an “ex-nurse”.
PATRICK & PENNY THEN GIVE TIPS FOR ANY MEDICAL PROFESSIONALS WANTING TO UTILISE SOCIAL MEDIA FOR SCIENCE COMMUNICATION.
Penny highlights the importance of remaining authentic and not comparing yourself to others. This is the way to avoid “imposter syndrome”. She also says that it is essential to always have evidence to back up your claims. Patrick advises to not get caught up in follower numbers. Focus more on quality content and staying true to yourself.
Tune in to this unique, insightful take on science communication through social media with Jessica Stokes-Parish. Communicating Science in a Pandemic (Pt 2).
For more like this, head to our podcast page. #CodaPodcast
In Part 2 of this podcast Hugh Montgomery, Liz Crowe, and Shelly Dev along with Peter Brindley continue their discussion on wellness, resilience, burn out and being a healthcare worker in the world now.
IN THIS EPISODE THE TEAM DISCUSSES THE BROADER ORGANISATION STRUCTURE AND HOW THIS CONTRIBUTES TO (OR DETRACTS FROM) TEAMWORK AND HEALTHCARE WORKER WELLNESS AND SATISFACTION.
Shelly delves into the topic of the organisations and whether they are supporting the clinicians on the ground in the best possible way. Senior leadership, in her opinion, has done a major disservice to healthcare workers in their support and leadership roles. The support needed on the ground transcends yoga classes and healthy cooking recipes. Organisational support needs to acknowledge the needs and desires of healthcare staff, namely, to deliver excellent care and have good days at work in the context of a healthy life.
Liz suggests that although the organisational leadership is important for the overall wellbeing of the workforce, they are one aspect of a broader picture. She believes that leaders should be mentored in leadership. Teaching people basic communication and feedback skills would make a huge difference. Similarly, fostering a culture of togetherness and unity amongst separate entities of a larger organisation would lead to greater worker satisfaction and lead to better outcomes for patients.
HUGH RAISES THE POINT OF CLINICAL OUTCOMES BEING INFLUENCED BY ENGAGEMENT OF HEALTHCARE PROVIDERS BY SENIOR MANAGEMENT.
Management teams engaging with clinical staff seem to increase the patient care being delivered. Hugh provides his thoughts as to why this may be the case. Without senior management support, clinicians are increasingly overworked in a system that is constantly pushing back. This can, and does, lead to staff finally breaking and resigning on the spot.
The core the issue of healthcare worker burnout and dissatisfaction is simple Shelly states. In her view, everyone in healthcare at their core are good and decent people. They desire support and structures that allow them to enact this value in their everyday work. Although the solutions to the broad range of problems facing health systems across the globe are not as straight forward, remembering this fact is a good starting point. From here, the team provide some of their insights into the way forward.
Tune in to this authentic perspective on healthcare worker wellbeing with Peter Brindley, Hugh Montgomery, Liz Crowe & Shelly Dev. Overcoming the Great Resignation through Realisation: Part 2
For more like this, head to our podcast page. #CodaPodcast
This podcast is brought to you by Teleflex
This episode discusses the effect of the pandemic on healthcare professionals at an individual level, and how this has broad reaching ramifications at a team and industry level across different country contexts.
IN THIS PODCAST PETER BRINDLEY IS JOINED BY HUGH MONTGOMERY, LIZ CROWE, AND SHELLY DEV TO DISCUSS WELLNESS, RESILIENCE, BURN OUT AND BEING A HEALTHCARE WORKER IN THE WORLD NOW. THIS EPISODE EXPLORES JOB SECURITY, PUBLIC RECOGNITION, AND THE EFFECT OF THE PANDEMIC AT A PERSONAL LEVEL FOR DOCTORS AND NURSES.
In the context of the pandemic, the good comes with the bad – as Liz explains. Throughout the pandemic we have seen health care professionals experience trying work conditions the world over. However, it is one of the few industries that did not experience staff layoffs and work reduction. On the other hand, all healthcare systems in the world are imperfect. Throwing a pandemic into the mix produced even more challenges. It was therefore unlikely that the mental health and satisfaction from work was going to improve over the past two years.
Hugh discusses the disposition of healthcare workers in London during the pandemic – one of the hardest hit regions in the world. Whilst the pandemic initially provided an opportunity for intensive care doctors and nurses to do what they are trained to do; the ongoing nature has proven to be challenging. The doctors in his system are weary – both mentally and physically.
Shelly highlights the touching nature of working within a close team during this difficult period. In her experience there is a comradery that has been emphasised through the pandemic. However, Shelly states that even in non-pandemic times healthcare workers have struggled to cultivate a healthy relationship with the rest of their lives outside of work. Therefore, her first thoughts at the start of the pandemic were not of the intellectually interesting challenge, but rather what was going to happen with her family. On a broader scale, Shelly posits these hardships may lead to more and more healthcare professionals leaving the industry.
Tune in to this authentic perspective on healthcare worker wellbeing with Peter Brindley, Hugh Montgomery, Liz Crowe & Shelly Dev. Overcoming the Great Resignation through Realisation: Part 1
For more like this, head to our podcast page. #CodaPodcast
This podcast is brought to you by Teleflex
Communicating scientific information as a health professional is far more than just posting healthcare tips online. What can & can’t be posted? Who do we really listen to? And who is allowed to say what?
DR JESSICA STOKES-PARISH CHATS WITH REGISTERED NURSES & SOCIAL MEDIA PERSONALITIES PENNY BLUNDEN (@sick.happens) & PARTICK MCMURRAY (@patmacrn) ABOUT THE BARRIERS FACING HEALTH PROFESSIONALS WHEN COMMUNICATING WITH THEIR AUDIENCES ONLINE.
Picking up where Professor Tim Caulfield’s “Great Rejection” misinformation podcast left off, Dr Jessica Stokes-Parish unpacks the challenge of communicating accurate information via social media as a health professional, specifically nurses. Penny Blunden and Patrick McMurray both have successful, widely-followed social media accounts which they use to provide useful insights into healthcare to mass audiences.
Jessica states how in recent years, including during Covid, she saw a rise in scientific misinformation across social networks. Whilst there was a strong presence of doctors attempting to de-bunk these myths, input from nurses seemed to be far less visible. This is why she recruited Penny & Patrick for some authentic perceptions of the relationship between science and social media.
Both Penny & Patrick outline how their own unique experiences as health professionals led them to use social media to provide more accurate, helpful healthcare information. The group explore the role & presence of nurses online and what kind of content resonates most with audiences. They also unpack how the perception of nurses as second-rate healthcare providers left them without a strong voice for a long time - which is why online accounts like Penny’s & Patrick’s are so vital.
THE TRIO THEN DIVE INTO THE KEY BARRIERS WHICH THEY FACE AS ONLINE INFORMATION PROVIDERS.
Challenges ranging from imposter syndrome & judgement from colleagues to social media policies & regulations are all investigated. Patrick states that existing on social media in a “helpful and meaningful way” must remain top-of-mind.
Tune in to this unique, insightful take on science communication through social media with Jessica Stokes-Parish.
Tune in to this unique, insightful take on science communication through social media with Jessica Stokes-Parish. Communicating Science in a Pandemic (Pt 1).
For more like this, head to our podcast page. #CodaPodcast
Nazih Assaad provides his expertise on the treatment of subarachoid haemorrhage. Treatment for aneurysmal subarachnoid haemorrhage (SAH) is an area that has had extensive research but not a great deal of success. Promising animal studies have not turned out as hoped in clinical trials and many questions remain unanswered. Nazih guides the listener through his approach on how to address the complicated presentation of SAH.
Firstly, subarachnoid haemorrhages can be graded clinically and radiologically. Clinical grades provide useful prognostic information, with poorer grades less likely to do as well as more favourable grades, despite best medical and intervention management. Nazih mentions the Fisher Scale which is useful for predicting vasospasm and how he integrates both into practise.
Nazih will guide you through the four elements in the management of established SAH. Moreover, these are the four areas he believes every clinician working in this space should consider with every patient presenting with a SAH.
The first is the effect of the haemorrhage itself on the patient. The sudden rise of intracranial pressure secondary to aneurysm rupture leads to dramatic clinical signs. These includes loss of consciousness and seizure like activity. There are no known agents to reverse the effects of the initial insult.
Secondly, managing the degree of hydrocephalus that most, if not all, patients will have if critical. Clinical hydrocephalus is treated with CSF drainage.
Thirdly, the prevention of re-haemorrhage is important. In bygone eras, patients with aneurysmal SAH did not have immediate management of the bleed. This has changed.
Finally, delayed cerebral ischaemia (usually relating to vasospasm) should be addressed. Gold standard of diagnosis is digital subtraction angiography, and following this, Nazih describes his aggressive management approach.
Nazih takes the listener through what he considers the most critical aspects of managing a patient with an aneurysmal SAH. This talk explores diagnostic techniques, patient examination, surgical options, and other management considerations. He touches on the most recent guidelines and protocols around Australia and the world.
Please note this episode was recorded in November 2018 as part of Brain, a CICM Neuro Special Interest Group meeting click here for more info.
For more like this, head to our podcast page #CodaPodcast
Whilst US medicine has always had issues, the pandemic sent the practice of medicine into a state of disarray. DR JUSTIN HENSLEY DISCUSSES THE STATE OF US MEDICINE THROUGHOUT THE PANDEMIC. THE POWER OF INSURANCE COMPANIES AND DESPERATE WORKING CONDITIONS IN US HOSPITALS.
In this talk, Justin outlines the "idealistic" view he had of emergency care before working in the ED. However, he was not prepared for the “joyless” nature of a medical system which seemed to place profits above patients.
Through a detailed account of what it’s like to work in the US healthcare system, Justin shares his belief that US medicine is “purely, 100% a business”.
He dives into the unavoidable financial struggles that patients must endure with private insurance companies for even the most basic care. Justin states that, at times, it felt as though he was just “generating a bill for the patient”.
Venturing further into the issue of insurance companies, Justin takes us through his own experience of delivering healthcare to rural Americans. His patient-first philosophy led this project, only to have it shut down due to insurance companies not recognising the importance of his work.
Justin goes on to tackle the issue of burnout. He explains how fear at the beginning of the pandemic saw ED patient numbers drop, meaning less cashflow and dramatic cutting of shifts. Once the patient volumes went back up, staffing failed to appropriately match the new demand. This lead to a burnout-fuelled “logistical nightmare”.
Finally, Justin outlines how “embracing the suck” led him to move to Australia to pursue his current endeavour. He has reignited his passion for providing much-needed healthcare to rural patients.
Tune in to this fascinating take on international healthcare with Dr Justin Hensley. Healthcare Wellbeing: Knowing when it's time for a change
For more like this, head to our podcast page. #CodaPodcast
In part 2 of The Great Rejection, Peter Brindley and Tim Caulfield return to continue their discussion of misinformation in the world of health science. This episode examines how to teach the public to think critically, how to deal with uncertainty as a clinician and how to better understand the pros and cons of transparency.
How do we teach science in an ever-expanding world of knowledge and information? Tim suggests going back to first principles and reinforcing to the public that science is a process. Secondly, Tim highlights how basic educational tools can make a big difference when teaching the public to cut through the noise. Moreover, creating engaging content with accurate messaging can help turn the tide on misinformation in the public realm.
This brings Tim and Peter to the idea of uncertainty and how it sits with the public. The research suggests that the public wants the scientific community to be honest about uncertainty. Reassuringly, the same research tells us that by being honest, an institution or medical body does not lose any credibility. Tim points out the incredible uptake of mask wearing in some countries. This is despite misinformation being disseminated online, an indication of the willingness to acknowledge uncertainty and still act in accordance with advice.
Tim discusses the downsides of population engagement. Whilst transparency is positive on its own, it may not achieve the aims originally intended. Tim highlights public reactions to literature retractions, medical debates, and conflicting results as an example of scientific transparency being counterproductive. However, that is science! And it is messy – as such it does not always lead to good, especially in the short term. However, Tim contends that whilst the ‘backfire effect’ (the negative ramifications of debunking scientific claims) exists, the real-world implications are small. Therefore, scientists and medical professionals should not worry too much about retracting or debunking previously established evidence.
Finally, for more like this, head to our podcast page #CodaPodcast
For more on Tim Caulfield, click here.
Please note this episode was recorded in November 2018 as part of Brain, a CICM Neuro Special Interest Group meeting click here for more info.
Oli Flower gives us a preview into the future of traumatic brain injury (TBI) management. It is late in the 21st century and a man suffers a TBI. Oli describes the on scene immediate management of this patient. Drones and closed-circuit cameras combine to provide the closest ever trauma centre, taking tissue samples and patient images. Not only that, but the samples have been analysed and referenced against a huge database, providing the awaiting critical care clinicians with an individualised and effective treatment plan for each patient.
But, this future depends on information. To develop the technology that Oli envisages, we need to collect more information in the right way. Ultimately, the future of TBI management requires the development of tools to apply masses of information to the patient in a meaningful way.
One such was to achieve this, is by using biobanks. A biobank is a repository of human tissues and samples with the corresponding appropriate and correct annotating data. Specifically, for TBI this primarily means blood and CSF. The tissue is annotated with prognostic information and patient centred long-term outcome data from its donor, allowing a huge pool of information that can be accessed to inform treatment moving forward.
Evidently, the potential for a biobank is enormous. Oli describes rapid genomic assessment, proteomic analysis and metabolomic profiling as potentials in the near future. This data would provide a plethora of information per patient. This does however, pose a challenge, and leads to the need for advanced computer processing to interpret the data, whilst being able to factor in the dynamic and evolving processes that define critical care. Artificial intelligence no doubt has a part to play.
Biobanks have started to be developed across Australia and the world. However, they requires a massive collaboration that spans across countries. In doing so, we can strive towards the future treatment of TBI.
Finally, for more like this, head to our podcast page #CodaPodcast
Peter Brindley and Timothy Caulfield answer the big questions around how science and health are represented in the public sphere.
What is science? When do we accept it and when do we reject it? The representation of science and medical information on social media has erupted in recent times – in large part thanks to the Covid-19 pandemic. Along the way, misinformation has come to the forefront. Why do people believe misinformation, where does it come from and what damage is it doing?
These questions are not new, however in the modern world (pre- and post-Covid) they are in the public conversation more than ever. Tim believes that the spread of misinformation is one of the greatest challenges of today – sparking an ‘Infodemic’. The ideological nature of misinformation has also grown in recent times. Whilst Tim contends that it has always been there, it has become more dominant with the ever-growing popularity of social media.
Social media is not going anywhere. As such, we must learn to live with it, and employ its use in such a way to be proactive and productive. Tim talks to the positives of social media, in particular its ability to decrease feelings of social isolation as well as its entertainment and information value. However, the current information environment rewards extremism, polarisation, and the spread of misinformation.
So, is social media the symptom, the disease or both...? As Tim explains, it is all the above.
How can healthcare professionals move towards a positive use of social media? Tim believes engagement is constructive and he favours healthcare professionals and peak medical bodies being on social media.
Finally, Tim addresses the shifting landscape when it comes to healthcare engaging on social media. Tim believes that clinicians can (and should) share valuable content online.
For more like this, head to our podcast page. #CodaPodcast
Reuben Strayer and Duncan Grossman discuss all things airway. Specifically, how the introduction of many airway technologies at once–some of them revolutionary, some not–have confused our airway strategy. So how can we incorporate the best of these technologies into contemporary airway management? They begin with a big question – what equipment should you choose? There are many options, including direct or video laryngoscopy as well as multiple versions of the laryngoscope blade itself. As Reuben explains, all these terms can be confusing and are often imprecise.
Direct laryngoscopy clears a line of sight between one’s eyes and the glottis to visual it. This is unlike video laryngoscopy which uses a camera to visual the glottis. The next distinction is the type of blade – standard geometry versus hyperangulated blades.
The differences between - and the varying uses of – standard geometry blades and hyperangulated blades are discussed. This discussion will clear up confusion about the nomenclature for all clinicians. The long and the short of it is that a camera can be attached to both standard geometry and hyperangulated blades allowing video laryngoscopy with both. It depends on the clinician’s comfort and training as to which one you will reach for.
However, using a hyperangulated blade does make viewing the cords easier. The hyperangulated blade also requires less force, which is favourable in instances of cervical spine injuries or tongue masses. But, there are downfalls, and Reuben takes us through what to expect.
The standard geometry blade on the other hand is faster, and easier to utilise suction. It is also easier to use a bougie when using a standard geometry blade. Moreover, the standard blade video laryngoscopy uses the same skill set as a direct laryngoscopy and this is beneficial for new learners.
With all the new, wonderful technology available to us, should trainees bother learning traditional techniques? Reuben contends they should for a few reasons. The first being that technology is fragile and can let you down at any moment. The second being that standard geometry video laryngoscopy contains within it the older technique – just with the addition of a video. Therefore, the way to get good at direct laryngoscopy is by getting very, very good at video laryngoscopy.
Jump onboard and join Reuben and Duncan as they provide a masterclass on airways.
For more like this, head to our podcast page #CodaPodcast
Please note this episode was recorded in November 2018 as part of Brain, a CICM Neuro Special Interest Group meeting click here
Terry O’Brien presents the evidence and recommendations around the use of continuous EEG. EEG is an old technology, first introduced clinically in the 1920s. As we move deeper into the 21st century, Terry argues that this technology should be brought to the forefront in ICUs around the world.
EEG works in a simple manner. Electrodes are placed on the scalp, measuring the potential difference between two points, and displaying the trends over time. EEG has a high resolution, providing information that no other investigative modality can provide.
How does this apply to intensive care? Continuous EEG (much like continuous ECG or oxygen saturation monitors), Terry insists, has a place in the monitoring of critically ill patients. It exists as the best way to diagnose a seizure and can provide information regarding treatment effect. Moreover, EEG gives real time information about depth of sedation and prognostication.
Although EEG is standard care in ICU in the United States, Australia is lagging behind. Patients frequently seize in the ICU, particularly after a brain insult or injury. To make matters more complicated, these patients are often sedated, and hooked up to ventilators and other monitoring equipment. This makes the seizure hard to appreciate.
If seizures are unrecognised, the treatment cannot be targeted. This leads to under or over treatment. Terry likens treating seizures in the ICU without EEG monitoring to treating cardiac arrhythmias without an ECG.
Depth electrode recording (in addition to scalp electrode recordings) have been used with interesting results. Looking harder proves to find more seizure activity with the more intense monitoring. Terry describes this as the tip of the iceberg. Does the rest of the iceberg matter? Seizures have been correlated with increased mortality. Seizures may be a prognostic marker in patients with brain injury. There may also be severe long-term morbidity in those patients who experience prolonged non-convulsive seizures in the ICU.
Randomised controlled trials are difficult to perform in this group due to difficulties with ethical questions. This means the majority of evidence is circumstantial. With that being said, the evidence seems to suggest the in-hospital mortality is less for certain populations with the use of continuous EEG without adding significantly to length of hospital stay. Experimental data also shows promise, as Terry explains. He elaborates on the most recent studies looking at continuous EEG.
Who should get continuous EEG, and how should it be used. Terry proposes the continuous EEG be used in the diagnosis of non-convulsive seizures and the treatment of non-convulsive seizures in the comatose patient – especially in the first 48 hours. Similarly, the use of EEG should be prioritised in patients with a history of seizures. In doing so, Terry believes that ICU patient outcomes and survival will be increased.
Please note this episode was recorded in November 2018 as part of Brain, a CICM Neuro Special Interest Group meeting.
Alex Rowell, Fahad Ashraf, Greg Selkirk & Luke Torre continue their discussion stroke management. In this talk they tackle imaging and treatment of stroke, including mechanical thrombectomy. Imaging is an enormous part of the process of stroke management. It is critical for diagnosis and stratifying patient treatments.
The first imaging modality to order is a non-contrast CT head. As Greg explains, not everyone with neurological symptoms has an ischemic stroke. Other diagnoses to consider include Todd’s paresis and intracranial haemorrhage. The CT will also inform the clinician how much established infarct is present and give an indication of where the clot is.
Moreover, carotid angiogram should be used to assess the intracranial vessels. It also allows one to plan the fastest way to remove a clot, should it be present. Transradial and transfemoral thrombectomy are two options. The imaging provides the clinician with valuable information about the most efficient and fastest way of reaching the clot for removal.
Lastly, the team discuss CT perfusion. A word of warning. This exists as a problem-solving test. It is a good idea to interpret with caution!
Evidently, geographical location and the availability of imaging resources restricts imaging. Where CT scanning is available, this modality combined with a thorough history and assessment of deficits can lead the clinician towards the most appropriate treatment options – including thrombolysis.
The question then becomes, does the use of thrombolysis in a rural or remote location preclude the eventual use of thrombectomy? As Greg explains, thrombolysis works well in conjunction with thrombectomy. Receiving thrombolysis does not preclude the use of thrombectomy and does offer advantages.
Furthermore, Greg will provide a detailed description on the procedure of thrombectomy, including the various methods used and the care of the patient after a thrombectomy. He touches on the use of general anaesthesia during the procedure, as well as antiplatelet therapy post-intervention.
Thrombectomies are not without risks. Complications include perforation of blood vessels. From a neurological perspective, Fahad describes the use of repeat scanning to ensure the absence of any subsequent bleeding and the implications for ongoing medical therapy.
Finally, the discussion concludes with a broader take on stroke services in general. This includes pre-hospital stroke awareness in the community, post stroke rehabilitation and neuroprotection measures.
For more head to our podcast page #CodaPodcast
Please see the webpage for the images referred to in this talk.
In this podcast, Alex Rowell, Fahad Ashraf, Greg Selkirk & Luke Torre review stroke management in 2022. Stroke management has changed dramatically in the last 10 years. In 2015, we proved the efficacy of mechanical thrombectomy. In 2018, we established evidence for mechanical thrombectomy beyond 6 hours in patients with favourable imaging. Moreover, there has been extensive research into dual anti-platelet therapy to prevent recurring stroke in minor stroke patients.
From a technical point of view, there has been an explosion of the number of suction catheters and stent retrievers on the market. This has made mechanical thrombectomy safer & has allowed us to chase distal clots.
So in 2022, it is not just that we are doing thrombectomy, but… we are doing it better.
And as a result, we are improving patient outcomes. Next, Fahad & Greg discuss what the patient journey looks like in 2022 from being out in the community, to receiving treatment. They discuss how we have streamlined the process - including creating general awareness of stroke in the public, implementing screening tests like FAST & coordinating with emergency first responders.
The challenge in modern day stroke treatment is how to determine which patients get thrombectomy, which patients get thrombolysis & which patients are given conservative treatment?
Greg Selkirk suggests that there are five main factors:
- Does the patient have severe cognitive impairment (what is their pre-existing quality of life?)
- What is their functional status?
- Where is the location of the clot and what is the risk of removing it?
- What symptoms does this patient have? Do the symptoms justify the risk?
- How much salvageable parenchyma is there?
Tune in to a #CodaPodcast by Alex Rowell, Fahad Ashraf, Greg Selkirk & Luke Torre. An informative & interesting update on stroke management in 2022.
Finally, for more like this head to our podcast page #CodaPodcast
In the Emergency Management of Chronic Pain podcast, Duncan Grossman and Reuben Strayer discuss how and why patients with chronic pain present to the ED.
Managing patients with chronic pain is challenging and often it feels like these patients present to the ED during every shift. But… is it as common as it feels?
Statistics suggest that 20% of American adults suffer from chronic pain.
Why? Well, opioids are both the disease and the cure. Opioids are effective for managing acute pain. However, when they are used for (even) more than a couple of days they can start to cause pain.
Therefore, we have to understand the spectrum of opioid benefit vs harm. Reuben and Duncan discuss a framework that accounts for the relationship between chronic pain and opioid use. Noting that each patient presents a unique challenge.
Take for example, the patient who is on daily, low dose opioids but is otherwise unaffected by their pain medication.
Or, the patient who has chronic pain but doesn’t take opioids. We need to be careful here as these patients can be more susceptible to developing an addiction from prescribed opioids due to their ongoing pain.
What about the patient who takes opioids daily but is buying them off the street...
Reuben takes us through some strategies for helping all of these patients. One such strategy is to talk to the prescribers. We need to help these patients by encouraging their prescribers to take the reins and to move the needle from opioid harm to opioid benefit.
Tune in as Duncan Grossman grills Reuben Strayer on chronic pain in patients, how to manage them and how to help them.
For more like this, head to our podcast page #CodaPodcast
In this podcast, Roger Harris sits down for a second time with South African Emergency Physician, Victoria Stephen (Tori).
Tori delves deeper into her first hand experience of the frightening political unrest and violence which erupted during the third wave of Covid-19 in Johannesburg in mid-2021. Managing Covid cases and gunshot wounds simultaneously was incredibly challenging both professionally and personally.
In the midst of the violence, Victoria made the courageous decision to leave the safety of her home after curfew and to drive through the riots to get to the hospital. Tori was not rostered on at the hospital that night, but she felt an overwhelming need to help her junior staff manage the chaos that was unfolding. It was a critical and intensely dangerous time in South Africa.
Reflecting on this experience, Tori emphasises the importance of a strong foundation of healthcare worker wellbeing. She identifies the need first to look after ourselves before we can look after others.
Tori speaks candidly about how she managed her own wellbeing through the three waves of Covid in South Africa. This included personally seeing a psychologist to help her process the situation, a regular exercise routine, meditating, and listening to music. In fact, Tori started a ‘survival’ playlist that other clinicians from all over the country listened and contributed to! We’ve included a link to the playlist here.
Ultimately, it is difficult to stay passionate about a job that is physically and emotionally exhausting. Staying focused on clinical medicine helps. But at the end of the day, healthcare is a tough job and it takes its toll!
For more like this, head to our #CodaPodcast page
Trauma Resuscitation and the Covid-19 Pandemic in South Africa
In this podcast, Roger Harris interviews Victoria Stephen about her experience as an emergency physician in a regional South African hospital.
Sadly, trauma resuscitation is a big part of working in Emergency Medicine in South Africa. Blunt force assaults and stab wounds are regular presentations.
However, July 2021 was unlike anything Doctor Victoria Stephen had ever experienced.
In July, South Africa was deep into its' third wave of Covid-19 infections. Vaccination rates were low and there was a huge burden of Covid patients in the Emergency Department. The ICU was completely overwhelmed, making this by far the worst of the pandemic that they had seen to date.
To compound this, piped oxygen levels were running desperately low. The hospital relied on daily oxygen deliveries to keep Covid patients alive.
Moreover, to add to the challenge, political unrest broke out and quickly escalated to riots with extreme violence across South Africa.
At the time the violence erupted, Tori had over 120 Covid patients in the hospital. Added to this the Trauma resuscitation was managing approximately 34 patients with gunshot wounds per day. With just four doctors working at night and six doctors working during the day, Tori’s team scrambled to manage an overwhelming number of high acuity patients.
For the first time in her career, Tori found herself frightened for her safety. Having grown up in South Africa, Tori was no stranger to avoiding danger but this felt very out of control.
The thought of managing a busy emergency department inundated with trauma patients in the middle of the covid pandemic is frightening enough for most of us, but to do so in such a resource-limited environment with so few nurses and doctors is truly incredible. Tori believes Emergency Medicine training in South Africa prepares the team to function under such pressure. She believes that the team knows that the lack of resources means they must all pull together. Their training is diverse enough that they have the mental and clinical skills to step up and of course as an ultrasound geek Tori adds that EFAST scanning has a big role to play.
Tori is a humble but inspirational clinician on the frontline of providing care in a volatile environment and she believes we can all learn something from her experience. Tune in to a compelling conversation with one of our favourites.
Trauma Resuscitation and the Covid-19 Pandemic in South Africa
Finally, for more like this head to our podcast page #CodaPodcast
Tune in to a cross over episode with Simulcast, as Jesse Spurr and Victoria Brazil discuss Safety-II, Drugs and Design Sprints in Intensive Care.
In this episode, Vic and Jesse catch up to talk through a human centred design project aimed at improving medication safety in the Intensive Care Unit.
Vic and Jesse discuss real world applications of Safety-II approaches, the core philosophy and practices of psychological safety and the importance of clinician led approaches to risk in practice.
The episode closes with drawing parallels between this work and the skills and practices of simulation.
Safety-II, Drugs and Design Sprints in Intensive Care
For more like this head to our podcast page #CodaPodcast
Or, head to Simulcast to hear more from Vic, Jesse & the team.
Irma Bilgrami, Alissa Starritt and Paula Lyons believe that the pandemic has narrowed the great divide between ICU and ward care.
Covid has put incredible pressure on healthcare systems around the world. This has forced hospitals into overdrive, whereby staff have been redeployed and models of care have changed.
Evidently, the pandemic has challenged the strict guidelines which we use to direct patient care and define critical illness. Wards are managing patients with much higher acuity, sparking the danger of normalising the abnormal.
How do we navigate these murky waters? Irma, Alissa and Paula take a deep dive into these challenging issues. Irma asks, how are the wards going? How are the staff going? And importantly, what lessons can we take away for the future?
Additionally, they address the health and wellbeing of staff in our hospitals after a challenging two years.
Evidently, healthcare professionals and nurses have found themselves with increased workloads, providing clinical support, emotional support and teaching support all in one go.
Irma, Alissa and Paula explain that there are lessons to be learnt from the pandemic.
The pandemic has forced some of the existing hierarchical walls to come down and there is opportunity for us to critically think about how we can work differently in the future.
Tune in to hear the full discussion: How the pandemic narrowed the great divide between ICU and ward care.
Finally, for more like this head to our podcast page #CodaPodcast
In this cross over chat between Medical Mums and Coda, Dr Chris Bowles & A/Prof Nada Hamad discuss gender equity – What is it and why does it matter?
Chris and Nada take a deep dive into gender equity in medicine, the impact of the pandemic and the possible solutions.
First, they discuss the difference between gender equity and equality. Equality is the act of treating everyone the same. Whereas equity, focuses on levelling the playing field so that there is more representation and participation. This includes asking questions such as why inequity exists? And why aren’t women progressing?
Evidently, women experience gender inequity at different times of their career. It may be after they’ve had children, or it may be when they want to step up and take on leadership roles.
What is most obvious however, is that the impact of gender inequity in medicine extends far past the individual. Gender inequity impacts how we look after female patients, what kinds of questions we ask in research and how we perform and apply that research in the context of women’s healthcare.
Chris and Nada discuss what needs to happen to make the system more accommodating.
This includes implicit bias training, intersectionality training and leadership training. Investment in leadership skills and training is crucial. We can have all of the right policies in place, however if leadership doesn’t set the standard to encourage uptake, inequity will always exist.
Join Emergency & Trauma physician, Dr Chris Bowles and Haematologist, Dr Nada Hamad, as they discuss gender inequity in medicine. They inspire us to identify and challenge the inequity that exists today.
For more like this, head to our podcast page. #CodaPodcast
From CodaZero Live, Steve Morgan talks to us about temporary mechanical circulatory support in cardiogenic shock.
Steve gives an example of a patient with refractory cardiogenic shock, who hasn’t responded to pharmacological support. So, how do we go about choosing between temporary circulatory support options?
First, Steve acknowledges that critical care echocardiography is central.
Additionally, he discusses the use of pulmonary artery catheters.
Finally, Steve hopes that future Randomised Control Trials might contribute to a better evidence base to guide the use of these supports in specific patients.
Finally, for more, head to our podcast page #CodaPodcast
Brain injury outcomes and predictors by Kiran Lele
Being able to prognosticate in the aftermath of a traumatic brain injury (TBI) is important as it assists with counselling patients and families. Moreover, it helps rationally allocate healthcare resources.
However, due to the heterogenous nature of TBI and variable pre brain injury patient factors and post brain injury course, this has proven to be a difficult task.
Large cohort studies have enabled improved accuracy in the prediction of 6 month mortality and unfavourable outcome.
Furthermore, many of the factors that contribute to long-term outcome have also emerged. However, it is not yet possible to use them in prediction algorithms or mathematical models.
There is emerging evidence that pre injury psychosocial and demographic factors may be of more relevance than injury severity. Moreover, that 'outcome' becomes increasingly subjective and complex as the post injury duration increases.
We end with three brief vignettes which highlight the fraught nature of long term outcome prediction.
For more head to, https://codachange.org/podcasts/
In this podcast, Celia Bradford talks to Bing Brotohusodo about a challenging time in his life.
Early in 2020, Bing contracted COVID-19.
This resulted in a two-month hospital stay and admission to the ICU.
Celia was one of Bing's physicians and together, they reflect on Bing's time in hospital and his recovery.
Bing was as a helpful patient. So much so, that he was able to prone himself!
However, Celia recalls how challenging it was treating Covid in those early days. Staff were desperately trying to work out what Covid was and how best to treat it. The question of "are we doing the right thing?" was always in the back of people's minds.
Furthermore, this was exacerbated by the confusion of multiple treatments being promoted in the media. There were countless opinions about how Covid should be treated. Information was flowing fast, making it challenging to discern what the best way forward was.
Celia and Bing reflect on Bing's time in ICU and his post-COVID recovery.
Tune in to a podcast from #CodaZero Live on a patient's perspective of COVID-19.
For more head to https://codachange.org/podcasts/
In this second episode on vascular access, the team from the Australian Vascular Access Society (AVAS) discuss vessel assessment with RaCeVa and RaPeVa as well as the use of Micropuncture and establishing optimal catheter tip position.
Before puncturing a vessel for vascular access it is important to: 1. Trace the anatomy of the vascular pathway for aberrancy 2. Ensure that the vessel calibre is suitable for the chosen catheter 3. Ensure no obstruction with thrombus or occlusion
Moreover, it is vital that the catheter doesn't occupy more than one-third of the diameter of the vessel. This will significantly reduce venous blood flow and increase the risk of catheter-related thrombosis. For PICC line insertion the arm can be divided into three zones to select an optimal vessel puncture site. The brachial fossa region is a "Red - no Go" zone, the mid-arm is the "Green - Optimal" zone and the proximal third of the arm is a "Yellow - Axillary" zone.
When inserting a line, the catheter tip should be at the cavoatrial junction approximately 3-5cm below the carina on a chest X-ray. The use of a navigation system like catheter tip ECG (intracavitary ECG) is extremely accurate. It is often still useful in patients in atrial fibrillation but more difficult for patients' with paced rhythms.
For more like this, head to codachange.org/podcasts/
The prehospital management of patients with moderate and severe TBI can be complex.
In this podcast, Marty Nichols talks us through managing patients with TBI in a prehospital environment. This involves avoiding hypoxia and hypotension, ensuring a safe transportation and getting to the right treatment centre the first time.
Notably, due to the nature of the accident, patients with a severe head injury also often present with other injuries. Managing multiple injuries at the same time has implications for how TBI's are managed and treated in prehospital settings.
First and foremost, clinician's should prioritise the prevention of hypoxia and hypotension when managing TBI patients. This includes effective airway management, however, airway management and the prevention of hypotension present some of the greatest challenges to clinicians.
Marty discusses the challenges in treating patients with TBI in prehospital environments. Furthermore, he discusses the processes in place which help to ensure that these patients have the best possible outcomes.
For more head to https://codachange.org/podcasts/
In this podcast, Ed Litton summarises 10 clinical trials in 10 minutes. Ed invites you to choose, based on the title alone, whether the findings were consistent with, or contrary to, the study hypothesis.
Ed discusses 10 non-covid clinical trials, all published in 2020. Notably, all of these were published in the New England Journal, JAMA or Lancet and had important findings.
The following hypothesises are discussed: 10. Firstly, the impact of resident physician schedules and the affect on patient safety.
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Early initiation of renal replacement therapy and whether this improved outcomes for Acute Kidney Injury.
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Does the implementation of early ECMO improve outcomes for patients with refractory VF and out of hospital cardiac arrest?
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Then, can a machine learning algorithm reduce hypotensive severity?
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In mechanically ventilated patients, is an approach of non sedation superior to light sedation?
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Moreover, in patients who are ready for decannulation, does timing based on the suctioning frequency improve outcomes?
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Does administering high dose tranexamic acid in patients with upper or lower GI bleeds decrease mortality?
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Next, does a decreased exposure to vasopressors improve outcomes in older critically ill patients?
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Will starting Dexmedetomidine at the time of cardiac surgery reduce AF and delirium in patients?
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Also, will being conservative with oxygen in patients with ARDS improve outcomes?
Tune in to a talk by Ed Litton as he shares the top 10 papers of 2020 in 10 minutes.
Finally, for more podcasts head to https://codachange.org/podcasts/
In this podcast, Claire discusses the role of clinician communication and its impact on acute pain management.
Claire explains how pain management outcomes can be optimised by enhancing patient expectations of benefit via patient-provider communication.
Firstly, what we say to patients matters. Secondly, how we say it also matters.
Pain is a complex phenomenon and managing expectations of pain and people’s experience of empathy is crucial.
As healthcare professionals, we see multiple patients and are often run off our feet, but, as the studies clearly demonstrate… communication matters. And it matters a lot in pain management.
This presentation shares research demonstrating the impact of clinician communication.
Specifically, this includes how clinicians' talk about pain and pain management. Claire discusses the importance of patients' experience of pain, the effectiveness of pain management and patients' treatment outcomes.
From CodaZero Live, tune in to a fascinating discussion on the importance of communication.
For more like this, head to https://codachange.org/podcasts/
From CodaZero Live, Alex Rowell reviews the available advanced liver supports for patients with acute liver failure.
Artificial supports for the liver are quite complex and difficult. This is largely due to the liver's complex function.
Some of the advanced liver supports include CVVHDF, Molecular Adsorbent Recirculating System (MARS), Single Pass Albumin Dialysis (SPAD) and high volume plasma exchange.
In this podcast, Alex takes us through the research and evidence for these supports and shares some guidance on when they should be used.
CVVHDF is familiar and effective but we need to remember to use it early with acute liver failure patients.
Furthermore, Molecular Adsorbent Recirculating System (MARS) is widely studied but unfortunately not available in all places.
Single Pass Albumin Dialysis (SPAD) is easily implemented. Although there is less evidence on SPAD, it is generally agreed to be an effective support.
Unfortunately, there are no mortality benefits in any of these supports. They are however, useful tools in bridging to transplant.
For more head to https://codachange.org/podcasts/
In this podcast, Ruth provides a summary of surgical considerations when managing an injured spine patient. She covers imaging considerations, indications for surgery and challenges to delivering excellent surgical care. Ruth shares a story of one of the most severely injured patients she has ever looked after. A 78 year old woman came into a trauma centre having been driven over by a 4WD... twice. She had a fractured lower limb, significant chest trauma, a significantly deformed torso, she could not feel or move her legs (other than wiggle her toes slightly) and she had tyre marks on her torso... When looking at her injuries, it was clear that she had a significant group of chest injuries. This is an important reminder that spine trauma happens in the context of multi trauma. This subsequently impacts every step of the care process including surgical planning and management. The objective from the outset is to try and get patients like this to theatre as quickly as possible but there are surgical considerations to take in to account. Tune in to an incredible story as Ruth shares that the key to success is simple things done well, done consistently and in a team environment. For more head to https://codachange.org/podcasts/
Chris provides a brief update on some of the postulated underlying mechanisms involved in subarachnoid haemorrhage associated brain injury.
These mechanisms provide hints to future therapeutic targets that will hopefully expand our currently limited repertoire of options.
Subarachnoid haemorrhage is a catastrophic type of stroke. Subarachnoid haemorrhage represents only 5% of the total stroke burden. Notably however, as it is most common in people aged 40-60 years, it has a disproportionate effect from a personal, social and economic perspective.
Subarachnoid haemorrhage classically presents as a thunder clap headache and loss of consciousness. Unfortunately, it is associated with high morbidity and mortality rates.
There is limited research in this area and there is significant opportunity to improve the way that we manage these cases.
The key is understanding the link between early brain injury and why we develop delayed cerebral ischemia. How can we stop this from happening? How can we better understand why good brains go bad?
From #CodaZero Live, Christopher Andersen provides an update on delayed cerebral ischaemia. Join Chris as he looks for future treatment options through the mechanism of brain injury in subarachnoid haemorrhage.
For more like this, head to our podcast page. #CodaPodcast
TBI Management: Beyond the Resus Room by Andrew Chow
In this podcast, Andrew Chow highlights the latest evidence for TBI. Andrew shares some clinical pearls for TBI management & highlights a future direction for the management of patients with a traumatic brain injury.
Studies have shown that the demographic of TBI patients has shifted. We are now seeing an increase in the number of elderly patients with a TBI injury that need intensive care admission.
Andrew suggests that with this change in demographic, we need to consider different injury patterns and treatment protocols.
Andrew provides a summary of the latest evidence impacting intensive care management of patients with TBI.
He shares some clinical pearls and provides a brief run through of multi-modal advanced neuro monitoring.
One thing is for sure and that is that our knowledge of TBI is still growing.
The future of TBI management is evolving and Andrew predicts that it will be individualised, patient centric and involve multi-modal monitoring.
For more like this, head to our podcast page. #CodaPodcast
From #CodaZero Live, Behny explains the importance of Echo and lists some of the ways in which Echo can help us during a cardiac arrest. It is more than we think!
Echo is a quick, easy and simple tool, making it invaluable in many situations including cardiac arrests. It is a bedside test that is non invasive and painless for the patient. It is easily taught to any doctor or nurse and is performed in real time at the bedside. It can be used to guide and inform management and treatment, so why isn't everyone embracing Echo? Behny challenges us to consider another bedside tool which compares to the effectiveness and usefulness of Echo. Moreover, in the chaos of cardiac arrests, Echo can help to exclude some of the 4Hs & 4Ts. It can help to check the rhythm, check the quality of compressions and assess for post-resuscitation care. It is an invaluable tool in managing a patient suffering cardiac arrest. Behny suggests that the focused 2D echo is our generations stethoscope. We need to open our minds and embrace the capabilities of Echo and challenge each other to learn how to effectively utilise this tool in times that matter. Tune in to a fascinating podcast by Behny Samadi on the value of Echo in Cardiac Arrest.
For more like this, head to https://codachange.org/podcasts/
Updates in pain management by Gavin Pattullo
Opioids are often a mainstay of therapy in trauma pain, though they are in turn the cause of much trauma. For every 4000 Australians prescribed an opioid there will be one death in the community as a result. In-patients similarly have greater risk of harm when their analgesia is opioid based.
This presentation will focus on some of the valuable lessons learnt in pain management resulting from the opioid crisis. These include:
- Our need to differentiate clinically between pain and nociception. Pain - the affective unpleasant experience - is assessed by clinicians enquiring with the use of the words: coping, bothersomeness and troubling. While nociception is focussed on asking about physical feelings and sensations.
Profound levels of nociception and the potential to lead to reports of significant pain, a major feature of trauma patients, requires firstly a focus on the two most effective anti-nociceptive strategies of neural blockade and NSAIDs/COX-2 inhibitors before introducing less effective strategies.
- Pain, the affective distressing unpleasant experience, when present with or without the use of anti-nociceptive strategies has historically been managed solely with biological strategies of opioids and adjuvant agents. An increasing focus in clinical practice on non-pharmacological strategies to manage pain, including placebo enhancing communication strategies and message framing.
- Avoidance of over-reliance on pain scores. Clinicians are too often misled and poor decisions are made when the robustness of pain scores is over-relied upon. Pain scores can be useful provided there is clear understanding in both the enquirer and the patient of whether the question is relating to the level of nociception or pain being experienced.
- Ensuring optimal effectiveness of the opioid avoiding strategy of neural blockade. Four clinical assessment endpoints indicate effectiveness of neural blockade: presence of Dynamic pain relief, Analgesia, Sensory anaesthesia and Opioid sparing/elimination (DASO).
For more head to: codachange.org/podcasts/
In this podcast, Ken Sakurai provides an update on the recent RCTs for Vitamin C in Sepsis.
The battle against sepsis continues, with Vitamin C the most recent weapon in our arsenal. Since Prof. Marik’s 2017 trial on metabolic resuscitation, there has been renewed interest in the use of vitamin C.
Ken reviews the rationale and pre-clinical evidence for Vitamin C use in treatments, as well as the most recent RCTs for Vitamin C in Sepsis.
For more head to: codachange.org/podcasts
Oli covers the initial management of patients with traumatic cervical spinal cord injury. He covers the neurological assessment – how and why we do the ASIA or ISNCSCI Exam and why it matters. It’s not always straight forward, but getting a motor and sensory level and determining if a patient has perianal sensation and voluntary anal contraction can be really helpful prognostically.
The importance of avoiding hypoxia, including ways to manage an airway in this context are then discussed.
Oli then talks blood pressure targets – still a controversial area, but aiming for a MAP > 85 mmHg may really help. Hypotension definitely doesn’t help.
Timing of surgery is another hot topic in acute SCI. Low quality evidence suggests surgery in <8 hours of injury improves outcomes, but is this true and achievable? There are many potential benefits in doing surgery early, but it requires the whole healthcare system to work together to make it happen. The age-old topic of steroids in SCI is touched on; nothing new here, with most centres still avoiding methyl prednisolone.
For more head to: codachange.org/podcasts/
The importance of sex and gender in medical research.
For many years it was widely assumed that the occurrence and outcome of disease was the same for women and men.
Our understanding was that studies involving only men would be equally relevant for women. In the last two decades however, it has been shown that this assumption is highly prejudice and can have a detrimental impact on the health of women.
It is, therefore, really important to incorporate a sex and gender research lens in medical research.
First, Kelly makes the important distinction between sex and gender and how this can impact medical diagnosis, treatment and outcomes.
Then, she identifies how the incorporation of sex and gender into research has allowed for advancements across healthcare: Improved accuracy, avoiding misinterpretation, reduced unintentional bias and greater social equity to name a few.
In this presentation, Kelly Thompson refers to case studies to examine the differences in the interpretation of health data when examining through a sex and gender research lens.
The severity of disease, risk factors and treatment effectiveness are just a few of the reasons why this is so important.
Kelly encourages researchers to ensure gender diversity in the research team and to explain how sex and gender are accounted for in research applications moving forward.
For more head to: codachange.org/podcasts/
Vascular Access Part 1: Reducing risk and increasing catheter longevity The aim of having a structured decision matrix in the approach to vascular access is to reduce catheter-associated complications and to increase device longevity. There are over 15,000 central venous catheters placed in Australia annually. The actual insertion process for placing a central line only accounts for a small part of the 'life span' of that line (approximately 1%), but the choices made at the time of insertion have a huge impact on the longevity of the device and the associated complications. In this introductory talk Evan Alexandrou outlines the top ten tips for reducing complications associated with vascular access devices: 1. Always use ultrasound: Never do a blind puncture 2. Ensure with the site chosen for the catheter that it exits the skin on a flat surface. 3. Consider the Axillary vein in preference for the subclavian vein 4. Use micro-puncture techniques 5. Avoid using a scalpel if possible 6. Avoid catheters being inserted all the way to the hub 7. Use impregnated dressings when possible 8. Use sutureless securing techniques 9. Secure the dressing on a flat surface (refer rule 2) 10. Ensure optimal positioning of the catheter tip by utilising ultrasound or intracavitary ECG
We hope you enjoy part 1 of the Vascular Access series: Reducing risk and increasing catheter longevity by Evan Alexandrou. For more head to: codachange.org/podcasts
From #CodaZero Live, Varun Harish provides an overview of the surgical management of burn injuries.
He talks us through how surgeons make decisions regarding burn management, including the importance of early assessment and intervention.
Burns evolve, what you see at the beginning is going to be very different in 24 hours and different again in three days.
Importantly, the management and principles of intervention differ for minor burns compared to severe burns.
For smaller burns, the golden rule is two weeks. If there is a good chance that the burn will heal in two weeks, intervention is avoided. If this is not the case, intervention in the way of a skin graft or other surgical procedure is usually the best option.
Varun details how the management priorities shift for larger burns. Larger burns significantly increase the chances of infection, making it important to intervene earlier rather than later.
Tune in to an interesting talk on the Surgical management of burn injuries by Varun Harish.
For more head to: codachange.org/podcasts
Global warming and the Jellyfish toxidrome.
From #CodaZero Live, Alice Young provides a brief update on the presentation, complications and management of Irukandji syndrome; and why we all need to know about it.
With ocean temperatures rising we are seeing an increasing number of Irukandji jellyfish and subsequent stings in waters further and further south.
On average there are approximately 50-100 people stung every year in Australia.
Reports show that people typically experience symptoms between five minutes and two hours post sting. Symptoms include systemic symptoms, severe pain, headaches, shortness of breath and often what is described as an impending sense of doom.
Irukandji jellyfish have the potential to cause Irukandji syndrome - a life threatening envenomation syndrome that causes severe pain, heart failure and intracranial haemorrhage.
As these jellyfish stings are becoming more and more common in southern regions of Australia, it is important that healthcare workers understand the characteristics of the sting and how to respond with treatment.
Listen to the full episode "Global warming and the Jellyfish toxidrome" wherever you get your podcasts.
For more head to: codachange.org/podcasts
Did you know that around a third of patients that present with a severe burn, also have a pre-existing mental health condition? Furthermore, around 80% of patients report having had a major life event or severe stress prior to the burn. Psychological management of patients with burns is complex and so important. This talk will help you discover if all burns are traumatic, how and why a trauma-related disorder may evolve and increase your understanding of how trauma responses can interfere with many aspects of physical and psychological recovery. How do we give our patients some control back in situations where they have no control over what is happening to them? How do we help our patients manage the rehabilitation process? Crucially, how do we support our patients through their journey of acceptance and loss? Tune in to a discussion by A/Prof Caryl Barnes on the Psychological Management of Burns. For more head to: codachange.org/podcasts/
Bias by design in medicine with Tarlan Hedayati
In the last episode of Carr's Clinic, David Carr chats to Tarlan Hedayati about bias in medicine.
A patient comes into the emergency department and they are complaining of shortness of breath.
Typical measurements are taken including heart rate, blood pressure, temperature, rest rate and O2 sat.
Once the patient has been treated, they want to go home and we rely on vital signs and devices such as a pulse oximeter to determine if it is safe to do so.
But... what if the pulse oximeter measurement is flawed, biased and could potentially harm your patient?
Tragically the pulse oximeter has been proven to be inaccurate for non-white people.
The consequences of this can be devastating and these devices need to be reviewed to acknowledge the bias in their design and correct the flaw in their products.
What's even more concerning? Tarlan encourages us to consider what other sources of racial bias we might already have in clinical medicine that we haven't even considered or acknowledged yet?
Tune in to a great discussion with David Carr and Tarlan Hedayati on bias by design in medicine.
For more head to: codachange.org/podcasts
ECMO CPR ECMO in Cardiac arrest has increased exponentially in the past 10 years, on the back of, up until very recently, non-randomised, predominantly retrospective studies. What is the efficacy? Appropriate patient selection? Cost effectiveness and model of delivery of ECPR? Finally is ECMO really the intervention or just optimising the chain of survival? For more head to: codachange.org/podcasts
Burns Fluid Resuscitation.
The first 24 hours for burns management is crucial.
The ability to deliver just the right amount of fluid in a patient with burns is the holy grail.
From #CodaZero Claire Seiffert presents on Burns Fluid Resuscitation.
Claire covers fluid overloaded with compartment syndrome, to underdone with an AKI and extension of burns.
This short update will provide an overview of how to achieve the “just right” fluid balance and targets for resuscitation, ultimately enhancing patient outcomes.
For more head to: codachange.org/podcasts
Carr's Clinic is back but this time - with the man himself. David Carr walks us through a case which had him spooked (and for good reason).
A 33 year old female comes into the Emergency Room with crushing chest pain.
She has terrible pain radiating down her arm and it has only been 36 hours since she gave birth to her fifth kid.
Her ECG showed a STEMI. But, 33 year old women who just gave birth don't have MI's. Do they?
Turns out, she has SCAD - Spontaneous coronary artery dissection.
SCAD represents 1 to 4% of all ACS angiograms.
30% of the time it presents as a STEMI and 70% of the time as a non-STEMI.
The kicker? SCAD looks like STEMI. It has the same story, the same ECG, the same biomarker that is positive... it just depends on who is getting it.
91% of people with SCAD are less than the age of 25 and 85-94% are women.
It also represents 43% of MIs in women under the age of 50.
So how do we catch it? Think about the plus ones.
ACS plus young woman with no risk factors.
ACS plus pregnant or postpartum.
ACS plus some significant stressor.
SCAD is something we need to remember and we need to consider.
For more head to: codachange.org/podcasts
What went wrong with publishing in COVID19. Naomi Hammond walks us through the good, the bad and the ugly aspects of COVID19 publications. The ability for researchers to rapidly design and conduct trials in the midst of a pandemic was valuable. With that however, came an 'infodemic' where consumers struggled to keep up with the abundance of information. In April 2020, there were 6,000 articles published in one month. This caused concerns regarding the quality of publications, the increase in opinion articles and the number of articles which were retracted over the course of Covid. Tune in to a fascinating talk about what went wrong with publishing in COVID19. For more head to: codachange.org/podcasts
From #CodaZero Live, Phil Parry shares the impact a medical retrieval team can have on the treatment and outcome of patients suffering from major burns. Over a two year period, the team were involved with 203 major burns in NSW. Phil discusses the benefits of a medical retrieval response to prehospital patients suffering from major burns. He explains what the response might look like and the treatment that they are capable of in the field that will set them down the correct treatment path. Despite being a small team, what they can offer to a patient with major burns is significant. Senior medical decision making capability, advanced pain management, the ability for an anaesthetic and airway control, the list goes on. First, they determine how much of the patient is burnt. Then, they commence treatment. Tune into the podcast to hear firsthand, the impact this team has on the outcome of patients suffering from major burns. For more head to: codachange.org/podcasts
Making a medical diagnosis with limited information is at the heart of emergency medicine.
Emergency physicians often have to make decisions without all of the information.
Dr Anand Swaminathan shares a case where EMS rolled into emergency with a patient who was short of breath, hypotensive, tachycardic and hypoxic.
She had syncopized at a rehabilitation centre and by the time she got to emergency, she was seriously unwell and unable to provide much information.
Dr Swaminathan shares the steps he took in diagnosing a patient who was too sick to go for a CT scan.
His first piece of advice? Ultrasound is key.
Ideally, we all want to have diagnostic closure before prescribing medication which could be harmful, however this isn’t always possible if a patient is too sick.
So how do we make the call without a definitive diagnosis? Think about the exclusions, weigh up all the options and do what is right for the patient.
For more head to: codachange.org/podcasts
From #CodaZero Live, Khairil Musa presents on Sepsis in different contexts. Sepsis is the leading cause of death for people in low income countries. Khairil shares his story of managing Covid-19 and Trauma in Yemen and Iraq whilst working with Doctors Without Borders in 2020. Khairil had never imagined his work with MSF would coincide with a global pandemic. He shares his experience and the challenges of managing Covid-19 in places where resources are scarce. To treat sepsis in different contexts, we must first start by learning and sharing knowledge. For more head to: codachange.org/podcasts
How a Crisis Resource Management failure led to a full-blown medical emergency.
It is estimated that 70% of avoidable deaths in healthcare involve a breakdown of the principles of CRM.
Crisis resource management, involves seven crucial steps:
- Know your environment
- Anticipate and plan
- Take a leadership role
- Communicate effectively
- Call for help early enough
- Allocate attention wisely, use all information
- Distribute workload, use all available resources
Unfortunately, a failure in adhering to the 7 principles of CRM lead to serious complications for the birth of Tamara & Garry Hills’s son.
We hear from Tamara and Garry as they explain the human and systemic factors that ultimately led to a full-blown medical emergency.
A lack of situation awareness, combined with poor communication, unfortunately led to Christopher Hills suffering a severe brain injury. This likely occurred during the 17 minutes of terminal Bradycardia.
Tamara, Garry and Christopher bravely share their story to inspire healthcare workers to embrace crisis resource management.
For more head to: codachange.org/podcasts
From #CodaZero Live, David Carr chats with Sara Gray about treating recurrent ventricular tachycardia.
A 50-year-old male arrives in the emergency room with chest pain. Upon examination, it is clear that he is experiencing recurrent episodes of V-tach.
Defibrillation isn’t working, so what happens next?
Treating recurrent ventricular tachycardia with Dr Sara Gray.
For more head to: codachange.org/podcasts
From #SMACC2019 Vic Brazil, Eve Purdy, Jenny Rudolph, Chris Hicks, Simon Carley & Jenny Vaughan discuss learning and culture in healthcare.
Simulation is a great learning tool but how do we organise simulation activities when we are resource and time poor?
How do we translate learnings from Sim into the real world, when the stakes and stress levels are high?
How do we encourage junior staff to be honest with their feedback?
How do we set a culture that promotes an open learning environment? The fastest way to discourage feedback is to ask people to be honest but do nothing about it.
Tune in to a discussion on learning and culture in healthcare from our stellar panel.
For more head to: codachange.org/podcasts
From #SMACC2019 Phil Dobson shares some productivity tips for healthcare professionals.
Society trends show that we are increasingly getting busier and busier.
This is making our ability to prioritise harder, limiting our capacity to focus and resulting in an inability to switch off. High pressured, demanding jobs only makes this worse.
Phil suggests that we need to take a step away from busyness and towards effectiveness. To be less reactive and more self-directive.
How?
The first way to do this is by prioritising. We often prioritise based on what is urgent but by becoming more outcome oriented, we understand that not all tasks are equal and we avoid spending time on the wrong things. Think about your long term goals, yearly goals and quarterly goals. Are you spending time doing the things that will help you achieve those goals?
Secondly, we need to manage our energy. Energy is a variable and it is a precious resource. It is not unlimited and we need to give our brain time to rest and recover. Utilise the times during the day where your energy is at its peak to tackle challenging tasks.
Finally, observe your attention. How distracted are you? Trends are showing that we are giving more and more things our partial attention. Become aware of your attention and how you choose to spend it.
For more head to: codachange.org/podcasts
Sustainable healthcare: A move to Net Zero.
If the health sector were a country, we would be the fifth-largest polluter in the world. It is crucial that we move towards a sustainable healthcare system, but what exactly does this mean?
The NHS has led the way in modelling a Net Zero healthcare system. They have done this by considering all aspects of the industry, including energy, transport, Telehealth, equipment, devices and disease prevention.
The reality is we live in a linear economy. Particularly in medicine - we buy things, we use them and we throw them out. The NHS has pledged to only use suppliers who match or exceed their expectations with Net Zero healthcare. You can’t address waste without addressing what you purchase.
How can we shift into a circular economy? We need to invent ways to produce things that have a life expectancy beyond single-use. For example, Covid-19 has resulted in an unthinkable amount of waste from PPE, but innovative projects have seen how recycled face masks can be broken down and used to make new roads.
The healthcare industry has two key priorities: first, we need to reduce our carbon footprint. Then, we need to prepare ourselves for the climate change that is locked in for decades to come. Whether this is managing heat waves or ensuring that our hospitals don’t flood.
So how can we achieve sustainable healthcare?
- Find a group of like-minded healthcare colleagues, go to your General Manager and make the case for clean energy in your hospital.
- Use your voice – healthcare professionals are the most trusted professional group in society, so speak up at every opportunity.
- Start making steps right now
Sustainable healthcare: A move to Net Zero is the way of the future. We just need to get there sooner rather than later.
For more head to: codachange.org/podcasts
In situ simulation for Trauma Team Training by Chris Hicks.
Chris explains how managing difficult cases often doesn’t have anything to do with medical knowledge.
The hard part is the practicality of getting things done in an interdisciplinary team environment.
We strive for implicit coordination – where team members work so seamlessly together that they barely speak.
This is the essence of high performing teams.
Chris talks us through the team based factors of trauma care and how to put this into action in your hospital.
For more head to: codachange.org/podcasts
From think tank, to ‘do’ tank – making great ideas happen in healthcare.
From #SMACC2019 our expert panel sit down to discuss how to put thought into action.
How do we prioritise physical and emotional recovery in such a highly demanding job?
How do we propel innovation in critical care and medicine?
How do we balance social media with creativity, nuance and deep thinking?
For more head to: codachange.org/podcasts
In the previous podcast, the SMACCForce Simulation Team performed a Resuscitative Hysterotomy in a high-pressured situation.
Now, we debrief.
Sim is a powerful tool, it allows for healthcare professionals to practice rare medical procedures, to refine team work and to enhance collaboration.
Importantly, it provides an opportunity for healthcare professionals to practice responding to challenging situations.
In this episode, the SMACCForce Simulation Team debrief on the learnings and opportunities from the Resuscitative Hysterotomy simulation.
For more head to: codachange.org/podcasts
From #SMACC2019 the SIM team demonstrate a Resuscitative Hysterotomy on a pregnant, 36 year old female who was involved in a high speed motor vehicle accident.
The catch?
She is the surgical registrar and friends with members of the team.
Watch or listen as the SIM team guide us through a Resuscitative Hysterotomy in a high-pressured situation.
For more head to: codachange.org/podcasts
Liz Crowe interviews Justin Morgenstern about curiosity in medicine.
Curiosity is the most important thing that Justin brings to medicine. Why?
Because he believes that you can’t be a great clinician or educator without first being curious.
The future of medicine is based on asking questions – what if?
In the critical care environment, when you are under pressure, your brain will often resort to the first solution that comes to mind.
Being curious helps us double check our decisions.
What could I be missing? What else could I be doing?
We often forget to ask about the person sitting in front of us.
One or two minutes of curiosity can change an entire management plan.
Curiosity makes you a better practitioner.
For more head to: codachange.org/podcasts
In the last 10 years, 50,000 articles have been printed about burnout.
As healthcare workers, we are exposed to an enormous emotional toll.
We need a plan to look after our wellbeing and we need to start thinking about it now.
Surround yourself with people you can trust and do things to boost your happiness.
Most importantly, work with your team. If a team member needs to be covered, cover them. One day you may need covering too.
For more head to: codachange.org/podcasts
Surviving Massive Burns: Jamie Manning and the Royal North Shore Hospital team.
In this panel discussion, we hear an incredible patient story from Jamie Manning and his wife, Karen Manning.
In March 2014, Jamie was involved in a horrific car accident which resulted in catastrophic injuries and extreme burns to 40% of his body.
Jamie and Karen reflect on their journey to recovery and their experience with the hospital system.
They are joined on the panel by a number of the healthcare professionals who were involved with Jamie's recovery.
In this discussion, the team reflect on learnings for the future, such as the importance of continuity of care.
Tune in to an unmissable podcast from #SMACC2019.
For more head to: codachange.org/podcasts
A round table check in between Ireland, Australia and the United States. Hosted by Cian McDermott from Dublin, Trish Henwood (Philadelphia, US), Kylie Baker (Queensland, AU) and Rachel Liu (New Haven, US) share their local experiences on remote education, innovation, and ultrasound in the remote environment. Finding new ways to work, changing priorities, and pivoting fast and hard.
In the second part of the podcast focused on POCUS, Cian, Trish, Kylie and Rachel take a deep dive into the ultrasound process during the COVID-19 pandemic. How do we keep our equipment clean? Who do we turn to as a reliable and up-to-date source of information? Now, that the traditional literature is struggling to keep up with the times, and social learning networks aren’t always best evidence where is the knowledge. The “InfoDemic” has been experienced by all. What we do know is that strong POCUS infrastructure and collaboration underpins flexible opportunities for innovation. Jump into the comments section to join the discussion!
https://codachange.org/2020/06/17/pocus-and-the-infodemic/
The Future of Battlefield Surgery.
The traditional battlefield involved soldiers on both sides, fighting against each other.
Today, the battlefield is quite different and this has impacted how we practice surgery. Why?
First, the world is full, more than half of humanity lives in cities. Hospitals in developing countries are exhausted and under-resourced.
Furthermore, the threats we face today are global - global warming, pollution, air pollution, terrorism and water supply.
Modern-day weapons are so powerful that conventional warfare is almost obsolete - atomic weapons, cyber warfare.. the list goes on.
Finally, diagnosis and surgical intervention relies on extensive technology and minimal invasiveness. This is unsuitable to battlefield situations and makes it incredibly challenging to provide care.
MSF goes where no one else will go, but doing this kind of good is not getting any easier.
For more head to: codachange.org/podcasts
Pacific Island Playlist 5: Mental Health.
From #SMACC2019, the incredible Jess Morton speaks candidly about her own mental health journey.
Jess knows first-hand how important it is that we give mental health the focus it deserves.
Eliminating the stigma that surrounds mental health starts with us as healthcare professionals.
We need to lead the way.
Pacific Island Playlist song: Unwell by Matchbox Twenty
For more head to: codachange.org/podcasts
In this episode, we examine accessibility in healthcare and the limitations to accessing equitable care for all. We must understand both the limitations posed by a patient's disability and the predicted accessibility challenges they face. This requires asking questions about a patient's disability. Healthcare accessibility is not only the physical ability to reach care but also the ability to engage and connect holistically with that care. To truly design a more accessible healthcare system, we need to involve people with accessibility issues right from the start and design new systems, based on them. Tune in to the podcast or watch the video to better your understanding of what accessible healthcare really looks like.
For more head to: codachange.org/podcasts
The Covid restrictions saw an increase in Telehealth services and a flow-on effect was that it provided a safe space for people with accessibility differences. To sustain this, planning must go into adapting existing clinical practices.
We need triage tools to identify which consultations are suitable to provide virtual care before we can engage with patients and provide them with a choice. We need to better understand the problem before we can determine what service changes might appeal to people with accessibility differences.
People with lived experience need to be involved right from the start in the planning process. Healthcare must be open to the knowledge of what it is actually like to live with a disability. Then we can design new systems that narrow the gap and make the process of getting a diagnosis and seeing a clinician faster. As healthcare professionals, we are all incredibly busy, but taking the time to listen is when patient-centred care shines.
For more head to: codachange.org/podcasts
Healthcare should be equitable and accessible for everyone, but what exactly is equitable access to healthcare? Access is the ability to seek healthcare. The ability to physically connect and to pay for healthcare. Most importantly, access is the ability to engage with healthcare. Open and honest communication with patients is key. Empower people to make decisions about their own care, finding a way to communicate even if in a non-traditional way. The reality is, a lot of clinicians live and work with disabilities themselves, yet healthcare is void of a system that caters to everyone. It is really important as clinicians, to not just look at the numbers but to look at the patient as a whole. We need to come together and reinvent how we deliver healthcare – to suit everyone.
For more head to: codachange.org/podcasts
Inspiring clinicians to embrace accessibility will deliver better patient outcomes. It is vital we consult consumers about their disabilities and about what would make their health experience better.
This must include listening to patients' stories and understanding both their abilities and limitations. It's an important step towards an equitable healthcare system.
When considering whether or not to offer a patient the choice of face-to-face or Telehealth, reflect on their ability to access healthcare. Patients with a disability require a lot more time and planning to meet the needs of everyday life. People with disabilities face a lot of barriers to equitable healthcare but the biggest barrier is the attitudes and beliefs entrenched in the system. A small step towards embracing the requirements of people with a disability is a large step in the right direction towards equitable healthcare.
For more head to: codachange.org/podcasts
Nas Campanella is a high-profile public media identity whose experience of being a blind patient provides a first-hand account of the access and inclusion challenges she faced within the healthcare system. Facing early childhood memories which involved countless hospital visits, she remembers needles, cannulas and feeling incredibly anxious about going into the operating theatre. That was, until the day that she stopped and said, I’ll do this (surgery) if it is my last. Nas wanted to live a happy life and to live her life blind. She wasn’t interested in cures, or medical procedures, because being blind is part of who she is. It is common for healthcare providers to see patients with a disability through a medical treatment lens, focusing on fixing or curing the ‘issue’. The concept that a patient with a disability isn't necessarily seeking a cure for a problem is often difficult to understand for healthcare professionals, who go into medicine to make people better. Nas’s experience taught her a lot about accessibility requirements in healthcare. The way information is provided, can make a crucial difference to a patient's decision-making and their outcomes. There is often a need for very simple explanations about how something is going to work. Remembering to not just explain in words, but to take a blind person's hand and trace it around a diagram. Nas encourages us to involve people with accessibility needs in their own care and to not just talk to careers and family members. At least 4.4 million people in Australia live with a disability. Understanding how to provide better care for this population is a crucial step towards achieving equitable accessibility and inclusion for patients with a disability.
For more head to: codachange.org/podcasts
Energy = mass x velocity2, something that travels fast has twice the fatality of potential injury. In the US firearm injuries are unfortunately common and this is a public health crisis. We need to learn how to best treat patients with penetrating neurotrauma injuries. Wendy Chang takes us through methods to best treat these patients.
For more head to: codachange.org/podcasts
Creativity in: non fiction
Let's face it, your real life is too strange for fiction.
And why go looking for the stories, when they come right to you?
During this session, we'll explore the tension between telling them, and taking them, how to keep their beauty, or their hilarity, without betraying confidence.
Bring your best story, and your worst, and we'll find their true heart.
One of the most common questions that gets asked by fellow clinicians, is what it takes to be a writer.
Well, if you're an ER doctor, medic, or nurse, you've already checked the "weirdo" box. Pivotal.
You can also add a position at the interface between the personal and the general as the right one for perspective.
Everyone wants to know what you've seen, what happened next, and what matters most.
The real answer, though, I stole from Annie Dillard: "Do you like sentences?" I mean, really REALLY like them?
Enough to spend even more time alone, in dark basements, puzzling over whether to remove a "that" or keep it?
Well, then you might have what it takes.
I'll tell you how I got started, the mistakes I've made, and what principles have stayed alive for me, through two books.
We'll talk about how to structure both your writing day, an argument, the joy when you turn in your finished work, years in the making, and the delight to receive it back, a few days later with the the advice: "you can do better".
For more head to: codachange.org/podcasts
FOAMed (Free Open Access Medical Education) is an important tool that so many of us are passionate about. The ability for medical education to reach countries around the world is powerful and is driving us towards a healthier future. In this episode of PIP, Alexandra Presler encourages us to lean into the FOAMed community. Everyone can utilise FOAMed, regardless of your position, so talk to everyone, branch out and help make the community bigger.
For more head to: codachange.org/podcasts
Emily Granger takes us through the original cardiothoracic conundrum: what to do about chest injuries and rib fractures?
New approaches to the management of severe chest trauma and rib fractures are re-shaping our practice. Tune in to discover how.
For more head to: codachange.org/podcasts
Andrew Dixon takes us through five Common Trauma Radiology Misses and Misinterpretations.
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Jim Manning tells us why the time is now for Selective Aortic Arch Perfusion in improving cardiac arrest outcomes.
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Does adrenaline require resuscitation or is adrenaline good for resuscitation? Gavin Perkins takes us through the research and findings.
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Previously at SMACC, Steve talked about NonSTEMI that needed the cath lab immediately and showed many ECGs which represented acute coronary occlusion (Myocardial Infarctions) but present on the ECG as very subtle findings (http://hqmeded-ecg.blogspot.com/search?q=subtle), particularly as subtle ST segment elevation that does not meet “STEMI” criteria and is diagnosed as NonSTEMI.
Now, he builds on that idea and challenges the whole idea of a dichotomy between STEMI and NonSTEMI. These are NOT distinct pathologies, but rather exist on a continuum of intracoronary thrombus. Nevertheless, this false dichotomy is rarely recognised by emergency physicians or cardiologists, and patients suffer because of it. There are obvious STEMI, which always need the cath lab emergently, and for which time is myocardium.
On the other hand, there are patients whose symptoms are resolved, ECG is non-diagnostic, shows no active ischemia nor subtle ST elevation, but whose troponin is positive and their resolved chest pain is due to an MI with an open artery and no ongoing myocardial cell death. These are NonSTEMI that can be treated with antiplatelet and antithrombotic therapy and get their angiogram the next day. And then there are the patients who have subtle ST elevation representing acute coronary occlusion, or who have active symptoms and/or persistent ECG ischemia. These patients do NOT have STEMI but do need the cath lab now. 25% of occlusions do NOT have diagnostic ST elevation and they do not get their angiogram until 24-36 hours later; their outcomes are worse: they have worse LV function, higher biomarkers, and higher mortality than NonSTEMI whose arteries are open at next-day cath.
Steve advocates for an end to another dichotomy: activate the cath lab (Pathway A) or do NOT activate. Instead, he advocates what they, at Hennepin County Medical Center, call “Pathway B”: emergent consultation with cardiology, including a high quality emergency contrast echocardiogram to look for wall motion abnormality. Finally, he shows a variety of ECGs which represent subtle coronary occlusion or ongoing ischemia.
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Trauma care should be easy… shouldn’t it? So why doesn’t it feel easy? The clinical component is the easy bit, the challenge is the non-technical factors. Clare Richmond, Chris Hicks, Cliff Reid take us through a SMACCForce simulation debrief and discuss the human factors of trauma care.
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An asthmatic who is hemodynamic compromised, can be killed instantly. This distinguishes these asthmatics from the standard asthmatic and how these patients are treated will make a huge difference to the outcome. Haney Mallemat recounts a story of an asthmatic who minutes after he was intubated, became bradycardic, hypertensive and coded. Haney discusses how breath stacking is what kills the asthmatic patient and how we can best avoid this happening to ultimately save lives.
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Airway management needs to be proven, predictable and as simple as possible. Silence = death. It is hard to open yourself up and ask to be coached through something but it can be lifesaving. Laura Duggan explains how to survive Trauma RSI and come out the other side.
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We are in the business of saving lives but we are missing the low hanging fruit. To save lives, we must teach ourselves but crucially, we must teach the public to do the basics exceptionally well. The first link in the chain, the bystanders, have to be involved and have to know what to do. Mike Abernethy talks to us about the importance of bystander action.
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Neurosurgery is time critical. Our job is essentially trying to avoid death and relieve pressure on the brain as quickly as possible. Acting rapidly is the most important thing we can do but achieving this in the outback and rural communities is challenging. How do we streamline the process to ensure that we care for all people, regardless of geographical location?
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Every child born today will be affected by the climate emergency and affected at every stage of their lives. Canadian sub-arctic is already 2.5c warmer than 70 years ago. Unfortunately, all sorts of health impacts are linked to the climate crisis. Heat stress, chronic disease from air pollution, infectious diseases, malnutrition, famine, displacement… to name a few. We are already resigned to increased global warming which is now locked in for decades to come, so healthcare professionals need to find ways to cope with the ramifications of this inevitability. We need to take action on two broad fronts, firstly Mitigation to prevent further rises in global temperatures by decarbonising, and secondly Adaptation to prevent as best we can the catastrophic effects on our patients' health. The choices we make right now will have massive impacts on our children and their children. We can take action at a Micro level (our personal actions), Meso level (our hospitals, universities, and local communities) and Macro level (the whole of government). The cost of taking action on the climate crisis will be high but the cost of inaction will be way higher. It’s paramount we work together towards a healthier, sustainable energy source. Politicians have responded to Covid but why haven’t they responded to climate change evidence? A united front by healthcare professionals will deliver solidarity and make an impact.
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The NHS has committed to a net-zero target in 2040, for the carbon emissions that they control directly and a target of 2045 for the broader emissions they can influence. So why is the NHS doing this? It has heeded the science pointing to the climate emergency as the biggest health threat of the 21st century. Nine in ten NHS staff say that they want to see the NHS act more sustainably. What is a net-zero target? As the title suggests Net Zero emissions mean achieving a balance between the production and removal of Green House Gas emissions (GHG). For the NHS this requires actions to remove emissions across an ambitious and wide supply chain... from buildings to pharmaceuticals, MRI scanners, syringes, inhalers, and so on. It also includes the emissions that come from the patients, from visitors, from travel to and from the NHS, and from emissions well beyond the borders of the UK. So how will this be achieved? The NHS has an 80% reduction target by 2028. Most importantly, it will only commit to companies that meet or exceed their commitments on climate change. It has approved a national design for a hydrogen ambulance, the world’s first zero-emission ambulance, and new hospitals, with a visionary goal of being net-zero hospitals. Action is what is needed to improve the health of our community.
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In this episode, we examine some achievable, sustainable and most importantly, meaningful actions that healthcare can take on the climate crisis. Firstly, the climate emergency is not only a healthcare emergency but also a wealth emergency. Financial markets have realised the monetary cost of not taking action to reduce carbon emissions and now whether governments like it or not, the markets are driving change. Secondly, as investors, we have enormous power through our personal superannuation funds. Simple actions in how we invest personally, can have very meaningful outcomes in driving change to lower carbon emissions. Thirdly, at the healthcare delivery level, we learn from the bold initiatives undertaken by the NHS in the UK to adopt a net-zero emissions policy. As healthcare workers, we have a basic premise to 'first do no harm' which behooves us to examine the carbon footprint of our healthcare delivery. Finally, we must recognise that every child born today will be impacted throughout their lives by the climate emergency. We must formulate actions at a Micro (personal actions we can all take), Meso (collective actions that our institutions, universities, local communities and business partners can all take) and Macro actions (the whole of government). Tune in to watch or listen to four compelling conversations and a rallying call to arms.
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Re-evaluating how your super is invested can have a huge impact on mitigating the effects of the climate emergency. Why... because most people are invested in the companies that are responsible for climate destruction. The broader Superannuation system is currently worth about $3 trillion. By 2038, it is projected to be worth $10 trillion. With that size comes immense power. Have you ever thought to engage with your super fund and ask, “what are you doing about the climate crisis?” It’s one small step towards influencing massive change. When it comes to healthcare professionals, we are committed to a better world, but this needs to include our actions outside of the hospital. As healthcare providers, we don't want to support the Tobacco industry, we wouldn't want to invest in Asbestos and equally, we shouldn't be letting our super finance the fossil fuel industry. It is confronting to think that we may be profiting from our super being invested in companies that are huge carbon polluters. We cannot stand idle and be indifferent, we must take action. Stay tuned and watch or listen for more...
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Financial markets have recognised that the climate emergency is also a financial emergency. A report out of Harvard recently stated that nearly 1 in 5 deaths globally are associated with burning fossil fuels. Incredibly, the Covid19 pandemic has changed how we see the climate crisis in a number of ways. Firstly, it resulted in an unprecedented decline in global energy consumption during 2020. Secondly, it showed us that in order to deal with the pandemic we must listen to science and take action at a global level. Thirdly and somewhat conveniently, a trade war emerged between Saudi Arabia, the U.S and Russia over oil, leading to a collapse in the price of both oil and liquid natural gas (LNG) and a 60% decline in the leading global oil companies. This resulted in pressure on the financial sector to transform their thinking around fossil fuels, as they realised the potential for the climate crisis to become a wealth crisis. A 60% collapse in the value of Exxon is a very good reminder to financial leaders that if they don't act on the science and they don't act on the risk, they stand to lose a lot of money. The price of wind energy has dropped 50%, solar energy 90% and batteries 90% over the past decade. The production of solar power in India is now cheaper than the continued running costs of existing coal-fired power plants. There is a tectonic shift that is accelerating and it is motivated by money. Watch or listen to this compelling podcast with Tim Buckley as to why financial markets are dictating that we pivot to renewable energy whether governments want to or not.
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We hear from passionate advocates in different medical fields, as they impart wisdom and discuss how we can all work to be advocates for what we believe in.
As healthcare workers, we constantly work together as a team.
We need to utilise that teamwork to stand up for what we believe in.
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A trauma patient has come in and they have a life threatening, non-compressible haemorrhage. We have a Code Crimson on our hands. In this scenario, your team and your performance can make a big difference to the outcome. We need to rely on protocols, standardised care, implicit communication and shared expectations to manage this as effectively and efficiently as possible. This is what Code Crimson is all about.
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The logistical challenge of opening a COVID-19 treatment centre in a developing country is enormous. There is a significant lack of resources such as PPE and essential drugs, as well as medical specialists and sophisticated technology. Khairil Musa reflects on a deployment to Yemen and how in a city with 1.8 million people, having access to only 7 ICU beds led to devastating consequences. During the height of the pandemic, the city recorded an 8 fold increase in the daily death rate. So how do we learn from this and provide a better outcome for the future? The bottom line is COVID needs a global response. Governments need a united approach, with adequate resources, infrastructure, and medical expertise. In times of uncertainty and tragedy, we need to remember our humility.
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Every two years the processing power of computers doubles, while the cost halves. Advances in technology are making ultrasound more accessible and effective than ever.
To adequately use ultrasound you need three things
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Have a machine
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Be able to acquire the images
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Interpret and utilise the images effectively, safely and accurately
Ben Smith and Jacob Avilla run us through how technology has enabled ultraportable, ultracheap ultrasound and how this stands to make an incredible global impact.
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We all have to be advocates for the role we play in patient care. We have to collectively navigate and challenge the decision makers to ensure progress into the future.
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Resa Lewiss talks to us about the evolution of point-of-care Ultrasound in Trauma, focusing on the FAST examination.
Three takeaways:
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Ultrasound cannot replace CT scan.
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Ultrasound is a data point in your patient care management.
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Ultrasound decreases time to definitive management.
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The exciting possibilities for tomorrow’s medicine are endless. There’s the chance that we could revolutionise diagnostics with AI. There’s the opportunity for us to use smart phones and wearable technology to allow health professionals to deliver care outside of hospitals. There’s the possibility to use 3D printing to manufacture drugs at local pharmacies, personalising drug treatment for individual patients. These are all possible with technologies that exist today. However, on average it takes 17 years to implement new technology. How can we change this? We must never stop asking the questions that begin with “what if”.
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RCTs deliver the most reliable evidence to guide how we treat our patients but they are badly designed, inaccurately reported and misunderstood. We can do better.
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Professor Owler discusses his experience in his various roles to achieve successful outcomes both in terms of health policy as well as legislative changes. He will discuss the role of doctors in this process and how to interact with government, media and stakeholders to achieve better outcomes for patients and the community.
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In this episode of CodaZero Cure our stellar line-up of panellists take a deep dive into Sepsis post Covid-19 and reflect on the many opportunities and challenges presented. First, we hear from vaccination uptake expert, Julie Leask, on Covid, vaccination and medical misinformation. Julie highlights some of the key drivers of vaccination hesitancy in society and challenges us, as health professionals, to work together to better inform our community. Next, Senior Intensive Care Registrar, Khairil Musa, presents a moving talk about his experience of managing Covid on the front line in Yemen. Reflecting on an unbelievable experience, Khairil describes the extent of the pandemic and how a lack of resources and infrastructure led to devastating consequences. Our panel examine the clinical management of Covid and what lessons can be learnt to ensure we improve in the future. How do we empower global organisation's to respond to Covid-19 in the best way possible? Access to information and public awareness is the solution to empowering a sense of personal responsibility in tackling diseases such as Covid and Sepsis. But how is this best achieved? What role does the WHO play as a global conductor? Finally, our panellists answer some challenging questions: what about Covid keeps them awake at night? What are the lessons for society and the healthcare system when hopefully the pandemic has passed? If you had the power what is the one thing you would change? Their answers are compelling. Tune in as they discuss everything from the successful roll out of vaccines, to the psychological safety of the medical community, to the need for a shared sense of action and a focus on equity.
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It's a challenge to think of a single large multicentre RCT or therapy introduced to critical care in the last 20 years that has meaningfully improved outcomes, yet across the board our outcomes improve year on year, largely due to improvements in Process getting the diagnosis right earlier, instituting therapies that work sooner, and minimising iatrogenic injury. The implementation of ultrasound into bedside clinical practice in emergency departments and intensive care units have accelerated that improvement in process, with new technologies now potentially putting personal ultrasound into the hands of medical students and junior doctors and changing the way medicine is learned and practiced. Are you ready? How will you supervise and train them? How can you implement this technology in your practice?
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If we harness the experiences of hundreds of colleagues who have managed the same rare clinical event we would discover what works, what doesn't and why.
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There is enormous concern within the health community regarding public misinformation and the successful rollout of vaccines. They are concerned about the psychological safety of medical professionals in the post-pandemic world. They are worried about the emotional toll that long periods of separation from family and friends have on people from around the world. Now more than ever, we should share our knowledge and experiences on an international scale. We should not lose the sense of equity and the focus on standardisation. And most importantly, we need to listen to what our community is saying and put that at the heart of what we do.
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The challenge of balancing public health and the law, with personal responsibility and freedom, is driven by access to information. We need to invest in public awareness, reflect on the learnings from COVID and use that for messaging at scale. Like Covid, we know that the prevention of sepsis relies on education, early detection, sanitisation, antibiotics stewardship and availability of resources. Post the COVID-19 pandemic, how do we ensure the correct information is available to the public so that people are empowered with a sense of personal responsibility? We need to encourage the community to collectively move together, to raise awareness, and to educate at a global level.
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COVID 19 has completely disrupted communities around the globe and caused enormous loss as well as untold human suffering. The development of such effective vaccines has given us hope for the future, but the unprecedented speed at which these have been developed has raised some questions. The WHO recently has identified vaccine hesitancy as one of the top 10 public health issues facing global health. To ensure a high uptake of vaccines globally, the community needs transparent, honest and factual advice from trusted members of the community. There will always be a small minority of people, "Activists" who ignore the science and spread misinformation or worse, conspiracy theories. We mostly cannot reach those activists and should rather concern our efforts with those "hesitant" but undecided. At the same time, we must also consider the logistical limitations of vaccine rollouts on a global scale. These include factors such as lack of infrastructure, accessibility, and financial constraints, to name a few... but if COVID has taught us anything, it has taught us the need for a shared sense of action.
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ECMO is a life-saving intervention for critically ill patients, but patients describe a recovery period that can take months to years.
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Those of us looking after kids know that making confronting situations better for those kids is one our biggest challenges.
A kid's experience of a procedure in hospital is not just about that particular procedure. It colours all their future interactions with health professionals and can impact on their behaviour outside health care settings.
Virtual (VR) and augmented reality (AR) are new technologies that really rely on old techniques - telling a story and transporting a person to another place.
There is now good evidence that these modalities can improve the experience of patients undergoing induction of anaesthesia (1)
having burns care (2)
and even effectively treat phobias (3).
More fundamentally, even brief exposures to VR can alter the way people behave.
Healthcare needs clinicians leading the discussion as to how to make it the best option for patients. Even more importantly, clinicians can use this technology to understand what kids want and how they think about procedures.
It is time for kids to help us design the VR and AR of the future.
This session will cover what we mean by VR and AR, what we already know about it, and how we're trying to learn from kids as we make the procedures of the future a bit better.
Or maybe even fun.
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In the ER, we are taught to turn towards the pain of others.
We are not given as deliberate advice on how to care for ourselves despite the adversity we see, and the inevitability of being hurt by it.
If our role is, at least in part, to steward health towards others, we defy its logic if don't extend the same caring to ourselves.
Being well, and if not, knowing the direction, is as vital as being able to get a blind subclavian line in a bleeding trauma patient.
Our culture, instead of a place of healing, can be toxic in itself, vulnerability almost inadmissible, meanness tolerated.
As we address this, and its root causes, we become better clinicians, more likely to help people in ways that matter most, take our skills and profession to places that need it.
It's possible for the ER becomes a place where, instead of getting beat up by it and recovering, we can live true values.
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Salim and Ken go toe-to-toe debating some hot topics in critical care. They take on mechanical CPR, adrenaline for out of hospital cardiac arrest, stroke ambulances and 1st pass with a bougie. Fun and informative.
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Sepsis is a common and deadly condition, but diagnosis in not always knowable in real-time. The optimal treatment during times of diagnostic uncertainty differs across patients.
Despite this reality, sepsis performance is uniformly assessed and reported for a population knowable only in retrospect—the patients ultimately judged to have sepsis at hospital discharge.
This limits effective audit and feedback to incentivise clinician behaviour. Personalised, real-time assessments of a patient’s risk of death and likelihood of infection could instead be used to guide treatment recommendation and performance assessment.
Clinicians and health systems could be judged on whether their responses are appropriately calibrated given the urgency of the situation. Were antibiotics prescribed at an appropriate time given the urgency of the patient’s clinical status? With the information available, were the best treatment decisions made? Did treatment plans change as new data became available? Organising treatment recommendations and performance assessment by risk of death and likelihood of infection could optimise sepsis care.
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Mulinda shares how setting up an emergency department at a public tertiary hospital resulted in contributing to improving a district primary care system improvement program in Malawi. The link between performance of a health system can affect the community's health seeking behaviours. Insight into how improving patient care pathways can assist in creating patient centred, efficient and effective emergency care provisions will be shared.
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An overview of causes of surgical vomiting in the neonate.
This includes malrotation-volvulus, intestinal atresias, necrotising enterocolitis.
ECMO is alife-saving intervention for critically ill patients, but patients describe a recovery period that can take months to years.
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What can Prehospital and Retrieval Medicine teach us about life? Natalie May reflects on lessons learned at Sydney HEMS - from the practical to the philosophical.
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Being able to open any mobile phone camera enables triage of scene (mechanism of injury) and patient (physiology). This enables better resource allocation and can start treatment sooner.
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PHEM is a male dominated speciality but why is that? Caroline Leech takes us through the reasons why this inequity exists and how we can breakdown barriers.
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Simon Carley, Natalie May, Ash Leibig and Libby Hanrahan discuss how we can take the ideas, inspirations and thoughts from SMACCFORCE and put them into practice. How do we combat the attitude of "that's not how we do it" to open ourselves up to new ideas and processes?
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Nuanced trauma care by the Queensland Ambulance Services High Acuity Response Unit (HARU). A brief outline of the capabilities of HARU and some key principles that make it successful. Could this be a model for other ambulance services to follow in the future?
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Wendy Chang takes us through the use of ultrasound for lumbar puncture and how this should be used consistently, not just for difficult cases and field cases. Recent reviews have shown that using ultrasound for lumbar puncture has the potential to improve our success rate, decrease the rate of traumatic taps, decrease time to success, decrease needle passes and ultimately decrease the patients pain scores.
Cardiac arrest physiology is an emerging field of research that may allow us to better understand why clinical trials of cardiac arrest have been so frustrating, why epinephrine doesn’t work, and how we can potentially do better in the future by augmenting blood flow and programming the cells with ischemic conditioning.
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Mark Forrest, Halden Hutchinson-Bazely & Jason van der Velde talk to us about 21st century simulation. They discuss how tools such as augmented reality are advancing medicine and assisting clinicians.
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Traditional selection of clinicians (nurses, paramedics and doctors) relies upon standard assessments. Or does it? Many clinicians are selected on the basis of their curriculum vitae, plus an interview and reference check. Is this the best approach to selecting high-performing clinicians to work in austere settings?
Performance equals capability plus behaviour. If we are to select clinicians to perform in a high-stakes, high-hazard environment, then what criteria should we use? What individual mental and physical attributes predict reliable performance? Should we perform psychological testing? Personality inventories? If so, should we select for a specific personality? Or is there strength in diversity? Given we provide health care in interdisciplinary teams, how might we select clinicians for their performance within a team? Are we selecting for leadership? Or followership? Or both?
Resilience is important. We think. So how might we select resilient clinicians? Some describe this process as 'weeding out the dreamers.' Yet might we require dreamers? And as our services grow and develop, do our teams have the agility to adapt to complexity and uncertainty? What are the barriers to selection? And are we the best selectors; is there a role for external human resource support? We will explore techniques used in the selection of other high-performing groups, ranging from astronauts to bankers to the All Blacks.
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The future of pre hospital care; Treatments and technologies on the horizon.
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Chile's has unique characteristics which pose several challenges for rescue and retrieval medicine.
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Over the past 30 years point-of-care ultrasound has been influencing patient outcomes in critical care environments by finessing patient assessment and optimising management. The newer generation ultrasounds are smaller and more portable, and as a result are joining physicians in the prehospital arena. Are they making a difference though? In the high-stakes environment of mass casualty events, ultrasound may provide the upper hand to clinicians by enhancing diagnostic accuracy, optimising resource utilisation and guiding crucial procedures towards those who need it most.
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Mulinda discusses standardising pre-hospital care in Africa and some of the major issues experienced such as access to prehospital care services.
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When the Chief of Defence Staff (CDS) of the Canadian Armed Forces decided to create a brand new forward aeromedical evacuation capability, he wanted it completed from the ground-up in a little over one year time.
In this talk, Lieutenant Colonel Leilani Doyle recounts how this was accomplished from the early concept, through development and finally to the deployment of the CMERT (Canadian Medical Emergency Response Team) on the UN mission Operation MINUSMA in Mali in 2018.
Lessons from the talk focus on three areas: commitment, cooperation and patience. The true test of commitment is seeing an idea actualised. Lieutenant Colonel Doyle and her colleagues had written a memo arguing that the Canadian Armed Forces needed a MERT-type capability. The CDS agreed with them, so despite the daunting nature of the task and tight timelines, they needed to bring the idea to fruition.
This project required immense cooperation. When tackling it, the team found experts from various disciplines were generous with their time and knowledge. Rather than reinventing the wheel, they sought assistance from colleagues, allies and established aeromedical services with training, equipment, SOPs, etc. With their help, they never felt that they were going at it alone.
Finally, patience when evaluating the results of these efforts is crucial. Once in theatre, they were eager to see if what they had developed was up to the task. If necessary, they were prepared to adjust plans based on the realities on the ground. They learned that conflicts have changed as casualty volumes are not the same now as what occurred in Afghanistan. This is obviously a good thing, but it also means that it will take longer to garner lessons learned and see where improvements will eventually need to be made.
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Training and psychological preparedness is essential for prehospital and disaster clinicians, in order to effectively care for victims in austere environments.
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Resuscitating a critically injured child is one of the most stressful jobs in pre-hospital medicine. We are all human, many of us parents and the unbelievable emotional cost of a child who has life threatening injuries can take its toll. A year of serious paediatric trauma gave me an interesting perspective on paediatric trauma resuscitation and a new take on the word "resilience."
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Explore "change" from the early days of PHaRM to the current day.
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The future of pre hospital care; Treatments and technologies on the horizon.
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Dr Sinead Campbell-Gray will be presenting the story of the Northern Ireland HEMS Service, from the Political and Public campaign to get it started right through to the team-work and hard work involved in making this project a reality. She will outline how the Service has been founded on excellence in Trauma Care and Resuscitation Medicine, how the Clinical Service Model works, some lessons learned along the way, and what the future holds for the Northern Ireland HEMS as it continues to develop and become more established on the Global HEMS stage.
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Surviving a cardiac arrest requires an optimised system of care, or Chain of Survival, that comes together as seamlessly as possible following a sudden collapse. No two communities or EMS / ambulance systems are the same and you need to intimately understand both using data to measure and benchmark how you are performing and then work to improve those elements of the system that you can change to improve survival. Improving survival from cardiac arrest is in our DNA at Ambulance Victoria and through our work we have seen cardiac arrest survival more double over the past decade, with Utstein survival rates of 37% across the State of Victoria and 41% in Melbourne. In this talk I will describe our journey of improvement across all elements of our cardiac arrest system of care including accountability, the use of registry data to map the journey from arrest to recovery; partnering to improve survival, the critical role of emerging technology and what the future holds as we strive to further optimise our system with a goal of improving survival by a further 50% over the coming years.
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This presentation will summarise the best recent science in cardiac arrest and shock management, and bring you up to date with what every one else is talking about.
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The Coda community have identified the Climate Emergency as the most urgent threat to global health. There is overwhelming scientific evidence that the climate crisis will become catastrophic if we don't take action immediately.
This episode of CodaZero Earth focuses on action stage one – 'identify' and lays the foundations for stage two - 'examine' (as set out in our Five Stage action process). We outline the urgency of the challenges that global healthcare faces and how as health professionals, we must sound the alarm for both our patients and for our children.
Conversation one dives into how gas is often positioned as a “safer transition fuel” when in fact it is completely unnecessary and a potential super-pollutant. The panel critically assesses the interrelationship of power, wealth and influence in government and how to overcome the sceptics in the fight for truth about the grave threat the #climateEmergency poses to health.
Then, we move on to how the climate crisis is exacerbating existing Injustice and Inequity, disproportionately impacting those patients without access to universal health care. Additionally our younger population and our children are the most likely to be affected by the climate emergency,however, they have limited power of persuasion in the crucial decisions that we make today, which will impact on their tomorrow.
Conversation three defines what sustainable healthcare is. Health care accounts for 5-7% of the global carbon emissions. The healthcare community and supporting industries must commit to Corporate Social Responsibility goals and demand products, packaging and materials which have a minimal impact on the environment. We need to consider the super-cycle of high turnover, disposable waste and to challenge ourselves to consider alternatives such as reusable gowns. The overall target must be NetZero by 2050!
Finally, we examine how the pandemic response has shown us the way forward for climate action. The first step of managing the pandemic was to stop the problem growing, similarly, the first step to combat the climate emergency is to stop the burning of fossil fuels. Then, we must build the capacity of our systems to adapt to the crisis, just as we built health capacity and finally we must search for the ‘climate vaccine’ which means drawing CO2 out of our atmosphere.
Our premise is first do no harm but “time is planet” and we need to get moving.
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In Australia a 300 bed hospital uses the same amount of Energy as 5000 to 10000 homes. In many ways what we do at work really does matter.
The good news is that this is a solvable problem and in some ways the Covid19 pandemic has shown us the steps to facing the Climate Emergency. Just as we learnt that first step for managing the pandemic was to stop the problem growing by limiting spread with physical distancing we know that our first step in controlling our carbon emissions is to stop burning fossil fuels. Secondly to deal with the crisis already at hand we must build capacity and resilience, not just in our health systems but also in our environmental systems. Thirdly the climate emergency equivalent of the search for a pandemic vaccine is the need for us to find a means of drawing CO2 back out of the atmosphere. We can draw CO2 out of the atmosphere through both our forests and the ocean.
We have already worked out these simple steps to solving the #ClimateEmergency, but the problem we face is a lack of willpower to implement them. How do we overcome this inertia? What levers can we pull to start taking these steps in the right direction?
The levers we can employ include:
- Legal actions against governments and institutions for inaction 2. Economic by divesting from fossil fuels
- Supporting independent science based groups to combat the concentrated media disinformation
- Target climate sceptics within government. Get political
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Healthcare accounts for 5-7% of global carbon emissions, which equate to approximately all or the emissions from either Japan or Russia.
A large part of those carbon emissions come from the manufacturing of medical devices and pharmaceuticals (‘Procurement’). This provides tremendous opportunities for us to drive how the medical technology industry designs and produces these goods in order to reduce carbon emissions. We must take responsibility for the entire life-cycle of what we consume in the delivery of healthcare – This responsibility is termed ‘Product Stewardship’.
However, there is a general lack of Governance in sustainable healthcare delivery. Healthcare workers, hospital administrators and government themselves lack awareness of our shared responsibilities in this area. As clinicians the lowest carbon footprint clinical test is the omission of unnecessary tests. In many ways low-middle income countries lead the way here as they have never embraced the super-cycle of high turnover disposable waste. As institutions like the Canadian Medical Association, the UK NHS and the Lancet Countdown commit to NetZero healthcare by 2050 we must demand the same from our medical device and pharmaceutical partners. Our first premise has always been “First do no harm”.
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Social inequalities mean that many patients without access to universal healthcare are disproportionately affected by the climate crisis given that their chronic health conditions are exacerbated but they cannot afford to seek treatment. Additionally intergenerational inequality means that younger generations will be more adversely affected by the climate emergency, but at the same time are less likely to have a voice in decisions effecting the actions we take now.
It is essential that both the healthcare community and industry realise our shared Corporate Social Responsibilities. We must act together on this across the entire health industry supply chain.
Additionally our colleges and universities need to be including education on both adaptation and mitigation strategies for the climate emergency into curricula. Currently 85% of medical students from around the world report no education on the #ClimateEmergency.
#ClimateEmergency deniers protecting their own interests, threaten our children’s’ future and in doing so their actions feel almost predatory. We need to shift our thinking and acknowledge the threat to our children.
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The Coda community identified the Climate Emergency as the greatest threat to global health and we have good reason to be alarmed for both our patients and our children. There is good scientific evidence that the climate crisis could be catastrophic. The global healthcare community comprises over 60 million people and together we can make a difference.
Global CO2 emissions continue to rise resulting in more energy trapped in our atmosphere and putting us on the verge of a tipping point. We must act now. We are all used to practising with a time imperative in healthcare, we know that “Time is muscle” for the heart and that “Time is brain” for stoke – In the case of the Climate Emergency… “”Time is Planet”!
Part of the problem for governments is that Power, Wealth and Influence skew the discussions around the climate emergency and in some ways the Fossil Fuel Industry has employed similar tactics to those taken by the Tobacco Industry lobbyists. Lobbyists have tried to promote ‘Gas’ as a safer transition fuel as we move from ‘Coal-fire’ energy, but Gas too is a potential super-pollutant and completely unnecessary.
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Financial institutions may not be known sustainability, but tune in to this session to see what is changing.
What are the Green Bonds? Social impact bonds?
Join Mark Peacock and Roger Harris in conversation.
Drug abuse is a worldwide problem responsible for a considerable number of deaths, functional dependence, and healthcare costs. Use continues to rise throughout the world and synthetic drugs have been added to the repertoire alongside cocaine, heroin, and methamphetamine. The acute intoxicating effects on the brain are well known; however, an understanding of the neurological complications is important in the acute period to guide workup and treatment. This panel is in the SMACC Brain pre-conference workshop will review neurological complications of intravenous drugs including endocarditis and the resultant septic emboli and stroke, intracerebral hemorrhages, and aneurysms. We will also dive into the less well-known neurological sequelae of other drugs including some not-so-uncommon zebras.
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Brandon Foreman shares top 10 signs of neurological badness.
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Ever wondered what life holds after discharge from ICU for the families and partners of patients with a severe brain injury? This interview-style session will focus on the challenges, unexpected good and bad outcomes, positive and negative impacts on relationships, and other issues experienced by patients’ loved ones post-ICU. Hearing first-hand from a patient’s primary carer will highlight that ICU is only an extremely small component of a patient’s long journey to recovery and remind those involved in neurocritical care that whilst short-term physical outcomes dominate in a patient’s acute ICU stay, it is the long-term functional and social outcomes that ultimately matter most to patients and their families. It is easy to be distracted by the physical problems, but we must not forget the potential impacts of a severe brain injury on higher cognitive functioning when discussing long-term prognoses with families.
Applying research in the Neuro ICU; Marketing and Branding; follow up after critical illness.
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Cooling the severely brain injured patient in the intensive care unit is far from straight forward. Who should be cooled and when? What do you call a fever, and is this the same as the bedside nurse? When should we start, and when should we not? What would make you stop? This talk will explore the cooling journey of a critically unwell brain injured patient in a neuroscience intensive care unit. It will expose all the potential challenges, questions and pitfalls of cooling at the bedside, and suggest some ways to overcome these.
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Health care providers who phantom or "quick look" ultrasound examine are causing the viral spread of an epidemic, which we can minimize by responsibly utilizing ultrasound inpatient care and by implementing the coaching that artificial intelligence provides.
Current trends in point-of-care ultrasound and how the health care provider community can respond are described:
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Phantom or‚ Quick look‚ scanning.
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Faculty credentialing and learning ultrasound.
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Artificial intelligence technology in ultrasound machinery image acquisition and interpretation.
I discuss the phantom or‚ quick look‚ scan and how correcting this behaviour can only come from yourself. Second I describe my experience with faculty credentialing: being told to learn ultrasound on your own or even being given a faculty credentialing ultrasound education plan generally does not work. I describe the passive and active ways to acquire training. You should not rely upon herd immunity.
Finally, I discuss how errors in human judgement will occur. Ultrasound machinery with artificial intelligence components is increasingly available for image acquisition and pattern recognition so human errors are increasingly minimized.
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The role of ultrasound in paediatric lumbar puncture.
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Action Stage: Stage One - Identify Technology in medicine is advancing at pace, providing unparalleled opportunities to process information and to improve both outcomes and safety for healthcare. But with this good comes many challenges and even dangers. How can we better share information and distribute the opportunities equitably? What are the safety mechanisms and who is providing the oversight?
This episode of CodaZero is the first under the Educate pillar. It is the perfect opportunity to start examining the benefits and risks posed by rapidly changing technology within healthcare. The Educate pillar remains at the ‘identify’ stage of our staged action-plan development process. At this stage the conversations are just beginning and are designed to highlight possible area for further action. Join us for this fascinating first session, divided into four concise but richly revealing conversations.
Conversation one examines the role of Artificial Intelligence in healthcare. What are the opportunities as we push the boundaries and where are the challenges? Are there inherent biases in the algorithms and could these cause harm? Will healthcare workers be replaced by AI or will it be that healthcare workers using AI will replace those that don’t?
In conversation two the tables are turned, and we move from discussing speed as the main goal to focussing in on Indigenous methods of learning. Perhaps slowing down is the answer? What might an Indigenous AI algorithm look like?
Conversation three examines what have we learnt from the pandemic and what learning processes can be evolved.
Finally, conversation four highlights the demise of public interest journalism as a result of media power being concentrated in the hands of a few tech giants. The echo-chamber of our own media feeds is a dangerous proposition. Perhaps the solutions to these early discussions lie in greater connections and breaking free of the echo-chamber by challenging ourselves to listen more to others with differing experiences and opinions.
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Public interest media is vital. However, there is a crisis in public interest journalism and it is not new, but some believe the pandemic may be an extinction event for this discipline. Global media power and wealth have become concentrated into a handful of tech giants. This concentration of power and its’ inherent biases not only poses a threat to public interest journalism but also to global health through medical misinformation. This dystopian concept is rapidly becoming reality and perhaps the only way to overcome this is through connection…. Connecting with those that think differently and challenge our beliefs. If we stay in the echo chamber of our polarised media we will not overcome this problem and it will become the end-game. We must get out of the echo chambers of our polarised media. We must get over our affronts and offences in order to listen. We must lean into these voices and realise that we all have something to learn.
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We can have all the evidence in the world in healthcare but at the heart of everything we do and every decision we make there is ‘us’.
The Pandemic has seen an incredibly accelerated understanding of Covid19, a virus none of us had heard of before January 2020, but it has seen a change in how Evidenced Based Medicine (EBM) is processed and presented. The ‘E’ continues to represent ‘Evidence’ but the ‘B’ has become ‘Belief’ and the ‘M’ is now ‘Media’.
Under the pressure of the pandemic we in healthcare have believed there is a need to act on levels of evidence that pre-Covid we would have thought irrational.
So we must adapt our traditional model of EBM to the pace of now and make it faster and more adaptive to become “EBA” or Evidenced Based Agility. We need to have the ability to rapidly filter out the good quality evidence and find ways to translate that into practice. However we must also be agile enough so that if the next month we find the evidence has changed we can admit we were wrong and move on – This has not been a feature of EBM in the past where there has been a lot of inertia.
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We often associate Indigenous cultures with a deep understanding of nature rather than computing or AI. However, deep learning, connected learning and relationships are integral to both AI and indigenous learning. Perhaps indigenous people are the future of AI.
It is essential that we bring groups together to design AI. Indigenous cultures walk in multiple worlds and cross many generations. These perspectives are different but often not represented in universities curriculums. Indigenous learning sees health as holistic. Which human doesn’t need to include spiritual, mental, physical, social and emotional dimensions to their healthcare?
It is essential as healthcare providers that we give ourselves a ‘software update’ and continue a process of life-long learning, particularly about cultural competence. The indigenous practice of coming together in ‘collectives’ and looking at big data sets yields different outcomes than say a ‘western’ trained epidemiologist might conclude. Indigenous knowledges work by accumulating over time with continuous quality improvement and reflection.
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Over the last 5 years there has actually been a confluence of a few different historical threats. We’ve had health data being increasingly digitalised and we’ve had the proliferation of accessible massive scale computing, both of which have un-locked a technique developed in the early 80’s called deep learning, which is really good at pattern recognition over large data sets.
Key trends in the last year include the first randomised clinical trials in the clinical application of AI in health, the potential for AI in clinical discovery particularly using multimodal data (including electronic medical records, imaging data, genomic data) and combining that to find patterns in very large data sets. This is the real beginning of precision medicine.
Finally there are day to day clinical process applications being used to predict resource allocation or disease outbreaks. At the same time there are some systemic challenges facing AI in health, including workflow integration, bias, equity and just access.
How can we mitigate these biases and make them fair. Finally how do we make this sensitive data safe?
Is the answer Federated machine learning where we send the AI algorithms out to local networks and apply them there?
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Rachel Liu, Creagh Boulger & Sharon Kay will provide a brief introduction into the use of gaming in education, more specifically ultrasound education, with live demos.
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In light of trials suggesting pocus delays CPR in cardiac arrest, should we be doing more transesophageal echocardiography in the resus room? A pro-con case-based debate.
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Abuse in the financial system impacts over 40% of the adult population, and CommBank is taking action. They studied 11 million transactions within the 3 months period, and found that 8,000 people have received abusive messages in the transaction description. Why would CommBank have an interest in customer vulnerability? Catherine Fitzpatrick has joined Roger Harris and Mary Freer for a fascinating discussion around financial toxicity, and what actions have been taken to combat abuse in the financial system.
Creativity is a highly valued and sought after skill; we all need to solve problems, think in novel ways, and generate ideas, but can creativity be learned?
This talk provides a practical framework to help you improve your creative thinking, enhance your problem solving and get greater access to your naturally creative brain.
You'll discover how creativity follows a process that can be developed at every stage. You'll learn how to challenge your assumptions and reframe problems. You'll discover techniques to help you generate more ideas and think more laterally. You'll even learn why you have ideas in the shower and how to access more creative brain states.
The talk will cover the following:
- Creativity as a process, and how to build the creative habit
- How questions help reframe problems and challenge your assumptions
- How to promote more lateral thinking using divergent thinking strategies
- Understanding convergent thinking
- The neuroscience of "A-ha moments" and how to access creative brain states
- The implications for improving creativity and problem solving
The speaker is Phil Dobson, author of "The Brain Book" and Founder of BrainWorkshops. Phil turns insights from neuroscience and cognitive and behavioural psychology into applicable skills for the modern workplace. His learning programmes provide brain-based toolkits of practical skills, backed by scientific research, helping people apply what we know about the brain to improve their performance and creativity at work.
For more head to: codachange.org/podcasts
It can be particularly challenging to care for dying patients who insist that they are not and request intensive, seemingly futile treatments. Physicians often feel disconnected from such patients.
For many, there is the belief that we are different from these patients, more able to accept our own mortality, less likely to desire high intensity, high technology treatments at the EOL. The literature on physician utilization of resources at the EOL paints a different picture. We are reminded how vulnerable we all are to the forces that drive patients towards aggressive treatment at the EOL and in that recognition of our shared humanity, better able to align with our patients.
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Clinical supervision in our busy workplaces is hard. We balance patient safety, learning opportunities, and the workloads of senior and junior staff. The conversations we have to navigate this balancing act can affect patient outcomes, and how we feel about each other and our work. But these conversations don't always happen, and may not always go well.
Sometimes the feeling of "I'm scared', comes out as, "I don't think we need to intubate the patient".... In a given clinical circumstance, a supervisor might label that assessment as incompetence rather than recognise and address the underlying fear- that might exist for any number of reasons. These are the IFF moments of clinical supervision conversations, Identity, Feelings, Facts.
Sometimes the words we use are not the best guide to how we are actually thinking or feeling but they COULD be. Understanding whether our words convey Identity, Feelings or Facts and matching responses to those we are talking with will bring our clinical supervision conversations to the next level.
Vic, Jenny and Eve take us through a case study of potential IFF moments and encourage reflection on your own. Learn how to notice the IFF moments, name them and reshape the conversation to benefit learners, teachers, and patients.
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Concussions have gained lay person attention over the past several years, due to high profile media stories from military conflict and professional sports. Also known as "mild" TBI, concussion affects millions of patients worldwide, many never seeking formal medical care.
Concussion remains a unique injury, in that no one medical speciality "owns" the disease, leaving treatment variable across the world. Concussion is not a mild injury, resulting in a spectrum of sequelae that plague patients for weeks and even longer in a minority of cases.
We will explore the downstream implications of concussion on families, employers, patients and finances, tying in clinical outcomes to social impact.
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Mark Wilson and John Myburgh discuss intracranial pressure. Some fundamentals, some history to put it all in perspective and all the issues with focusing on just one number. Fascinating insights from two true experts.
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Creativity is a highly valued and sought after skill; we all need to solve problems, think in novel ways, and generate ideas, but can creativity be learned?
This talk provides a practical framework to help you improve your creative thinking, enhance your problem solving and get greater access to your naturally creative brain.
You discover how creativity follows a process that can be developed at every stage. You learn how to challenge your assumptions and reframe problems. You discover techniques to help you generate more ideas and think more laterally. You even learn why you have ideas in the shower and how to access more creative brain states.
The talk will cover the following:
- Creativity as a process, and how to build the creative habit
- How questions help reframe problems and challenge your assumptions
- How to promote more lateral thinking using divergent thinking strategies
- Understanding convergent thinking
- The neuroscience of 'A-ha moments and how to access creative brain states
- The implications for improving creativity and problem solving
The speaker is Phil Dobson, author of The Brain Book and Founder of BrainWorkshops. Phil turns insights from neuroscience and cognitive and behavioural psychology into applicable skills for the modern workplace. His learning programmes provide brain-based toolkits of practical skills, backed by scientific research, helping people apply what we know about the brain to improve their performance and creativity at work.
For more head to: codachange.org/podcasts
High quality Virtual Reality (VR) gaming is not a thing of the (dystopian) future; the technology is here and showing promising therapeutic benefits for patients. Consumer VR is projected to be a $21Billion global industry by 2020. Home grade systems are available providing deep sensory immersion including touch sensors (haptics). Healthcare has a poor track record of adopting new technologies. We need to understand our work better to forecast where emerging technologies may do a better job for patients and systems. This presentation steps away from VR as an increasingly explored and popular training tool for healthcare workers, and instead looks at the growing evidence of therapeutic benefits of some VR applications. We need to go into our workplaces and hunt for problems we have not yet found good solutions for the answer may just be VR. You are Player One - be ready.
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Treatment of cardiac arrest requiring CPR has been transformed by the use of extra-corporeal membrane oxygenation. Patient stabilised on this innovative therapy can be transferred for coronary angiography and possible stent intervention. Time is critical, time is muscle! However when the muscle is gone but the other organs still work what options do we now have? For the patient in sustained unrecoverable cardiogenic shock with neurology intact where should we go? What therapies are appropriate and possible?
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This talk provides an approach to life-threatening upper GI bleeding, including management of the grossly contaminated airway, the impact of hypothermia on bleeding, and balloon tamponade insertion. Knowing which balloon tamponade device you stock (is it a Minnesota or a Blakemore?), and where to find it, are just as important as knowing how to insert it. Refining your approach to variceal bleeding can help you optimize your resuscitation of these challenging cases.
For more head to: codachange.org/podcasts.
Unprofessional behaviours by health professionals, in hospitals, are associated with a significantly increased risk of preventable patient complications. Such behaviours result in an environment that results in increased, and unnecessary psychological stress of health professionals and resulting in teams not working to the best of their ability. Flattening the hospital hierarchy creates an environment where team members feel safe to speak up, without fear of reprisal and knowing their opinion will be given appropriate consideration. Speaking up and calling out inappropriate behaviours, in a respectful, non judgmental manner will result in the majority of people modifying their behaviour. Improving the culture of our workplaces will result in people wanting to go to work, improved team communication and performance, and ultimately better patient outcomes.
For more: codachange.org/podcasts.
You are a member of the resuscitation team looking after a shocked blunt polytrauma patient. The patient is intubated and ventilated, splinted, and is receiving a massive intravenous blood product transfusion. To your surprise, Whole Body CT scan fails to show any active haemorrhage. This talk describes the common and rarer causes of hypotension following trauma and highlights how a meticulous history and primary survey examination may often reveal the cause before imaging.
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What's next after RESCUEicp? -The results of this study may have been disappointing, but there are some questions about the trial itself which we review. Irrespective, study into how to improve outcome for TBI patients marches on, with a look at goal directed therapy and multi-modal monitoring as a couple of examples of the future in TBI research. Prognosis in TBI - What tools do we have to help patients and families faced with the question of "what next?" after TBI? We will look at some of the available tools and discuss the dilemmas in reconciling what we know and more importantly what we don't know with what the patient and families are seeking.
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I review multiple papers that cover the merits of ultrasound use in the prehospital field. From identification of CHF, to IV starts, to a possible treatment modality for strokes.
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Inequity within the healthcare profession harms both providers and patients. Diverse teams have been shown to offer better care and improved productivity. The Coda community has the goal of developing achievable, sustainable and measurable actions (within the Ethics pillar) to tackle inequity within healthcare and disseminating these in 2022.
In order to take action we need to develop plans through a five-stage process. Stage One is to Identify: This preliminary stage, which is where the Ethics domain is currently, seeks to identify possible actions. Once identified these actions enter stage Two where they are examined by a global team of experts for the feasibility of application. The expert recommendations then return to the community in stage three where they are proposed for modification and acceptance. Once accepted these expert designed but community modified actions enter the Fourth Stage of Sharing or implementation. Finally the outcomes from implementing the actions must be measured.
Coda.Zero provides the perfect platform for the early stages of developing our action plans. In this episode we explore what does gender inequity and racism look like within healthcare today. The pandemic has exposed and exacerbated many inequalities. What are the challenges? In the final conversation the panel proposes some powerful advice for our community action:
· Speak up / don’t be a bystander: Become an activist
· Human rights start at home: Educate our children
· Read literature from authors with diverse experiences / cultures: We need insights into these lived experiences
· Have tough conversations – discussions not debates
We have brought together a dynamic and diverse group of opinion leaders to launch this topic. Each conversation is both informative and highly engaging. Welcome to Coda Zero.
For more head to: codachange.org/podcasts.
In this conversation Lauren challenges us to consider: "What does hate look like in the world today?" The conclusion she draws is that hate looks like pain. Pain as a result of the pandemic, the marginalisation of women and girls, colonisation and the exploitation of people. And who does hate hurt? It hurts the individuals, whether they be practitioners or vulnerable patients. It hurts the broader community through inequitable distribution of services, wealth and opportunities. Finally, hate hurts you, it hurts all of us! What puts me at risk, puts you at risk, because we all need to live in this world together. So how can we cure this ‘hate virus’? Don't miss this compelling conversation and the conclusions from the incredible panel. For more head over to codachange.org/podcasts
Amy challenges us to think about our healthcare systems and the entrenched inequality within them. How does a legacy of white supremacy impact healthcare in 2020? Why do we continue to see the same power imbalances repeated again and again, whether it be in healthcare, education or politics? We have a young system and pushing back should not be seen as threatening. Many of our healthcare systems were built in a time when women and in particular Indigenous women, were not seen as equal. That legacy continues to live on because at no time have we stopped the old system for a hard reboot. The same teachings still live on and are now deeply embedded in our healthcare systems, perpetuating the harm! For more head over to codachange.org/podcasts
Not all women experience discrimination to the same extent or in the same ways. The pandemic has resulted in a dramatic increase in women's caregiving responsibilities to both children and the elderly. Additionally everyone is in the home so the domestic load has increased. Prior to the pandemic women in Australia were spending on average 1.7 hours more per day on care and domestic duties than men and now in the pandemic this has increased by a staggering 50% to mean women are providing 2.5 more hours of care than men! We need to disrupt.... so that both men and women can both work in high value roles from caring through to strong technical roles as well. We need to redistribute paid work and domestic work more evenly between men and women. For more head over to codachange.org/podcasts
Is sexism in healthcare subtle or overt? - The answer is both! .Dr Kate Ahmad shares her experiences training in medicine. Women are frequently not recognised as doctors because of their gender and they are more likely to have comments made about their appearance or questions about their relationship status....these examples are subtle, undermining the position of a woman as a doctor. At the same time there are often far more confronting examples of overt sexism. We need better systems for calling this out and we need to protect the women who come forward. We also need to ensure that bystanders come forward and don't keep their mouths shut. This needs to be called out in public. Women enter medicine at the same rate as men but their ascension up the career ladder is far from equal. This is because of sexism, a system set up by men for men and unequal family responsibilities which is a societal problem. Female patients often chose a female specialist and there is some evidence that female patients have better outcomes when treated by a female doctor. For more head over to codachange.org/podcasts
Australia has established a global competitive advantage in agriculture. However innovation in the agriculture and food industries globally is changing and the entrance of new technologies, capital, and perspectives is putting pressure on existing systems and ways of thinking. Entrepreneurs especially are playing a critical role in this transformation. This presentation will provide insights into how Australia can build on a competitive advantage in agriculture to become a competitive global player in agrifood technologies and will give practical take-home principles for how we can all innovate to improve the world we live in.
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Brandon will be giving high-impact, rapid-fire talks on assessing stroke symptoms, using EEG after acute brain injury, and advanced multimodality monitoring.
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Anne Creaton is interviewed by Peter Brindley. She talks about her experience in setting up Emergency Medicine Training in Fiji and give advice to those who may want to work in a similar setting.
www.codachange.org/podcasts
Sexual assault affects 1 in 3 women and 1 in 6 men during their lifetime worldwide. It is more common than most medical issues we are trained to look for, despite this being a patient population we are going to see by virtue of the "anyone, anytime" nature of an emergency and critical care. Generous estimates find than only 20% of survivors present for medical care and may not disclose this initially in their visit. Look for it during public holidays, large parties or concerts, college or university fresh week, particularly in young women. Other scene awareness clues that a sexual assault may have occurred include sedation that does not match the substances taken or clinical level seen, ripped or missing clothing, or being separated from their group.
Documenting your suspicions and findings is key - as this chart is more likely to go to court, but not for 2 years. Direct quotations of what was said by the patient or EMS, body diagrams for what was found, and your clinical decision making are the essentials. Physical findings may be absent or minimal; this does not mean that no assault took place! The discussion that you had with the patient around further treatment and legal options needs to be recorded.
Care of a sexually assaulted patient is complex and can have long-lasting detrimental psychological effects if not done well. Referral to a specialized care program to bridge the gap between medical and legal in a patient-centred trauma-informed manner is best. Treating survivors with belief, support and humanity as you assist them with making an informed decision as to the next steps in their care is vital as the first step in healing.
www.codachange.org/podcasts
This first episode of Coda Cure has set the scene. The importance of clear definitions, treatment strategies, managing Antimicrobial Resistance, vaccination programs and dealing with the long term outcomes of sepsis were all identified. The Cure pillar remains in the early stages of identifying areas for our community to take meaningful action on global sepsis.
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We apologise for the low quality audio, Dr Flavia Machado kindly delivered her talk in the middle of a hospital shift in São Paulo during the global pandemic.
LMIC's bear 85% of the global burden of septicaemia. There are three main determinants of mortality:
1. Pathogenic factors
2. Host Factors
3. Healthcare Inequality Factors (Prevention / Water & Sanitation / Access to Care,Resources, Education)
Interestingly, the effects of the current Covid-19 Pandemic appear to be more related to the pathogen than the other two factors and so the burden of disease has been more evenly distributed globally. That said, the pandemic has further exposed some weaknesses in healthcare systems in countries like Brazil. Namely, the high rates of secondary hospital acquired infections and antimicrobial resistance, high mortality rates, unreliable supply chains, cultural challenges with end of life care and broader social challenges like corruption.
At the same time, some good things have come from the pandemic in Brazil. There has been an increase in Philanthropy towards healthcare, more recognition of the work healthcare workers do, and an increased appreciation of the need to support public healthcare institutions.
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Blanket standards applied in research design, particularly those applied traditionally in a "peace time" setting are worth being carefully examined for their relevance now in this pandemic "war time" setting so that we don't hog-tie ourselves with irrelevant and unhelpful regulations.
At the same time, we don't want the 'wild wacky west'.
Everyone is under pressure in research to move quickly, but we need to ensure that if we change standards we do so intelligently so that the choices we make for more pragmatic design are perfect.
The pandemic has shown how as experts we are so narrow minded.
It is sad how little we really listen to each other.
On a large scale COVID-19 has really shown up that many of us in medicine have become super-specialised, and it is very hard for us to think across different domains and to think with any range.
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While the timely use of Antibiotics for sepsis is well recognised, the rise of Antimicrobial Resistance (AMR) is a huge threat to global health.
The current pandemic has highlighted our vulnerability to infection and we are now experiencing first hand the public health and economic cost of a pandemic.
We know now what it really means to not have effective diagnostics, treatments and vaccines for an infectious pathogen.
AMR accounts for 700,000 deaths annually.
Antibiotic use is the key driver for AMR. Some use of antibiotics in COVID-19 infections is likely appropriate and some likely inappropriate, so this is where AMR comes in.
Vaccines can help in AMR by reducing the carriage and transmission of AMR pathogens and by reducing the clinical symptoms of certain infections that can result in appropriate antibiotic use.
Vaccines can specifically help reduce AMR within three categories:
1: Vaccines against common bacterial pathogens like Haemophilus Influenzae
2: Vaccines against specific AMR pathogens like Tuberculosis or Gonorrhea
3: Vaccines against viruses that ma result in symptoms then prompting the inappropriate use on antibiotics and this is where a COVID-19 vaccine comes in.
codachange.org/podcasts
The global burden of Sepsis continues to challenge clinicians in its definition, diagnosis and treatment. The current Covid-19 pandemic seems to have almost taken our understanding of the Sepsis Syndrome back decades. What are the similarities between the current pandemic and sepsis? And what can we learn?
We have never avoided healthy controversy and in this episode Simon Finfer puts the case that the multi-organ dysfunction and cytokine storm seen in critically ill Covid19 infected patients is analogous to the conventional Sepsis Syndrome and ARDS.
Perhaps if we consider the current pandemic through a Sepsis lens, we can avoid making the same mistakes that we have made in Sepsis research for decades resulting in no licenced treatments for the Sepsis Syndrome.
Derek Angus agrees but makes the case that there are two distinct differences. Firstly that the endothelial dysfunction appears different in Covid-19 and secondly unlike sepsis in the case of Covid-19 the pathogen itself proceeds unabated by any currently proven treatment. This means we need a two pronged approach in Covid19 research:
1: Strategies purely aimed at combating the virus
2: Strategies aimed at applying Sepsis lessons to the pandemic response.
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Rhonda Cadena talks IV Alteplase for wake up strokes using MRI criteria. Tiger territory! After a NEJM paper in 2018 this is now on the table - hear the perspective from Rhonda, an ED / neurocritical care specialist from North Carolina.
For more head to: codachange.org/podcasts
This talks gives some guidance on how to deal with your anxiety and fear when dealing with children. We will also cover some key topic areas: sepsis, fluids, seizures, asthma and bronchiolitis
CODACHANGE.ORG/PODCASTS
Back by popular demand Phil Dobson joins Oli Flower and Liz Crowe in conversation around psychological wellbeing. We ultimately decide where to spend our attention, which is a limited resource, during a typical day. Finding it hard to focus, and at the same time finding it hard to switch off? Multimedia multitasking is training your brain to be distracted. Tune in for some effective strategies to master your attention.
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A case example of a large vessel obstruction of the brain and our current techniques available to treat it. How we make decisions on endovascular treatment and management points for emergency and intensive care colleagues.
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in March 2006, six healthy volunteers underwent cytokine-induced injury and multiorgan failure from a Phase 1 first-in-human drug trial with a novel monoclonal antibody. This talk describes the clinical and incident management ramifications, drawing connections to other non-conventional incidents which may pose a different pattern of clinical, operational and communications challenges to the 'classic' trauma-based model of major incidents.
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This talk will introduce the audience to the dynamics and effects of childhood abuse from a human rights framework. It will explore pertinent aspects of recovery and illuminate the healing possibilities that exist within every relationship between a child and any adult professional.
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What makes you fulfilled? What are your top 3 things that you love doing? All too often we tend to prioritise work over the stuff we love doing; we overcommit and work even harder. What's important to realise is that doing the things that we love is not a luxury, it should be pre-empted.
Phil Dobson shares strategies for achieving resilience through psychological and emotional recovery.
codachange.org/podcasts
Since 1991-1992, competing sepsis definitions have--with varying degrees of success--attempted to capture the difference between normal and abnormal host responses in order to help researchers and clinicians improve care. The most crucial basis of "usual care" in sepsis treatment is, simply, who is deemed fit to receive it.
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Laura Rock and Jenny Rudolph give strategies for managing interprofessional conflict at the bedside in a critical care setting.
Healthcare is generating 4.6% of the global greenhouse emissions- to put this into perspective, the entire aviation industry is responsible for 4.9% of emissions.
Tune in to join Roger Harris & Andrea MacNeill in conversation about moving towards a circular economy where products are designed to be reusable, durable, repurposed and recycled.
With net zero referring to the greenhouse gases, Andrea shares a framework for meaningful action.
https://codachange.org/2020/07/20/net-zero-for-healthcare-by-2050/
We will describe our program which included:
- Supporting and developing sustainability and resilience, and workplaceleadership in our clinicians
- M&M / Incident management
- Medication safety
- Implementation of a formalised Clinical Emergency Response System (CERS) in ED
Resuscitation fluids save lives in humans with life-threatening hypovolaemia. The fluid of choice should have biochemical characteristics close to the type of fluid lost and replaced at a rate and volume sufficient to correct severe fluid deficit. Then stop and consider the early use of catecholamines. There are few indications to give critically ill patients resuscitation fluids after 24 hours of admission. There is no place for synthetic colloids of non-physiological crystalloids. The effects of unnecessary fluids last well beyond the initial resuscitation period and are associated with adverse effects and harm to the patient. Fluids are toxic drugs and must be used with great care.
"The pandemic is a reminder of the intimate and delicate relationship between people and planet. Any efforts to make our world safer are doomed to fail unless they address the critical interface between people and pathogens, and the existential threat of climate change that is making our earth less habitable." Dr Tedros Adhanom Ghebreyesus, WHO Director-General. In this cross generational catch up on the post COVID world, Roger Harris, Courtney Howard and Omnia El Omrani are talking about the old normal, and the opportunities within the new normal.
In the second part of the podcast focused on POCUS, Cian, Trish, Kylie and Rachel take a deep dive into the ultrasound process during the COVID-19 pandemic. How do we keep our equipment clean? Who do we turn to as a reliable and up-to-date source of information? Now, that the traditional literature is struggling to keep up with the times, and social learning networks aren’t always best evidence where is the knowledge. The “InfoDemic” has been experienced by all. What we do know is that strong POCUS infrastructure and collaboration underpins flexible opportunities for innovation. Jump into the comments section to join the discussion!
This talk introduces the concept of a new generation of pulmonary embolism (PE). What was once considered a deadly disease process now carries a mortality rate of <3%, which may be driven by overtesting as well as overdiagnosis. This talk will explore this phenomenon and current evidence-based approaches to the evaluation and treatment of PEs.
By Lauren Westafer
Naomi Hammond talks about why follow up after critical illness matters, and why we need to know more about how to do it. Presented at SMACC 2019 in Sydney, Australia
In Australia, we have been hearing from colleagues and the media about how challenging it has been providing healthcare during the pandemic in many parts of the world. We have expected and are prepared for the battle and perhaps to get a chance to be “heroes”. Given that Australia has experienced relatively few COVID infections, some people may feel almost as if they have missed out on their “hero” moment. Some colleagues have expressed feelings such as 'I have had it easy and my colleagues overseas are having it so tough?' There have been an unusual mixture of emotions from relief to guilt. It seems for some of us that after the “hero” phase comes the “disillusionment” phase. What should we do with these emotions? Tune in to join Roger Harris, Mary Freer, Karen Gaunson, and Kym Jenkins in conversation.
The pandemic has turned everything on its head, and, like with any major catastrophic event, there is an abundance of lessons, take-aways and the new opportunities to be explored in the healthcare setting. By harnessing the power of digital technology, we are now able to connect with the people from different departments, and open up to new ways to communicate. Sliding briefing and debriefing into the frontline work- briefing at the beginning of the shift and debriefing at the end, including mental rehearsal- provides the comfort of predictability, which enables us to better cope with the unexpected. What lessons have you learnt from the COVID-19 pandemic, and what does your new normal look like? Read more
An anaesthetist, Dr Rachael Grimaldi is a mum of 3 children under the age of 4, and is currently on maternity leave. Frustrated at not being able to join the frontline in the fight against COVID-19, Rachael saw an opportunity to improve communications with the patients whilst in full PPE by developing an innovative and simple resource, an app called CardMedic. Launched in 72 hours, the app is now improving patient care in 50 counties across the world.
Tune in to hear Rachael tell Roger her remarkable story. MORE
Jesse, David and Swami are back in the second part of the Carr's Clinic podcast, nerding out on the ESPN's Last Dance documentary, featuring Michael Jordan and the Chicago Bulls. It's interesting to see how the popularity of sport is leaning into the public health. What are the lessons can we learn from the NBA and The Last Dance documentary? Let's chat! https://codachange.org/2020/06/01/carrs-clinic-part-two/
After being in the trenches for 3 months, just how different will the medicine be in the future? Jesse, David and Swami talk about pivoting, steering the dinosaurs, and the lessons learnt along the way. One thing is certain- social inter-connectedness in healthcare is very important. To stay connected with Coda, subscribe https://codachange.org/you
In the part 2 of the special podcast with Simon Carley we touch on the issues of cognitive bias, that everything you see is COVID-related. Surrounded by the sea of COVID, just how do you manage the strokes, the acute myocardial infarcts, fractured neck aphemas, and the rest of it amidst this catastrophe? Simon shares his thoughts on the life outside COVID.
The legendary professor Simon Carley is joining us all the way from Manchester, UK to talk about positive innovations and evidence based agility. There is a fine balance between being slow to change and missing out on something that might benefit the patients, and jumping in too quickly into something harmful. The panic is understandable, what can we do about this virus, how can we treat it? The pressure to change is so high that the people are losing the plot with the evidence based medicine.
Haney Mallemat is sharing his experiences in Baltimore with Roger and Oli, talking innovation and the phases of creating and culling, as well as the importance of communication in the implementation stages. It's all about finding balance between what would protect you as a provider and give good outcomes for the patient. And sticking to the five principles for assessing new treatments and processes - Safe, Simple, Familiar, Reproducible and Robust.
This is part 2 of the special podcast featuring Reuben Strayer, sharing his first hand experience of the COVID-19 situation in New York with Ashley Liebig, the medical operations commander for the Travis County and a flight nurse. "There was only a brief period between when we first started noticing coronavirus and when seemingly everyone in the city had coronavirus", "emergency providers are working in an environment that resembles a lake filled with coronavirus".
This is part 1 of the special podcast featuring Reuben Strayer and Ashley Liebig, sharing their first hand experience of the COVID-19 situation in New York. "So many people in the region got infected at the same time, long before we were paying any attention to it. And as the patients got sicker, we started to notice a few things, such as this was oxygen deficit we never seen before".
Fear. Is it normal to be frightened during this pandemic, in this period of uncertainty, when we're so used to being very certain about what we do in an emergency and critical care? Does fear and uncertainty impact our communication? Do different departments use different language, do different departments communicate differently? And what do we need to address to help open the flow of communication, and make sure we are closing the loop?
Liz, Roger, Chris and Jon talk about communication and interdepartmental collaboration becoming the norm. If one good thing can come about from this COVID-19 crisis, it's that it could help us, staff members, but also more importantly, the patients in the future.
This is the second episode of the three part series of the podcast dedicated to technical and communications aspects of managing the airways of COVID patients. In this episode we are breaking down the case of a particular difficult airway case published online by Chris Hicks earlier, and discovering that the approach is not all that different to the guiding principles, communications and checklists we would have used in the non-COVID related intubations.
What seems to trip us up is the process, precautions and PPE. Sticking to general principles and processes is the rule here but we have to be careful in how we’re communicating, and the specific terminology we’re using.
Bottom line, COVID or no COVID, best way to manage a difficult intubation is via the tried and tested emergency resuscitation procedures that have proven to be safe, effective, simple and familiar.
Join Coda community of healthcare leaders: codachange.org/you
The Coda v COVID podcasts have been focusing on the non-technical skills we need to manage the pandemic crisis, but we have received increased requests to discuss more technical aspects of management. Accordingly, this is the first in a three part series dealing with the process for emergency intubation in the crashing patient with the novel corona virus. Here we discuss the technical protocols and the nomenclature around aerosol generating and airborne type precautions. Importantly, we also discuss the recent decision by some UK and Australasian bodies to designate chest compressions as a non-aerosol generating procedure, a decision that has caused ripples of confusion with different craft groups. This has added to confusion around PPE, again with different professional bodies providing conflicting advice for their members. Tune in to join the conversation as we attempt to decipher the messages and give our take on what we are doing and why.
Mary Freer, Roger Harris and Jane Sloane digging deep into the issues of gender equality during the current pandemic. At least 70% of those in the front line as health and community workers are women- and so they have a higher exposure to the virus. But often policies are designed by men, with no diverse representation of women, highlighting the issues of social inclusion. One thing is certain, when women contribute to strategies, we save lives.
Why are we all so tired and hungry? Mary Freer, Jesse Spurr and Fiona Kerr talk about the value of human connection, and the effects of communication technology has on human brain. As many people are currently working from home, not sharing the same space and touch has a roll on effect on our mood and energy levels. We find ourselves going into inertia, getting tired easily, different parts of our brains are trying to look for information as we live in the emerging environment and don't know what is going to happen week on week. And this makes you very fatigued. The good news is that what if going to come out of this is our choice.
Today Roger and Liz invite Angela Tonge, the Intensive Care and Trauma Social Worker, to talk about how distressing it is to not be able to have the families visit patients in the ICU. With the focus on treatment, family distress has been out of sight, out of mind. And the distress of someone dying in the ICU is immense.
The muscle whisperer Kym Siddons, talks with Mary Freer, Roger Harris and Oli Flower about sprinkling self care into your day. How important it is to be checking in with your body, and incorporating movement into your routine. Little movements can make a lot of difference, like shifting up your body weight may provide a welcome relief, or a covert stretch alleviate lower back pain. Great tips that are easy to implement.
If you're finding yourself reaching for a bowl of cereal late at night after a long and stressful shift at work, you're not alone. Roger Harris, Mary Freer and Emma Strutt talk diet, and what to do when your body is craving quick release carbs.
Jane Munro takes us through the Pandemic Kindness project, and the way the Maslow's hierarchy of needs is applied in the current times of the COVID-19. We have to get the basics right, psychological safety at work is important.
To learn more about Jane's Pandemic Kindness fundraiser follow the link.
Human factors are affecting our performance day to day. How do we make it easy for other people to work with us? Covering a wide array of issues, from PPE to simulation, Martin Bromiley, Liz Crowe and Oli Flower share valuable communications tactics, and the ways human factors affect teams and safety during the COVID-19 crisis.
Many of us are having troubles sleeping. The levels of stress have impacted sleep. Are you waking up multiple times a night, not feeling rested? In this podcast Roger, Mary, Liz and Andrew Davies tackle the issue.
Frightened, anxious, unsure, overwhelmed- just a few of the emotions we are experiencing at the moment as the front line of the global public health crisis. Could it be that all the surrounding noise is provoking the fear? Roger, Mary, Liz and Jesse are discussing possible strategies on breaking free from the grips of the ever escalating anxiety during COVID-19 times. Podcast by Roger Harris, Liz Crowe, Mary Freer, Jesse Spurr.
Laura Rock and Jenny Rudolph give strategies for managing interprofessional conflict at the bedside in a critical care setting.
Since 1991-1992, competing for sepsis definitions have--with varying degrees of success--attempted to capture the difference between normal and abnormal host responses in order to help researchers and clinicians improve care. The most crucial basis of "usual care" in sepsis treatment is, simply, who is deemed fit to receive it.
Clinical trials are expensive and take years to go. Do they generate patient and economic benefit that justifies the cost of trials?
Bec Nogajski takes you on a 20-minute journey about YOU. How your team, how you follow, and what leadership style would work for you.
Evie Marcolini talks about an aspect of neurocritical care that we commonly wrestle with: prognostication. Putting the patient at the centre of all conversations is essential.
For more head to: codachange.org/podcasts
How can something that makes so much sense physiologically not have any positive trial outcomes? Are we disrupting an important potentially beneficial cellular function by our current processes and timing of cooling? Is it targeted hypothermia or is it therapeutic? Will the TTM2 shed any further light and lead to practice change? All these questions and more will be answered in a snap-shot talk of what is (at least!) a decade-long debate, filled with numerous high-quality studies.
For more head to: codachange.org/podcasts
Everyone has the potential to live a creative life - As healthcare professionals, how might we do so? In this talk Grace Leo chats about what creativity is and what it might look like in various areas of our lives. She also interviews Hugh Montgomery; a climate change advocate, story book author and Guinness world record holder for playing the piano underwater.
This presentation will give you an update of the current chest pain protocols; including risk scores (HEART, TIMI, EDACS) with / without high sensitive troponin. But also on the newer pathways with rule out of acute coronary syndrome with a high sensitive troponin below the limit of detection or two troponins with a delta. How do we use these chest pain protocols in tomorrow’s clinical practice? How do you choose a protocol that fits in your institution? Which chest pain patient can we discharge safely from the emergency department and for whom should we organize outpatient follow up? And how do you share your decision with the patient in front of you.
Andrew Dixon from Radiopaedia goes through 5 classic fails - common misses in trauma imaging. Learn from this rather than missing them yourself! See if you can spot the pathology before Andrew explains it to you - you can scroll through the scans on Radiopaedia here: https://radiopaedia.org/playlists/1976c00393ca4c9d9878566c3487d97a?lang=gb
In order to be as good as you can be (self actualisation) you need to understand your own performance and how you are seen in the world. Sadly you cannot do this alone. Arguably all the beliefs about yourself, your actions, your performance and even your own image are skewed, biased and incorrect. You cannot reach your peak without help. Healthcare is complex though. In the resus room decisions are often time critical and information light such that we cannot apply a simple rule as to what is good and what is bad. Similarly, who can judge success? Only those who understand our systems, our aims and what the difference between process and outcome is. That's where Peer Review comes in. As a tool it is a way of gaining insight into how you really perform in the real world. This talk explores the why, the when and gives tips on the how you can maximise the power of peer review in your clinical and education practice.
Sexual assault affects 1 in 3 women and 1 in 6 men during their lifetime worldwide. It is more common than most medical issues we are trained to look for, despite this being a patient population we are going to see by virtue of the "anyone, anytime" nature of an emergency and critical care. Generous estimates find than only 20% of survivors present for medical care and may not disclose this initially in their visit. Look for it during public holidays, large parties or concerts, college or university frosh week, particularly in young women. Other scene awareness clues that a sexual assault may have occurred include sedation that does not match the substances taken or clinical level seen, ripped or missing clothing, or being separated from their group.
Documenting your suspicions and findings is key - as this chart is more likely to go to court, but not for 2 years. Direct quotations of what was said by the patient or EMS, body diagrams for what was found, and your clinical decision making are the essentials. Physical findings may be absent or minimal; this does not mean that no assault took place! The discussion that you had with the patient around further treatment and legal options needs to be recorded.
Care of a sexually assaulted patient is complex and can have long-lasting detrimental psychological effects if not done well. Referral to a specialized care program to bridge the gap between medical and legal in a patient-centred trauma-informed manner is best. Treating survivors with belief, support and humanity as you assist them with making an informed decision as to the next steps in their care is vital as the first step in healing.
The rising death toll from our nation‚ opioid epidemic has been rivaled in modern history only by that at the peak of the AIDS epidemic in the early 1990s. Consider, in 1995 at the peak of the AIDS epidemic, 51,000 Americans died from the disease. In 2015, 52,000 died from drug overdoses. Emergency departments have stood at the front lines of both crises. As a specialty that prides itself on rising to the occasion at times of great need, our time to lead on this crisis is now. As a response, EDs nationwide are expanding their roles in the care of patients with opioid use disorder (OUD), and many have begun ED-MAT programs. In December of 2017, we launched the Get Waivered Campaign which aimed to get our physicians the DEA X waivers needed to be able to prescribe ED-MAT(buprenorphine) to patients coming to our hospital seeking recovery. In May of 2018, our ED instituted its first ED-MAT protocol and while greater than 90% of our attending physicians had their DEA-X waivers and were able to prescribe buprenorphine, we found that there remained an opportunity to increase the rate of MAT initiation in our ED. Through semi-structured interviews we set out to examine the barriers to providers, use of our MAT initiation protocol and patients‚ willingness to seek help in obtaining OUD treatment in our ED. Our work has identified multiple barriers, affecting both providers and patients, that have limited wide-scale early adoption of our protocol. The barriers identified from our ED-MAT program‚ first year of operation, and the interventions aimed at making the use of our ED-MAT protocol as effortless as possible may serve as useful lessons as other hospitals seek to lead by operationalising their own ED-MAT programs.
For more head to: codachange.org/podcasts
A case example of a large vessel obstruction of the brain and our current techniques available to treat it. How we make decisions on endovascular treatment and management points for emergency and intensive care colleagues.
This talks gives some guidance on how to deal with your anxiety and fear when dealing with children. We will also cover some keytopic areas: sepsis, fluids, seizures, asthma and bronchiolitis
in March 2006, six healthy volunteers underwent cytokine-induced injury and multiorgan failure from a Phase 1 first-in-human drug trial with a novel monoclonal antibody. This talk describes the clinical and incident management ramifications, drawing connections to other non-conventional incidents which may pose a different pattern of clinical, operational and communications challenges to the 'classic' trauma-based model of major incidents.
This talk will introduce the audience to the dynamics and effects of childhood abuse from a human rights framework. It will explore pertinent aspects of recovery and illuminate the healing possibilities that exist within every relationship between a child and any adult professional.
Resuscitation fluids save lives in humans with life-threatening hypovolaemia. The fluid of choice should have biochemical characteristics close to the type of fluid lost and replaced at a rate and volume sufficient to correct the severe fluid deficit. Then stop and consider the early use of catecholamines. There are few indications to give critically ill patients resuscitation fluids after 24 hours of admission. There is no place for synthetic colloids of non-physiological crystalloids. The effects of unnecessary fluids last well beyond the initial resuscitation period and are associated with adverse effects and harm to the patient. Fluids are toxic drugs and must be used with great care.
We will describe our program which included:
Supporting and developing sustainability and resilience, and workplace leadership in our clinicians
M&M / Incident management
Medication safety
Implementation of a formalised Clinical Emergency Response System (CERS) in ED
This talk introduces the concept of a new generation of pulmonary embolism (PE). What was once considered a deadly disease process now carries a mortality rate of < 3%, which may be driven by overtesting as well as overdiagnosis. This talk will explore this phenomenon and current evidence-based approaches to the evaluation and treatment of PEs.
Coming soon to a hospital near you! 3D printing is a revolutionary technology that allows for the creation of objects with complex geometry and anatomy with unprecedented accessibility and ease. By developing anatomical models from patient-specific medical imaging for various treatment applications, medical 3D printing represents the next great leap in personalised medicine. In critical care, there are almost limitless possibilities for this new technology in simulation.
However, current barriers to the widespread adoption of 3D printing in medicine include the lack of expertise among clinicians, the perceived costs and perceived inaccessibility of this technology. In giving this talk, I hope to demystify 3d printing by sharing my step-by-step guide on starting a 3D printing lab, by sharing my experiences and journey with this technology. I'll show you how you can start a 3D printing lab for less the average critical care physician's annual coffee budget.
Peter Brindley interviews Luise Sayers and they discuss the taboos death, bereavement and what we can do to make it better. This Pacific Island Playlist chosen by Louise opens with Moonshadows by Cat Stevens: https://vimeo.com/271105270 and closes with Monty Python's "Always look in the bright side of life" https://vimeo.com/129646517
Panel discussion: key features of a team or corporation that facilitate creativity and innovation; exploring how creativity marries up with change management (which sometimes gets a bit of a bad wrap ‚ is it all buzzwords and no action?).
A panel with the chairs of ILCOR discussing their two newest protocols. Hosted by Scott Weingart.
David takes us through a tricky case that might test you! Can you pick the diagnosis before Dave reveals all?
Des Gorman talks about real-world outcomes and controversies following traumatic brain injury. His extensive research and experience in this area give a unique insight into what actually happens to the patients we care for.
Hallie Prescott tells us about why the back-end of sepsis matters and is a neglected aspect of our management. This sub-acute phase can really affect long term outcomes. Long term exposure to broad-spectrum antibiotics and too much fluid are aspects that matter and that we can modify.
Peter Brindley interviews Khairil Musa and they discuss Khairils passion outside of medicine: dance. This Pacific Island Playlist chosen by Khairil opens with Medicine by Daughter: https://vimeo.com/215106696 and closes with Momma's Prayers by JP Cooper: https://vimeo.com/237966073
Kat takes us through the reality of managing pre-eclampsia in South Africa, highlighting what we mustn't miss.
Andrew Dixon from Radiopaedia covers the common pathology seen on CT scans in critical care. He covers basic anatomy and important areas not to miss, strokes, trauma, herniation syndromes, hypoxic brain injury and diffuse axonal injury
Adam gives practical pearls about managing the unexpected difficult airway. He uses a good example, emphasises the importance of effective teamwork and draws from the Vortex approach and the DAS guidelines. Watch out for more from Adam via the Safe Airway Society.
Treating pain is important. Treating pain in a vulnerable population like infants, who cannot speak for themselves, is especially important. Unfortunately, there is a great deal of evidence, from many clinical settings, that suggests that we don't do a great job treating pediatric pain. Recognizing this problem, and based on a large number of randomized controlled trials, many experts recommended the use of sucrose to manage infants' pain. I question this approach and suggest we are safer to assume that sucrose is not a pain medication. Unfortunately, we can't measure pain in infants. The experience is entirely subjective. However, sucrose has been studied in populations who can report their pain (older children and adults) and does not work. Sucrose changes behavioural scores in infants, but those scores do not measure pain. Even if they did, observation is inaccurate for estimating pain in older populations who are able to report pain scores, so we should be skeptical of their accuracy in infants. Furthermore, in brain imaging studies, despite looking calmer, infants‚ brains still react as if they are in pain when sucrose is given. Therefore, I think the safest approach is to assume that sucrose is not a pain medication, and focus on other analgesic options (with proven effect in patient populations that can report their pain). Instead of relying on sucrose, I offer my top five tips for pediatric pain control. 1) Limit painful procedures whenever possible. (Think carefully about whether tests will actually change management. Use oral meds instead of IM or IV. Group painful procedures together.) 2) Think topical. EMLA is a proven option, but amethocaine works faster, and therefore might be a better option. 3) Consider using nerve blocks. 4) Remember the intranasal route. Fentanyl, ketamine, and midazolam are all excellent agents that can be used intranasally to help with pediatric pain and anxiety. 5) Think about distress, not just pain.
John Myburgh gives a philosophical talk about what life (and death) is really about and what the new challenges are in critical care. Modern critical care has so many potential interventions. John challenges whether doing more is always the right thing to do and gives a good argument for doing less being best.
Liz Crowe gives sage advice about dealing with grief and loss in the critical care setting, for both relatives and health care professionals.
There are many ways to skin a cat. Rhonda Cadena discusses management of intracranial hypertension, specifically substantial practice variation, what the evidence shows and what she does in reality.
Muscle wasting in intensive care is the thief of future health. Hugh Montgomery shows us what a big issue this is and what can be done to mitigate the problem.
Neurological insults such as trauma and haemorrhage disturb the brain in complex ways, affecting multiple outcome domains. A substantial number of patients with even mild brain injury experience long-term emotional, cognitive and physical deficits. Measuring these deficits is at the core of prognostication and research in neurocritical care. However, the most commonly used outcome measures are simplistic scales that focus on functional outcome. There is increasing concern that the way we define and measure outcomes is failing to capture the multidimensional patient experience.
This presentation of 3 case studies will explore the complexity of assessing long term outcome from brain injury and explore the need for improved outcome assessment measures that better capture patient recovery.
A case example of a large vessel obstruction of the brain and our current techniques available to treat it. How we make decisions on endovascular treatment and management points for emergency and intensive care colleagues.
Chris Nickson talks about personal moments in his career in critical care that have really challenged him. Jenny Rudolph then builds on the work in the previous sessions. She shows us how to react, accept, reset and engage and outlines the psychological principles which underpin these concepts. Hopefully, these sessions will really help us deal with the workplace stressors we all encounter.
Emotion is always present in critical conversations. When we recognize emotion, validate feelings and respond with empathy and curiosity, we allow patients and their families to engage in the process, to build trust, and to better understand their values. When emotions are too intense, or feelings are not validated, people become disengaged, less trusting, and often fail to explore and understand the deeper values‚and instead may act on raw, surface emotions that actually may not be in their best interest.
We often answer feelings with facts. Instead, we should G.I.V.E. when we encounter emotion. G.I.V.E. is a mnemonic tool that offers a simple approach to responding when an emotion arises in conversations. First, get that there are emotion present and pause. Identify what you think the emotion might be or describe what behaviours you are noticing. Validate the feelings expressed. Explore to understand better and offer your curiosity and caring. And if you can't remember what G.I.V.E. is prompting you to do, it may be enough to give your attention and patience to the other person at that moment.
The secret of success in teams is not individual behaviour, it's team-based.At the core of every elite team is psychological safety -- defined as shared belief in a team environment that permits interpersonal risk-taking.Risk in this context means the ability to be open, honest, ask questions, seek input, admit mistakes and drive relentlessly towards being better: key behaviours for high performing team leaders and members alike.Psychological safety in health care is both elusive and difficult to achieve.Social contagion theory can help explain how each team member can contribute to a study team environment that accelerates group performance.Be a positive emotional contagion.Carry the fire.
The rehabilitation of people who have cognitive impairment after TBI should be based on an understanding of what is the likely cause of that impairment,
Crystalloids and colloids used in critically ill patients have different fluid composition. The composition may affect many things, including response to administration, clinical outcomes, and adverse effects. This talk with discuss the evidence behind the different types of fluids in critically ill patients, including a discussion of pros and cons of each fluid type.The session will be an interactive discussion led by investigators who have conducted randomized trials of different types of intravenous fluids.
The SMACC Opening Ceremony is an integral part of the conference welcoming delegates to an educational experience unlike any other. Inspiration for SMACC Sydney included the inverted triangle: the alchemical symbol for water which is steeped in history and meaning to represent the City of Sydney and a celebration of diversity and resilience. Retrofuturism influences the design and theming of SMACC Sydney by playing on different aspects of 80’s and 90’s popular culture. Using music as a storytelling medium the show presents a mesmerising and unique soundscape combining elements of classical, electronic and popular music deftly created by Composer and Music Director Jake Meadows. This year’s opening ceremony echoes the program through four stems and performances each illustrating the unique and essential role we play as critical care professionals: Learning and Culture, People and Planet, Bedside Critical Care and Science and Innovation. The show opens with a spoken word performance by Nardi Simpson, an Indigenous performer telling an electrifying story of the land and the importance of Country to Indigenous culture. This is then followed by a vocal ensemble performing Queen’s Bohemian Rhapsody, a cheeky throwback to an iconic piece of music and an homage to the importance of humour and levity in our line of work. A change of scene brings a dramatic dance performance performed by ICU Registrar Khairil Musa and his dance partner Sarah King reflecting on the tragic final moments leading to a cardiac arrest. The finale blends classic 80’s pop with the iconic sound of the synthesiser with a toe tapping performance of Van Halen’s Jump led by vocalist Maya Weiss as an uplifting tribute to creativity and innovation. Performed in the Sydney International Convention Centre Theatre to over 3000 delegates we present to you our best and most memorable opening ceremony yet.
Social media has allowed for important spread of medical knowledge to the public but has also seen the inexorable rise of fake news. Mistrust in the medical profession may be exasperated by misinformation in public domains. Prominent cases such as the Jahi McMath case have led to ethical discussions regarding death. How are we going as neurocritical care professionals?
Technology is good for learning‚ information and even wisdom at our fingertips, tech like simulation and virtual reality is cool. And technology really hit its straps with social and collaborative learning. But technology is bad‚ distracting, and multi-tasking impairs learning, our health can suffer, and good technology can be badly applied (eg PowerPoint as a "crime against connection" in presentations). Some technology is expensive without learning impact, and social media and the internet have dark sides. Vic offers us some thoughts on navigating the good, bad and ugly and suggests some personal strategies for making the most of technology for learning. And there is no Powerpoint.
It's hard to die without passing through MET-calling criteria; if you try to do so on a hospital ward, chances are you'll have an Intensivist next to you. By designing systems to detect patient deterioration, we've inadvertently invented acute palliative care. How did we move from resuscitators to out-of-hours death doulas so rapidly? Is death the future of Intensive Care Medicine?
A neonates journey, just what feedback would your neonatal patient give you after 3 months of intensive care? Listen to the innocent observation and experience of daily life in NICU and perhaps approach a future patient with little voice slightly differently.
How can you live a full creative life in the midst of a busy medical career? Fiona gives a very inspiring talk at the Get Creative Workshop, discussing the fascinating pathway her life has taken, allowing her to fulfill her creative potential whilst still developing her medical career as a paediatric emergency physician.
Delivery of safe healthcare currently faces unprecedented challenges in the UK and globally. This arises, at least partly, from a rising involvement of the criminal law in the investigation of medical errors apparently conflicting with the need to respect a "duty of candour". As a result, doctors face enormous pressures in fear of being blamed for medical errors. David Sellu is a consultant surgeon who was convicted for gross negligence manslaughter in late 2013 after the death of a patient in a private hospital. I (@DrJennyVaughan) was the medical lead for a group of David Sellu's friends as we launched a campaign to overturn his conviction. There has never been a successful 'out of time' appeal in this area of the law so we were dealing with almost impossible odds from the start. The positive result was extraordinary, both for David and our whole profession (www.medicalmanslaughter.co.uk). Since these events, I have supported other doctors facing criminal conviction, such as the paediatrician Dr Hadiza Bawa-Garba, through my work with the Doctors Association UK (DAUK, @TheDA_UK). Thousands of doctors crowd-funded a campaign and successfully overturned a court decision to erase her from the UK medical register. Her case proved to be a lightning rod in the UK for a profession at breaking point. Many healthcare staff are working on critically under-staffed wards and in under-resourced departments, with an increasingly unmanageable workload.
DAUK have since launched a "Learn Not Blame" campaign to improve safety for patients and healthcare professionals. We believe that the involvement of the criminal justice system in these cases often does not allow an appreciation of the interplay of individuals within complex health systems. We also remain particularly concerned that a recent analysis of conviction trends shows an excessive conviction rate of black and minority ethnic (BME) healthcare staff.
OHCA, Out of Hospital Cardiac Arrest is surrounded in controversies from bystander CPR and the use of Adrenaline, to airway management and mechanical CPR. Who better to hear the latest updates from other than Gavin Perkins, author of Paramedic 2 and lead on ILCOR guidelines
Learn how to reinvigorate yourself after nights, a period of downtime, or when you are recovering from compassion fatigue or post critical care exhaustion - Reflection is Key
What can Prehospital and Retrieval Medicine teach us about life? Natalie May reflects on lessons learned at Sydney HEMS - from the practical to the philosophical.
Many critical care practitioners, like workers in other industries, sleep less than recommended amounts, in what is truly an epidemic of poor sleep in our modern industrialised society. The effects of sleep deprivation are serious and visible across all levels of our community. The actual proportion of people who can live on insufficient sleep is extremely low and the first step towards improvement is to recognise when our sleep tank is running on empty. Simple changes in daily habits based on optimizing sleep hygiene can lead to improved wellbeing and are highly likely to lead to profound improvements in physical, mental and emotional health and performance. Sleep quality may well be more important than sleep quantity. Shift work and the scheduling of multiple consecutive daily shifts are a serious impediment and must be considered carefully by our institutional managers. Taking naps is another seemingly simple but logistically challenging method to improve overall sleep. The bravado that sleep is not important needs to be carefully redirected in our hospitals as the health and performance improvements of practitioners seem likely to lead to greater work satisfaction, less burnout, improved teamwork and ultimately improved patient outcomes. Of course if most of us need more sleep, and will benefit from doing so, just imagine what might happen if our patients could get more sleep.
According to the WHO, there are more than 400,000 homicides globally each year, with millions more suffering from non-fatal injuries. Our hospitals and emergency departments care for many of these patients; however, many return with repeat injuries or are killed within 5 years. In order to reduce intentional violence, it is necessary to discuss and understand its root causes. Dr. Gore’s talk will touch on some of the root causes of violence and further discuss the program he founded called KAVI, a hospital,school and community based intervention as a way of both improving recidivism as it relates to violent trauma and decreasing the incidence of intentional violence overall.
Oli Flower presents at the Get Creative workshop on how to communicate with graphics. We all use images to get our messages across - how can we do this more effectively? He talks about understanding your target audience, techniques for brain storming, and the importance of getting criticised.
Evidence based medicine holds RCT's, randomised Control Trials, as the highest level of evidence but they are often poorly constructed and misinterpreted. This talk by world renowned clinical researcher Professor Simon Finfer analyses the common mistakes and failings of RCT's and describes way that we can do better.
Emergency Medicine operates early in the course of disease when uncertainty is high and information light. We need to do things that help us cognitively offload in the care of critically ill patients.In how many specialties would you be expected to acutely manage (and possibly resuscitate) anyone who comes to you for care‚ young or old, surgical or medical, sick or not sick with limited time and information. We are constantly having to think outside the box.Consider these 4 topics when thinking outside of the box: Bougie 1st Intubation, Mechanical CPR in OHCA, HD-Guided Epinephrine Drips in OHCA, and Stroke Ambulances.What side of the discussion do you fall on in these controversial areas?
Episode 3 follows the trauma patient into the ICU and focuses on the management of Septicaemia, Antibiotics, Steroids for sepsis and how gender inequality within medicine can adversely effect patient outcomes.
Presenting the best literature on resuscitation published 2018 including Paramedic 2, Airways 2, CAM, A rapid fire review critically analysing the hottest papers published during 2018. A fantastic overview of all things resuscitation.
Cognitive bias and risk management are vital understandings to high performance teams in medicine . My extreme sports seem like extreme risk to many people but I have survived 20 years in these disciplines following risk management strategies learned in critical care medical environments. I am interested in the role cognitive biases play in every day and critical decision pathways. In particular I am interested in the Affect Heuristic. My talk borrows from my extreme sport and critical care experience to highlight the role that fear plays in every decision we make and how we can lessen the emotional bias of the Affect Heuristic. It will be a fun and visually spectacular presentation.
The presentation guru Ross Fisher gives a workshop on how to be creative and engaging when you're presenting, no matter what your topic is.
Ken Milne the author of skeptics guide to emergency medicine SGEM reviews the hottest critical care literature for 2018 2019. Ken reviews articles from the Lomaghi trial on magnesium for rate control in Atrial fibrillation, Expulsive therapy for renal calculi with Tamulosin, Oxygen therapy in critical illness in the Iota trial and finally aromatherapy for nausea and vomiting.
Peter Brindley interviews Khairil Musa about Performing Arts, specifically dance, and how this complements his career in critical care.
Episode 2: Series of three episodes spanning the patient journey from roadside pre-hospital trauma through the emergency and resuscitation rooms to the Intensive Care unit. In this first episode Ashley and Rueben use a panel of experts to examine some of the major pre-hospital resuscitation controversies including Pre-hospital intubation and blood tranfusion.
After many years of feeling frustrated about gender inequity and harassment in healthcare, I decided to do something about it. My advocacy in the age of social media has been a surprising and exhilarating journey, and led me to believe that even the most ordinary person, when activated around a cause, can have impact.
Exploring the many aspects of creativity which may, or may not, assist you in a life of critical care medicine.
Paediatric constipation is a common problem and the biggest problem clinicians make is not taking a thorough bowel history. Forty percent of paediatric patients in Emergency have abnormal bowel habit. Constipation is not what you pass as a bowel habit but what you don't pass - Its what is left behind that causes the constipation.
The delivery of nutrition to the critically ill is incredibly complex. There is little evidence that providing standard nutritional requirements of 25K/cal/Kg improves outcome. Foremost amongst this evidence is the TARGET trial, a large randomised controlled trial of 4000 patients in Intensive care.
Road to Resus is a three day series of a patient experience, with critical decision points at every turn allowing the audience to decide on the course of action after hearing from topic experts.
Humans aren't wired for connecting immediate pleasure (unprotected sex, alcohol, drugs, cigarettes) with some ethereal medium-term risk. As a result, 'public health campaigns' rarely work. Meanwhile, we make decisions far less based on 'fact' than on 'emotion'. When did you ever see a chocolate ad telling you about the ingredients? This may be why we have failed to convince public or politicians alike to take action on climate change. Hugh will discuss such issues from his personal work in the climate change field over 20 years, giving examples of what he has tried- and why most of what he has done has failed.
SMACCMini: The snakes and ladders of paediatric DKA - how to win every time by Heather Murray
SMACCMini: So you think you can dance? Play and purposeful skills in PEM by David Krieser
Neuro ICU: DEBATE: Currently randomised controlled trials are of no use in advancing the care of patients with severe traumatic brain injury
SMACCForce: E-CPR - Panel by Brian Burns, Paul Gowens, Lional Lamhaut, Steve Bernard, Nikki Stamp, Alice Hutin
All healthcare professionals should have a strong sense of situational awareness. Particularly in uncertain and unpredictable prehospital environments, situational awareness is an important skill to master. As we know, things can go south in an instant. So, what is situational awareness? Isn’t it just about paying attention? According to Mike Lauria, it is about much more than that. Situational awareness is a complex, cognitive process which involves perceiving the environment, comprehending the situation and taking steps to avoid error. If you look at every major disaster in history, a loss of situational awareness is one of the top causative factors. In the prehospital space, we need to develop ways in which we can teach our colleagues and trainees about how to be acutely aware of their external environment and what is happening around them. Mike suggests that there should be someone focused on local situational awareness and global situational awareness. Local awareness involves focusing 100% on the critical task at hand. Then, other team members should be focused on global situational awareness. This could involve scanning the other areas of the patient, looking at the monitors, looking out for teammates and observing the surrounding environment. In this talk, Mike Lauria talks us through how to build active systems of awareness and how to turn these systems into habits. He describes how to build a system of awareness and how to turn this behaviour into a habit. To do this, we must start with a cue, have a specific action sequence and provide a variable reward. Finally, we must repeat, repeat, repeat until the process becomes a habit. Tune into a talk from DAS SMACC on Situational awareness in Resuscitation and Repetitive Practice.
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SMACCForce: LIVE EMS Nation Podcast - "Feeding the Flame" by Faizan Arshad, Raed Arafat, Lamhaut and Anne Creaton
Acts of violence against paramedics is disgraceful but not doing anything about it is much worse. From DAS SMACC, Craig Wylie speaks to us about violence against paramedics in South Africa. In the four years leading up to this talk in 2017, there were 250 attacks against paramedics. In a neighbourhood where there can be up to 100 gunshots in three hours, this almost shouldn’t be surprising. Craig tells a story where he was called out to an emergency where his colleagues were under attack. His first thought? Why didn’t they get a police escort? But in a low to middle income country, it is rarely that straightforward. Where there is a high crime rate and may only be two police vehicles on duty, it isn’t always as easy as waiting for a police escort. Additionally, if paramedics had to rely on police attending their emergencies, is this just introducing another barrier to care? Craig asks three simple questions: 1. Has our management failed our staff members? 2. Have we done enough that the paramedics that we employ can protect themselves? 3. Have we as an EMS system entirely lost the plot towards our paramedics and how we respond to patient emergencies? The solution? Craig suggests it is all in the training. Paramedics need to be trained to understand the situations, to have a strong action plan, to have an exit plan and to involve community leaders. The team need to be trained to understand how to protect themselves so that they can provide care, whilst also looking out for themselves. Tune into a talk from DAS SMACC on Violence against healthcare workers - Paramedics under siege.
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Communication is something that we all do every day. Communication in healthcare however, isn’t the same as communicating in other areas of our lives. The nature of what we talk about is difficult, particularly when we are delivering bad news. This is amplified even further when communicating with children in medicine. How do we make their experience as enjoyable as possible, whilst communicating effectively with their families? One such way is to acknowledge the role of culture in communication. Culture underpins the way in which we give and receive information in all circumstances. It informs the way we think about things and in many cases, our reactions. We could provide two families with exactly the same diagnosis and information but they could respond in completely different ways. Families will react to information within the cultural framework for which they operate. We may perceive a sprained ankle as a minor injury, however for one family it could mean an inability to participate in sports which is a crucial element of their day to day lives. As healthcare practitioners, we should acknowledge that we won’t change people’s way of thinking by arguing with them. We need to recognise the role that culture is playing, be humble, be understanding and be flexible. Furthermore, studies show that children often understand more than we anticipate. So, it is our job to ensure that we are communicating in the best way possible. Natalie’s advice? Be prepared, manage expectations and provide explanation. From DAS SMACC, Natalie May shares her tips for good communication skills in healthcare.
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From DAS SMACC, Charles Larson and Andrew Beck discuss intubating sick kids - small holes, big problems. When intubating a critically ill child we fear that they are going to arrest on induction and we consider the skill required to intubate in difficult circumstances. The most important thing to remember is that we will never be so good that we won’t make mistakes. The greatest critical care physicians are those that have good skills but that are also able to identify what might go wrong. Understanding the risks and having a plan for when something goes wrong is crucial. Managing critically ill children is a difficult task. We must understand their physiology, have a plan for induction and have a plan for if things go wrong. Importantly, we need to consider that it takes several minutes for drugs to kick in for children. What matters more than what drug you give is how you give it. Children don’t follow recipes so nor should you. Furthermore, some golden rules in managing airways in children: 1. Simulation and training is key: We don’t want to be educating ourselves on our patients, particularly in rare scenarios. 2. We must know our equipment, know our limits and know our support systems. Being able to call down help early is priceless. 3. Assess, plan and communicate with the team. 4. Don’t repeat without change. Trying to put the same size tube down the same size hole will always lead to problems. 5. Training needs to be ongoing and skills need to be revisited. Confidence does not always equal competence. Charles Larson and Andrew Beck share stories of Paediatric intubation in high pressure scenarios.
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SMACCForce: Silver Care - Panel by Conor Deasy, Gregor Prosen, Mark Wilson, Raed Arafat, Cheryl Cameron
Matt Morgan describes critical care physiology through history. Matt’s story begins in Copenhagen, 1952, when an 11-year-old girl in developed acute and severe polio. The last iron lung had been used. So, a young anaesthetist, Bjørn Ibsen, organised a tracheostomy and positive pressure ventilation (PPV) and changed the world. From that point we have discovered and understood the physiology of traumatic brain injury, mechanics of PPV, HFOV, APRV and echo to name a few. However, Matt contends that this story was not the beginning of our understanding of physiology. Matt will take you back through time to show how giraffes, dogs, fish and even frogs can teach us about physiology. Giraffes can tell us about the delivery of CPP. They utilise massive mean arterial pressures and a complex system of venous valves. The MAP is achieved through massive left ventricular hypertrophy – a completely normal finding in giraffes. High frequency oscillatory ventilation was first used in the 1970s… however, dogs have been doing this for 100s of 1000s of years ago. Airway pressure release ventilation was described in the late 1980s… again this is not new. Frogs and lizards have been using this method for millennia. Finally, Matt tells us about ice fish – who live 1.5 kilometres under the Antarctic Ocean surface. The ice fish CAN transcribe haemoglobin; however, it does not bother. All its oxygen is provided by dissolved oxygen in its harsh environment. Matt will pin his tale of historical physiology on the events around one of his patients – Nathan – who suffered a TBI. During delivering Nathan’s treatment, Matt relies on all these animal lessons. Matt wants you to remember these animals when thinking about physiology. In doing so, he hopes you will educate, innovate, and connect with other medical professionals.
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Join Timo de Raad as he discusses the complexities of CPR in paediatric congenital cardiac disease. Timo introduces the listener to Emma, a 4-year-old cheerful and playful girl. Emma was born with hypoplastic left heart syndrome – a condition where the left side of the heart is poorly formed. As a result, the heart cannot support adequate circulation around the body. 5 out of 10 000 live births in the Netherlands have this congenital heart defect. Timo was there for Emma’s birth, and he was there for Emma’s death. Treatment of hypoplastic left heart syndrome is a palliative three stage repair. The first procedure is the Norwood – within the first two weeks. Subsequently the Glenn procedure is undertaken, and finally the Fontan. In this procedure the pulmonary artery and aorta are combined to create one outflow tract from the heart. In essence, this creates one functional ventricle. As a result, there is a change in the cardiac physiology. This changes the dynamics when considering resuscitation in these patients. In Fontan hearts cardiac output is dependent on the preload which in turn is dependent on how much blood flows through the lungs. Accordingly, spontaneous breathing is critical for these patients. Constriction of pulmonary veins make it difficult for blood to flow back to the heart. When dealing with cardiac arrest in these patients Timo suggests treating it the same as any resuscitation – utilising chest compressions and epinephrine (adrenaline). He does suggest one extra thing, that being abdominal compressions. Timo describes the technique he uses. He pushes between the belly button and sternum. He recommends pushing as hard as if you were palpating the liver. In trials on awake patients, there were no complaints of pain when using this technique. Additionally, Timo discusses the ratio of 1 to 1 chest to abdominal compressions during the resuscitation. In conclusion, resuscitation of a paediatric congenital heart defect is challenging. Consider the growing evidence base on abdominal compressions whilst acknowledging the differing opinions in this space.
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Camilla Strom discusses the outcomes for elderly patients in the intensive care. Camilla recognises a persistent “negative vibe” when people talk about elderly patients. This is inappropriate. We should acknowledge older patients for what they are! They are survival masters. This group of people have experience wars, famines, and recessions. They have seen many failures and successes in their long lives. They have overcome all in their path to be where they are today. Healthcare is facing an oncoming flood of older patients. In fact, this process is already happening across the world. The challenge is that these patients cost a lot of money to care for – especially in the ICU. In the general population, there is a 10% 1-year mortality rate for those 80 years and above. This jumps to 40% if they are admitted to hospital. If a patient older than 80 years is admitted to the ICU there is a 50-90% 1-year mortality rate. Therefore, the question is, should this population be admitted to ICU at all? Camilla argues that age is really much more than a number! Life is a deteriorating process. We pay to live our lives. We pay through the accumulation of DNA damage, through shortened telomeres, diminished physiological reserves and loss of muscle function and strength. These are all unavoidable occurrences. Consequently, it is these things we must consider when caring for the elderly people in our communities. Unfortunately, there is a dearth of data when looking patient outcomes in various settings in the hospital. As a result, we have limited prognostication tools. With more research on the way utilising various scores – more concerned with frailty than age – this will change in the future. With that being said, Camilla urges us to consider the patient as more than their age. Age should not be the limit when deciding who should or should not be admitted to the ICU. Talk to your older patients. Determine what is important to them and use your clinical knowledge to help guide their decision-making process. Finally, set realistic goals and re-evaluate them regularly.
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Manu Malbrain presents the four phases of intravenous fluid therapy. He takes you through the big questions of fluids - What, when, why and how? To Manu, there are four Ds of fluid therapy: Drug, dose, duration, and de-escalation Drug Fluids are drugs. This means, like any drugs, consideration must be taken about the type, indication, contraindication, and adverse effects of fluids whenever prescribing them. The evidence suggests that we should stop using starches in sepsis, albumin in TBI and stop using more than 2L of saline in resuscitation. For maintenance – eliminate the use of unbalanced isotonic fluids, and do not forget to cover daily needs. The bottom line is starting to consider fluids as drugs. Dose As Paracelsus famously said “The dose makes the poison” This holds true when administering fluids. There are different doses for different patients dependent on the indication – whether using fluids for maintenance, resuscitation, or replacement. Duration When do you start and stop? You must weigh up the benefit and risk of fluid administration. Duration should be appropriate – more often than not this means tending towards a shorter duration. Similarly, do not use fluids to treat numbers (such as low CVP or MAP) but rather to treat shock. Finally, fluids can be stopped when shock has resolved. De-escalation Water is a problem. Just as hypovolaemia is bad, so too is hypervolaemia. Weigh up the benefit and risk of fluid removal. Manu describes the ROSE acronym – Resuscitation, Organ support, Stabilisation, Evacuation removal. Essentially, after early management with adequate and goal directed fluids, stop ongoing resuscitation, and move to conservative fluid management (de-resuscitation!) We need to make good fluids better So let Manu guide you through the complex world of fluids. Answer the four questions, address the four D’s and remember the four phases of ROSE.
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When looking into someone’s abdomen, the first thing you'll notice is that it almost looks like there is nothing there. For Dr. Lauren Westafer, the gut looks like a black box. There's a lot of gas which makes it hard to see arteries and organs. In this podcast, Lauren discusses point of care Intestinal Ultrasound. To do an intestinal ultrasound, first, rub the curvilinear probe over the abdomen... That's it as far as technique is concerned! There is nothing overly complicated for such a useful procedure. Why do we still need an ultrasound for small bowel obstructions when we already have other tools like patient history, a physical exam, and x-ray? Unfortunately, these tools are all unreliable for diagnosing small bowel obstructions. What's more, the training for gut ultrasound doesn't take much time. It takes around 10 minutes to do 5-10 scans. The scanning procedure itself takes less than five minutes to perform. For such a high-value procedure, it takes an incredibly low amount of effort and time! When conducting a gut ultrasound, you are looking for dilated bowel (greater than 2.5 cm) and abnormal peristalsis. Lauren explains exactly what to look for, especially when recognising patterns of abnormal peristalsis. Lauren encourages us to embrace a gut ultrasound. From DAS SMACC, tune in to a discussion on Point of Care Intestinal Ultrasound by Lauren Westafer.
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Neil starts off by telling us a story about a plane that took off from JFK and flew to Portland. As they approached to land, they realised that they had a problem with the undercarriage. Instead of listening and taking advice from the flight engineer, who was on board and aware of the problem, the pilot chose to continue to fly the plane around in circles. This led to the plane eventually running out of fuel and a subsequent plane crash. Tragically, the plane crash killed multiple passengers on board, including the flight engineer. The moral of the story? Don’t be the captain who doesn’t listen and don’t be the flight engineer who didn’t speak up. Neil defines command gradient error as the actual or perceived difference in rank which inhibits communication, leads to a loss of the shared mental model and ultimately an undesirable event. We as healthcare professionals are doing much more to patients than we’ve ever done before. This sparks the need more than ever, to generate teams that are functional and collaborative. As we go through any single job, we may move between leading and following the situation. We should embrace this model of teamwork. Neil’s advice for those leading is to be receptive. We should develop an environment that allows people to question our actions and decisions. When following, we should be assertive. After all, it is usually the people following that have the bandwidth to identify a problem in the first place. In this podcast, Neil Jeffers explains how Command gradient error in Prehospital Care can ultimately lead to tragic circumstances. We should focus on collaborative teamwork and clear communication to ensure that we avoid tragic outcomes for our patients.
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Cognitive offloading for critical care retrieval by Stephen Hearns Everyone’s cognitive capacity is limited. It is easy to become overloaded and subsequently for our performance to be impacted. In medicine however, an overloaded cognitive capacity could be the difference between life and death. There is little room for healthcare professionals to be unfocused, yet retrieval medicine is comprised of unpredictability, critical time pressures and fast-paced emergency responses. Let’s face it, there’s never a time where we are more cognitively overloaded than at a multi-casualty incident. Cognitive overload in retrieval medicine results in an unsafe environment and compromised decision making. We need to rely on strategies and processes to reduce our cognitive burden. Eliminating the need to make decisions, allows for a better response to unpredictable scenarios. One strategy is to identify the predictable recurring components and plan for them. Practice implementing the plan, fine tuning the response and ensuring that the whole team is on the same page. It is critical that everyone is well versed and understands the processes and procedures. Furthermore, streamlining communication can have a significant impact on the outcome of high-pressured situations. It can also help us reduce stress and stay in control. Articulate and tell the team when you are overloaded. Encourage your colleagues to do the same when they are overloaded. Delegate and outsource decision making. Teamwork is critical and can make or break an outcome. Rely on writing lists and prioritising actions. It is an excellent way to seek clarity in high-pressured situations. Plan, practice and predict the predictable so that when the unpredictable happens, it has our full attention. Tune in to a DAS SMACC talk by Stephen Hearns on cognitive offloading for critical care retrieval.
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Critical care is viewed from different perspectives. How to clinicians, patients and families experience this life changing part of the health care system?
Jack Iwashyna discusses his research into persistent critical illness in the ICU. While much of resuscitation focuses on the dramatic early minutes to hours of critical illness, many patients stay for days or weeks in the ICU. Jack wants to know, why do patients get stuck in the ICU, and what might we do better to improve their care? Jack became an ICU doctor because he loved drama. He wanted to find the golden hour. The golden hour describes the time to intervene, to make a difference, and to save people’s lives. It is an extraordinary thing to be able to do this, and it is sometimes possible. However, sometimes, it is not. Sometimes the golden hour is not there. Jack describes his experience with patients who would come into the ICU unwell. They would be treated aggressively and begin to get better. However, they would then take a turn for the worse. He describes this as a chronic critical illness. His patients were stably critically ill, and he could not work out why. This led Jack on a sabbatical year where he was afforded the opportunity to try to make sense of these people. The first question he and his team answered was, among patients who spend a long time in the ICU, how common are new, late organ failures? They discovered that in patients who are in the ICU longer than 14 days, there is an average of two new organ failures. Subsequently, Jack developed the persistent critical illness hypothesis. This states that there is a point in the ICU stay beyond which the ICU admission diagnosis and severity of illness in the first 24 hours no longer differentiates patients regarding their probability of in-hospital death. Put simply, the patient that you treat on Day 1 in ICU is different to the patient you are treating on Day 10. After Day 10 who the patient was before entering ICU matters more than what put there in the first place. Therefore, persisting critical illness defines those patients whose current reason for being in the ICU is more related to their ongoing critical illness than their original illness that took them to the ICU. Jack extrapolates his ideas surrounding persistent illness and critical care. In doing so, he raises thought provoking ideas regarding the long stay patients in the ICU.
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After getting his chance to interrogate SMACC Superstars the people finally get their chance to get their own back as everyman Iain Beardsell asks the questions that everyone wants an answer to. Covering a wide range of topics it will focus on Peter's previous SMACC talks, including subjects such as teamwork and burn out and no doubt reliving his interviews across the week.
The ethics of incidental findings: James Rippey Ultrasound is an incredibly useful tool for clinicians. According to James Rippey, there are two main groups of clinicians who use ultrasound. First, there are the POCUS providers, who have a specific, focused question and use the ultrasound machines accordingly. Then, there are the ultrasound experts, who look beyond the specific questions and embrace ultrasound as a valuable diagnostic tool. The advancement of high quality, handheld ultrasound machines means that we will all have imaging available at our fingertips. Notably however, questions are raised regarding the impact that these machines can have on families and the ethics behind incidental findings. James shares a personal story about how using a handheld ultrasound machine on his son, incidentally found a retroperitoneal tumor. Luckily James’s son survived, however it raises questions as to the risk-benefit ratio in the discovery of an incidental finding. This extends not only to the likelihood of the finding being serious but also to consider the financial and emotional costs of incidental findings. It causes us to consider Ethics in Healthcare and the value of procedures that can be unnecessary. For those practicing POCUS (the simple single question, focused form of bedside ultrasound) James’s suggestion is to remain focused and not be distracted by incidental findings that you are not qualified or taught to recognise. Communication regarding the limitations of your scan is far more important. For those clinicians with advanced ultrasound education, James encourages you to identify and consider any incidental findings you come across while performing an ultrasound. Rely on the help of other experts to guide interpretation of incidental findings where appropriate. Tune in to a DAS SMACC talk by James Rippey on the Ethics of Incidental Findings.
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Critical Care survivors: Margaret Herridge In this podcast, Margaret Herridge considers this well-known quote from Nietzsche, “That which doesn’t kill us makes us stronger.” But… Does it? What about our patients who suffer from a critical illness? The continuum of critical illness and what lies ahead for recovery should not be underestimated. Post critical illness, it is not uncommon for patients to suffer from a functional disability, a neuropsychological disability, or a decline in their general sense of wellness and vitality. Patients who have suffered from a critical illness regularly have trouble trying to reintegrate back into normal life. What about the mental illness concerns for both patients and their families post critical illness? We know that post traumatic stress disorder is common for recovering patients and their families. So… knowing this, are our patients actually stronger post illness? Traditionally, the focus of critical care has simply been on keeping patients alive. This is not enough, now we need to focus on giving them their lives back too. We need to make sure that we know our patients and their families and that we help people understand the continuum of illness and recovery. We need to make sure that the treatment which we deliver every day aligns with the goals and values of our patients and their families. We must know them in order to understand this. Margaret explains post traumatic growth as a change in the perception of oneself, a change in the experience of relationships or a change in one’s life philosophy. So... post critical illness perhaps there is an opportunity for growth and this is a positive outcome, however we must not underestimate what it means to be a critical illness survivor. From DAS SMACC, Margaret Herridge delivers an inspirational talk on what it means to be a critical care survivor.
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David Menon discusses the complex and fraught world of managing traumatic brain injury (TBI) in the ICU. In particular, David discusses the management of intracranial pressure and cerebral perfusion pressure in these patients. Although the Brain Trauma Foundation provides guidelines for the management of severe TBI, including targets for ICP and CCP, there is no Level 1 recommendation for the use of any intervention to modulate ICP/CCP. General principles remain simple in theory, if not in practice. David describes good basic intensive care, which he describes as doing lots of little things well. The main focuses should be maintaining blood pressure high enough to get oxygen to brain, optimising oxygenation and modulating carbon dioxide. This is in combination with other modalities such as hypertonic saline, cooling people, and using metabolic suppression. The trouble lies in the fact that there is no evidence base for second line therapy. In fact, some of these therapies have been shown to cause harm. When considering a therapy, it boils down to this - is the disease desperate enough and have the benefits and risks of therapy been weighed up. When controlling ICP, the indications for treatment are different so acceptance of iatrogenic risk must also change. Therefore, ICP treatments must be calibrated using a risk benefit ratio. For instance, utilising hyperventilation to decrease intracranial pressure can be a useful lever to pull. However, going too hard can reduce the cerebral blood flow to a detrimental point. The point here is to use it briefly, to make time for another less potentially harmful intervention. Similarly, when considering CCP, targets and protocols use population averages. No single optimal CCP exists across all patients. So, clinicians need a rationale way to titrate treatment to physiology. David suggests using graded thresholds to escalate treatment in an individualised way. Underlying these principles is good detection and minimisations of treatment harm. Underlying all of these principles is a grounding in the data and the utilisation of this data to effectively communicate with families. By doing this you can deliver the treatment and aim for the outcomes deemed most acceptable by the patient and their loved ones.
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We regularly have difficult conversations in critical care. We deal with sick and complex patients who may be at the end of life. The families we talk to may be in a state of shock and acute grief, unable to think clearly and make important decisions. Moreover, patient safety incidents and other challenging issues such as organ and tissue donation may further complicate the patient journey. In this talk by Jon Gatward, we follow the story of Leah and the difficult conversations that were needed in caring for her and her family. Jon examines some of the key elements that can contribute to successful communication in difficult circumstances such as: • Having a plan and a structure before embarking on these difficult conversations. • Working towards a common agenda and ensuring that everyone feels safe and able to ask questions. • Showing empathy and using silence well, allowing people the space and time to process information. • Giving people the benefit of the doubt, after all, these are their family members that we are talking about. As clinicians, our training in this type of communication may be limited to observing our mentors, and we may feel inadequately prepared. We will investigate how simulation training can be used to improve the quality of communication, increase our skill and comfort level so that we can guide patients and families through complex and challenging situations. We will also investigate how lessons learnt from simulation debriefing can be transferred to the conduct of difficult conversations in real life. Most importantly – we need to ensure that we look out for ourselves and for our colleagues. These conversations are draining and difficult. Tune in to a DAS SMACC talk by Jon Gatward on Critical Moments in the Intensive Care Unit.
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Failure is something that even the very best in the industry regularly experience. In safety critical roles, that failure can ultimately lead to death and maiming. So how do we accept failure? Martin Bromiley explores how we can understand and learn from our failures and difficult moments. He identifies the essential behaviours and mindsets that will help us make sense of those complex moments. One such mindset is being confident that you have the skills to do the job but also humble enough to know that you could be wrong. This is a delicate balance but is so crucial for personal growth. We are all human and we will all make mistakes. Taking responsibility for our mistakes is essential and is what allows us to learn from those errors. Furthermore, Martin suggests that setting a good example is key. We need our leaders to listen and to lead by example, acknowledging their own failures, to grant us permission to do the same. Failure is inevitable but understanding what we can learn from failure, is what makes us better at what we do. Unfortunately, not everyone has the platform or the ability to share their failures or difficulties. We need to encourage people to share their stories and to allow people the space to learn from their mistakes, so that they can achieve success in the future. Tune in to a DAS SMACC talk by Martin Bromiley on how to fail.
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SMACCForce: CRM Panel Discussion with Clare Richmond, Neil Jeffers (Pilot), Per Bredmose, Mike Lauria, Tom Evens
From DAS SMACC, Vera Sistenich explains why it is critical that we care about the global refugee crisis. The global refugee crisis exemplifies some of the greatest challenges facing our global institutions and liberal world order today. From human rights, to xenophobia, sexism and economic protectionism, terrorism and climate change. National and international responses to the refugee crisis are sculpting moral and political norms around the globe. It is critical that we care about the refugee crisis today because it exemplifies some of the greatest challenges to our social order. As Hannah Arendt, the German-born Jewish political theorist wrote, "The manifestation of the wind of thought is not knowledge but the ability to tell right from wrong, beautiful from ugly. ...[T]hinking gives people the strength to prevent catastrophes in these rare moments when the chips are down". It is now critical that we not only care, but think deeply, about our attitudes and policies towards refugees, wherever we come from. Tune in to an engaging and informative talk by Vera Sistenich, as she challenges us to consider how the global refugee crisis threatens liberal world order.
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John Greenwood discusses the use of vasopressors in the emergency room. His talk focuses on three areas. First, he reviews vasopressors and categorises them based on resuscitation end points. Secondly, he addresses the concept of “pressor angst” and how it can significantly impact patient mortality. Finally, he will empower you to start vasopressors early in patients with distributive shock and sepsis. The tale of a 45-year-old lady with sepsis in the context of pneumonia is retold. John asks - what do you do? Initial fluid resuscitation has improved the vitals somewhat, but she is still hypotensive. Continue to give fluids? Sure – it seems to be what happens commonly. Starting vasopressors starts a cascade of events that will consume time and resources. It impacts flow, timing, and ability to see other patients. Often, the clinician knows it the right thing to do but does not want to pull the trigger. This process of having two conflicting beliefs in your brain at the same time is cognitive dissonance. In the context of using vasopressors, John terms this “pressor angst”. The hesitation to use vasopressors even when perhaps you know it is the right thing to do. It is a complex confliction of behaviours, beliefs, goals, and practices. Regarding vasopressors specifically, the clinician will be considering the logistics, bed crunch and procedures amongst other things! Why does the time matter? As John explains with reference to the literature, the time to the decision to commence vasopressors is hugely important in influencing patient mortality. There is a clear mortality benefit to starting vasopressors early. Norepinephrine started early can aid in adjusting preload, cardiac output, and afterload parameters. John steps you through the effect of norepinephrine on all metrics that contribute to. The conclusion is that early norepinephrine administration improves both macro- and microcirculatory function in vasoplegic shock. John wants you to avoid pressor angst! Do not be afraid of vasopressors and pull the trigger early. Finally, consider norepinephrine early in sepsis.
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Luke Regan presents the emerging evidence for prehospital ultrasound and telehealth in his talk from the SMACC stage. Luke has a personal interest in improving prehospital care. He lives in the north of Scotland. It is an austere and challenging environment, far from technology. Compounding this, it is underserviced and there is an absence of critical care with no critical in reach. Unfortunately, the morbidity and mortality of the area does not match the spread of care. Therefore, it is one of the motivations for his research. That being said, he is not alone in his desire for this research. Pre-hospital ultrasound topped the list of technology-based research priorities in pre-hospital critical care, as determined by a European research collaboration. This is in large part because much of what is done in pre-hospital care still exists in an evidence free zone. Luke discusses the extended pre-hospital patient journey in his practice. This presents a challenge, but also an opportunity. If time zero is further back, testing a pre-hospital intervention becomes very achievable. There is precedent for this. Benefit of pre-hospital interventions have been highlighted by the relative benefit of stopping and performing roadside ECG in transit. This has allowed road crews to receive updated treatment advice based on that ECG. This bundle of care is similar to what is possible with pre-hospital ultrasound. Currently, there is a very apparent practice creep when it comes to the use of ultrasound. This means there is an increase in the use of pre-hospital ultrasound around the world. However, it remains an evidence poor area. Luke describes two studies conducted in Scotland looking to answer the big questions in pre-hospital point of care ultrasound (POCUS). Firstly, can it make a difference? Secondly, does it take too long? Finally, who should do it and how long does it take to train them? This is done in large studies, with lots of patients and inputs from a diverse meeting of minds. Join Luke Regan as he discusses the evidence behind the application of pre-hospital ultrasound and telemedicine.
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Sara Gray discusses the complex topic of prognostication post cardiac arrest in neuro intensive care. There is a short list of things that keep Sara up at night. She describes a specific cardiac arrest nightmare she has. She is looking after a patient post cardiac arrest. They remain in a coma after cooling. As they meet brain death criteria and they are an organ donor, they are transferred to the operating room. Whilst there, they regain spontaneous respirations. Although this is terrifying, these situations do happen! And cases like this defy all efforts at accurate prognostication in post cardiac arrest patients. Prognostication matters. It matters for the patient, their family and got judicious resource management. The trouble is, that varying guidelines around the world do not agree. In patients who have not been cooled, then you may start prognostication 72 hours post return of spontaneous circulation (ROSC). Before that time the brain may not have had adequate time to heal from the arrest and the clinical indicators may not be accurate. In the hypothermia group there is differing guidelines. Some guidelines suggest doing it the same way – prognostication after 72 hours. Others suggest 72 hours after achieving normothermia. This equates to 4.5 days. Why the difference? Different medicolegal environments may play a part. However, as Sara explains, some guidelines may be guided by concern over the emerging data about people who wake up late. Sara fears looking a family in the eye and telling them the patient won’t wake up and being wrong. Her advice is to wait 4.5 days. She then recommends starting with a subgroup of patients with a low motor score on GCS. From there you can use indicators with the best accuracy which are bilateral absence of pupillary response, corneal reflex, and somatosensory evoked potentials. Bilateral absence of all three equals a dire prognosis.
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A no-holds barred series of 6 provocative medical interrogations. We challenge the state of research, social media, pharmacology, social work, women in medicine, medicine in the developed work, and the health of healthcare workers. It should be novel, it may get heated, and it is not scripted. Sometimes to comfort the afflicted you also need to afflict the comfortable. This is why no prisoners will be taken, no topic is out of bounds, and no ego will be pampered. It may even offend: you have been warned.
Raed Arafat describes the amazing lessons he has learnt about functional systems for emergencies, mass casualties and disasters. SMURD (Mobile Emergency Service for Resuscitation and Extrication) is in Emergency Rescue Service in Romania. It was set up by Raed Arafat in 1990 to respond to a largely non-existent and broken system. By doing so, he created a pre-hospital care system that he could be proud of. SMURD has today transformed into an integrated, country wide, emergency response system providing high quality care. Romania is one of the only countries in Europe where you have a right of emergency care. That is, you cannot be charged for being rescued or accessing emergency healthcare. This is largely due to Raed Arafat. He has created a functional system that deals not alone with daily emergencies, but also disasters and mass casualties. The national monitoring system and coordination service responds to fires, emergency incidents, critical transfers, and supports the whole country with resources from a national level. To highlight the amazing work that SMURD does, Raed describes in detail the service’s response to two tragedies involving Romania. The first happened in Montenegro, in 2013. A Romanian tourist bus fell 40 metres off a cliff. 19 people were killed and 28 were injured (12 of whom were in a critical condition). What followed was a large scale patient transport and casualty repatriation effort that included local ambulances, SMURD vehicles and military aircraft. The second incident was a tragic fire in a nightclub set off by fireworks. 400 people were trapped inside. The emergency response was mobilised an arrived in 11 minutes. In the minutes, hours and days that followed, SMURD coordinated the mass rescue, treatment, and transfer of patients. This included sending 41 patients to other countries, due to the high number of them that were critical. Despite these extraordinary efforts, SMURD consistently faces backlash and criticism. Raed takes the opportunity to answer his critics from the stage. Listen in to Raed as he demonstrates the enormous capability of SMURD. From disaster response to resource management and deployment, their reach is impressive. As Raed says – it all boils down to teamwork and functional systems that work both from the bottom up and the top down.
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Haney Mallemat states the case for ultrasound in cardiac arrest resuscitation. He tells the story of Stephen, a 43-year-old male who suffers a cardiac arrest. Unfortunately, whilst looking for reversible causes with a transthoracic echocardiogram (TTE), chest compressions stopped, and Stephen died. Enter the trans-(o)esophageal echocardiogram (TEE). A trans-esophageal echocardiogram is an amazing diagnostic tool. It works in exactly the same way as any other ultrasound – there is a transducer on the end of a handle. The difference is that the stem is flexible and inserted down a patient’s oesophagus. This provides fantastic clear images in any patient, with no soft tissue or bones in the way. The beauty is, if you already know how to look at transthoracic echocardiogram, then there is no learning curve. The images are just flipped. TEE can rapidly identify reversible causes of cardiac arrest, for instance a pulmonary embolism, a clot in transit, aortic dissections or papillary muscle ruptures. It can do this without causing any interruptions to the resuscitation effort, including the chest compression. TEEs can also demonstrate the effectiveness of CPR in real time – goal directed chest compressions. In a similar vein, TEE can measure the depth of compressions providing valuable information for the team involved in resuscitation. Back to Stephen. Instead of interrupting chest compressions, a TEE was used instead. A TEE echocardiogram elicited fine ventricular fibrillation that was not picked up on telemetry. This led to a lifesaving intervention, and Stephen walked out of the hospital a few weeks later. Henry will convince you that TEE is a game changer in cardiac arrest resuscitation. TEE provides high quality images of the heart without interruption in CPR. Additionally TEE provides useful information about compression depth and quality that no other diagnostic tool provides.
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Pik Mukherji will change your mind on assessing risk and benefit in resuscitation. There is a bent towards action in the Emergency Department. This is for a few reasons. We are risk adverse – we do not want to miss the acutely sick patient. We do not want to miss the patient that “falls of the cliff”. In fact, as Pik discusses, in emergency medicine and critical care, training is focused on looking for the sharks, even when the waters appear friendly and calm. This is highlighted acutely well by Pik in a story about an elderly gentleman. The man presentedto the ED after a minor trauma. On history and examination there was nothing to find, apart from a minor scrape. Due to the risk adverse nature of the ED, the patient got a CT scan. It showed an acute subarachnoid haemorrhage. This meant he stayed in hospital for observation. The next day he fell off a bed being transported back to the scanner and disaster followed. On review, the original CT showed no abnormalities. This story highlights the risk of the devastating harm that can come to patients in the medical system. Every time a test is ordered there is risk of incidentalomas, biopsies, and repeat visits – to name a few. Pik wants to drive the message home - not every patient can be helped. Every patient can be hurt. Time and time again, doctors overestimate the benefits of their treatments and underestimate the harms. Even armed with this knowledge and knowing the guidelines does not seem to change behaviours. Pik demonstrates this fact with the live SMACC audience where he shows this “cover my backside” mentality in real time. Unnecessary testing and over cautious approaches flying in the face of the evidence. As health care professionals we are taught to “do”. We are programmed to act. The trouble is that sometimes the only person this is benefitting is the clinician. After all, we feel better having done something over nothing. Hippocrates was wrong! “Do no harm” is impossible. So, take a step outside of your comfort zone and try to do less.
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Brandon loves wavy lines. He will draw the curtain on the use of continuous EEG in neuro critical care. Brandon will first take you back to medical school with some neuroanatomy and physiology to underpin you understanding of the EEG. He then steps you through what an EEG is telling you. Bumps, lines, amplitudes and hertz are all demystified. With this knowledge, there is a lot you can do with continuous EEG. A few examples: EEG can be reflective of external stimulus – be it a shock, a sound, or a pinch. This is used to test for reactivity and is useful at the bedside. Reactivity demonstrates whether a signal is getting from the body to the brainstem, to the thalamus and to the cortex. Reactivity is one of the most conserved, independent prognostic indicators in coma – making it important to capture using EEG. EEG is fantastically active when you are asleep. In the ICU, an EEG can show atypical sleep – indicating they are very unwell. Due to sleep being a network heavy, very complicated phenomenon. If sleep is generated on Day 3 post TBI – you have the capacity to recover. With this in mind, Brandon wants you to interact with your patient’s EEG and remember that EEGs are not just for seizures.
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Cliff Reid educates the audience on structured teaching of crisis resource management. Cliff works for Sydney HEMS in extreme conditions. The environment tries to kill them, and the patients try to die. He works in a big team, with a lot of the doctors never having worked in prehospital care. The team covers a huge area, completing many missions every year on both fixed wing and rotary wing platforms as well as road ambulances. Every case is scrutinised, both formally and informally. When things go wrong, it is rarely due to the clinical factors alone and often due to non-technical skills. These skills are discussed often but not taught in a structured way. Cliff presents the Zero Point Survey. A magical window before touching the patients where planning can start for when things go wrong and what can be done about it. It is as simple as STEPUP: Self, Team, Environment, Patient, Update and Prioritise. Self – get you head in the zone. Checklist’s can be useful for both physical and psychological safety and preparedness. Training also plays a crucial part to ensure that a situation is perceived as a challenge and not a threat, enabling high level performance. Team – make sure everyone is on the same page. Assign roles and tasks as they are the key to smooth team flow through the mission. Have a plan for dealing with disruptive individuals. Environment – control and mitigate any safety hazards and create a safe workspace. Own your resuscitation real estate. This means adequate space, sufficient light, appropriate heat, control noise and crowd. Patient – gather information ahead of time to start planning a course of action. Update and Prioritise – throughout the mission, use constant communication and a standard operating procedure to regroup and update priorities. The simple strategy of the Zero Point Survey gives structure for both performing and debriefing resuscitations and simulations in crisis resource management.
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Join Celia Bradford as she discusses blood pressure control in intracranial haemorrhage in neuro critical care. Intracranial haemorrhage risk factors include hypertension. The question becomes, what do you do with hypertension in the management of intracranial haemorrhage? Does blood pressure being high cause the bleed to be more severe or does a severe bleed cause increased blood pressure? It is a classic chicken or egg scenario. Celia takes you through two prominent trials in the area and gives you valuable and practical tips on how to manage these patients. The INTERACT-1 trial looked at haematoma expansion in two groups randomised to blood pressures of <180mmHg or <140mmHg systolic. This trial suggested benefit in patients treated with more aggressive blood pressure control. INTERACT-2 was a much larger trial looked at controlling blood pressure within 6 hours in patients with blood pressures between 150-220mmHg systolic. They used the same parameters for two groups (<180mmHg or <140mmHg systolic) and the results were less clear when comparing intensive and standard blood pressure control targets. ATACH-2 also looked at outcomes of tight control of blood pressure control. Two groups were randomised to 110-140mmHg or 140-180mmHg. This study demonstrated no benefit to more aggressive control of blood pressure and the group with more intensive treatment had worse renal outcomes. There were also some issues with the study that Celia discusses. There is an unanswered question in that controlling blood pressure too aggressively may impact the penumbra (which may or may not exist!) Celia’s thinking from all of this? Aim blood pressure targets low but not too low (130-150mmHg). Aim for smooth control. Chose agents with a rapid onset of action and avoid agents such as SNP/GTN.
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The information we consume leads us to believe that failure isn’t an option. Stories and movie depictions of characters who avoid the odds at all costs, tell us that failure is unacceptable and should be avoided. We expect elite performance and hyper competence. In medicine, where we are responsible for the lives of our patients, it is easy to understand why we set the bar high for ourselves and somewhat expect ourselves never to fail. The reality is however, that this is all a myth. Any complex system you can observe from around the world has experienced failure. In fact, the biggest lessons usually come from the biggest failures. In healthcare, we work in the ultimate complex system, where nobody is hyper competent and failure will always occur. It is inevitable. According to sociologist Diane Vaughan, wherever science, technology and risk to human life coincide, failure is inevitable. The answer is in finding ways to appropriately deal with failure and to overcome these challenges. So, given that failure is inevitable, is there a better way to fail? How do we fail gracefully? We need to learn to fail and understand that we do so out of a love for our profession. By savings lives and helping others. Our system needs to allow for failure to occur but also to ensure that we fail gracefully. Kevin Fong shares a compelling talk on how to prepare to fail, how to expect failure and most importantly, how to forgive yourself for failing. A talk that Kevin describes as “useful advice for failing at everything.” From DAS SMACC, we hope you enjoy this podcast and we hope that it inspires you to embrace failure in a new light.
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Laszlo Hetzman discusses cost effective high fidelity simulation training for performance in pre-hospital and hospital critical care. One the great benefits of simulation training is the diversity of training it provides for all levels of experience. Based on his own hugely positive experiences of simulation, Laszlo was compelled to implement effective simulation in his country. The trouble was budget constraints. However, with a little bit of lateral thinking, Laszlo will show you that low budget does not necessarily mean low fidelity. Laszlo discusses the three areas of fidelity that are needed to have a successful simulation. These are equipment, environmental and psychological fidelity. Life like equipment, life like environment and a strong fiction contract. The later referring to the agreement that is held between all participants and trainers that the plastic mannikin they are working on is a real-life dying patient that they must help. Laszlo divulges seven tips and tricks he has developed to make training with any budget effective and to help sign the fiction contract for less! First, use real stories in your scenarios. Get credible and well-prepared instructors - they paint the picture of the training scenario. With good instructors it is possible to minimise “God’s voice” (instructions coming from people external to the scenario.) It is useful to use participants voices, or cheap applications to deliver vital signs, and having distractions/actors to steer the scenario. Similarly, background noise (be it farm noise, train stations or industrial sounds) can be found for nothing on YouTube and enhances the emotions of the situation. Clothing is important – Laszlo stresses everyone in the scenario should be dressed up to resemble the role they are playing. Additionally, models and mannikins can be altered cheapy and easily using whatever is lying around the ward or house. On the same theme, think outside the box when considering equipment. DIY is a magical thing. Laszlo describes how he has used useless junk to do everything from making ultrasound probes to simulating a thoracotomy. Finally, be sure there are no spoilers. Help all participants to be believable with their actions and words and to stay in character to enhance the experience for all. Follow these simple tips to make all simulation experiences the best they can be. As Laszlo says, medium fidelity rules.
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A study showed that 15% of healthcare responders hesitated to start CPR because they thought that they would harm the patient. 21% didn’t want to start defibrillation because they thought that they were doing something bad. Hesitation means time. We are harming the patient by not starting sooner. A culture of excellence in resuscitation relies on an excellent system, not excellent individuals. As individuals, we could have all of the training in the world but the reality is that all parts of the system need to function or we will sink. Maaret Castren suggests that culture of excellence is a choice. We need to choose to be extraordinary and we need to commit to implementing systems that aspire for excellence. Maaret inspires us to think outside of the box and to think about what we can do to be better. When you look around the world it is evident that there isn’t one single system that has actually achieved excellence. We need to encourage our team not to settle. To avoid saying things like “this is the way that we’ve always done things.” Local implementation is usually the weakest link in the chain. We have good science, we have highly educated people but we don’t implement optimal systems into our normal everyday lives. This is where we go wrong. Leadership is key, even in scenarios where there are only two first responders performing a cardiac arrest. Maaret outlines the three key elements of achieving a culture of excellence: 1. Leadership 2. Training 3. Quality improvement All parts of the system need to be optimised, to allow for us to achieve greatness. From DAS SMACC, we hope that you enjoy this podcast and we hope that it inspires you to achieve a culture of excellence in your workplace.
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Simulation, assessment and technology in medical education. This session brings together a panel of educators with a track record of innovation and design in medical education. Chris Nickson, Daniel Cabrera, Jenny Rudolph, Sandra Viggers, Simon Carley, Victoria Brazil, Walter Eppich & Jesse Spurr join to discuss the past, present and most importantly the future of how we will teach and learn critical care. They address some burning questions including, what does it mean to be an educator? Is simulation the answer to everything? What do we need from medical education to encourage healthcare professionals to thrive into the future? They explore the future changing role of the medical educator from one of information delivery and assessment to co-learner and developer. This is particularly challenging when asking senior healthcare professionals to unlearn processes and to be flexible and open to new ways of doing things. We are encouraged to consider the role of culture... how can we create a culture which embraces learning and new ways of doing things? How do we establish a system where positive role models are in abundance and lead by example in challenging situations? Furthermore, the panel consider whether new technologies really change education or simply form adjuncts to traditional learning models? FOAMed is so easily accessible and is an excellent tool for learning but how do we also integrate and adapt traditional models of learning? From DAS SMACC, our panel of experts light the flame of medical education and challenge the audience to consider the complexities and role of simulation, assessment and technology in medical education. Tune in for an interesting and engaging discussion about medical education in healthcare.
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Jordan Bonomo delivers the run down on intracranial haemorrhage and anticoagulants in critical care. Jordan freely admits – this is not a simple topic. For the simple reason that intracranial haemorrhage (ICH) sucks – and that’s a problem. There are no treatments for it. Nothing seems to work. Add an anticoagulant and it is even worse. The mortality for an ICH is around 30-50%. With an anticoagulant onboard it goes up to 40-65%. So how do you manage an ICH in an anti-coagulated patient? The critical care starts in the Emergency Department. Roughly speaking 30% of intracerebral haemorrhages will increase in size by 30% in 3 hours. Time matters. In the Emergency Department there are three immediate actions that need to take place. 1) Control the blood pressure, 2) get the specific history and, 3) deliberately ascertain what medications the patient is taking. What to do about the anticoagulation? Jordan addresses three areas with his take on the best practice. The PATCH Trial compared standard care to transfusion of platelets. It showed that the platelet transfusion group had worse outcomes using a modified Rankin scale. Although this trial bothered Jordan – he was concerned about all the patients he HAD transfused with platelets in the past – it changed his practice. His hospital no longer transfuses platelets in ICH patients. With patients that are on a NOAC/DOAC there are 50% fewer ICHs. Compounding this, there seems to be less expansion of ICH in patients on a DOAC compared to on a Vitamin K antagonist (ie Warfarin). You bleed less and are less likely to expand on a DOAC. However, it is far more practical to test for VKA, and possibly easier to reverse them. Jordan takes you through your options. Finally, Jordan addresses tPA. He will discuss the rationale for use tranexamic acid to reverse tPA and why he uses it in practice. Jordan makes the complicated a little less complicated when discussing intracranial haemorrhage and anticoagulants in critical care.
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Daniel Cabrera wants you to play the game of anaphylaxis… a serious game! You are faced with a monster, with the name anaphylaxis. Daniel takes you through the resuscitation of refractory anaphylaxis. We do a terrible job managing anaphylaxis, missing 50% of the diagnoses, only giving epinephrine in 50% of the cases who need it. After the acute episode, only 40% of patient go home with an epinephrine auto-injector and only 20% get the appropriate follow up! 1-2% of the population will be affected by anaphylaxis, and 2% will die. Although this may not seem like a huge number, Daniel stresses the point - deaths from anaphylaxis are highly preventable Anaphylaxis is a sudden onset, rapid progressing multi-system organ failure due to the activation of mast cells. Anaphylactic vs anaphylactoid… it does not matter. What does matter is that it is becoming more common. Further, fatal anaphylaxis is very fast to progress highlighting the need to make the diagnosis and make it quickly. Although anaphylaxis kills through shock, hypoxia, ischemia, arrhythmia, and myocardial dysfunction, it is the lack of education and access of providers and patients that is the real issue here. Lack of education of what anaphylaxis is, and how it presents. Lack of access of patients to early care and lack of access to epinephrine. Daniel guides you through the management of a patient suffering from anaphylaxis. His advice: epinephrine (adrenaline) is the only thing that will change mortality outcomes. Use it and use it early! Remember to decontaminate the patient – be it a bee string, or food exposure, get rid of it. The patients will also need lot of crystalloids. There is weak evidence for steroids and antihistamines – they will not save your patients. Use them if you like but not at the expense of early epinephrine and fluids. In refractory cases, increasing dose of epinephrine, norepinephrine, vasopressin, glucagon, methylene blue and ECMO are considerations. Patients with airway compromise require advanced management. Finally – when patients go home they need three things: education, an epipen auto-injector and an anaphylaxis action plan! So know your enemy when dealing with anaphylaxis and you too can be the hero and save the day!
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Brandon Foreman takes you through physiological targets for traumatic brain injury in neuro-critical care. Intensivist and emergency medicine physicians already use physiology targets. They understand the complexity of these targets and the pitfalls of overreliance on any one parameter. This is also true for the use of physiology after traumatic brain injuries (TBI). TBI has never been defined by its physiology. In fact, specific targets of physiology to drive successful outcomes have all failed in the research in this patient group. It is no doubt a complex area. Physiology after traumatic brain injury is not simply defined on the pressure and volume in the skull. There are a huge variety of variables, including blood pressure, autoregulation and flow coupled functioning. Even with all these parameters, there is no Level 1 or 2A evidence for physiologic thresholding in TBI patients. As such, Brandon takes you through his approach to using physiology to manage TBI patients in neuro-critical care. He guides you through the approach, breaking up outcomes measures into three groups. First mechanics. Brandon will discuss blood pressure targets, and the real purpose of controlling them. Ultimately, he explains that thresholds are arbitrary and what is most important is blood flow. Secondly, Brendon considers metabolism. Here he guides you through the importance of glucose and ventilation with specific advice on parameters to use. Finally, he will take you through brain function, along with different clinical indicators that are useful when caring for a TBI patient in the neuro-critical care setting. This talk will encourage you to look at mechanics, metabolism, and brain function, considering each for the individual patient in front of you to guide best practice and deliver best outcomes.
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Numbers people, give me the NUMBERS! We need CONCRETE data points and percentages...! Go buy another machine to deliver the numbers and data points. We need it to be delivered by gadgets, gadgets that go ping and pong...more and more gadgets. Let’s plot it on graphs and write it into a protocol to then be memorised verbatim in training and dutifully regurgitated in medical exams. That makes us excellent clinicians right? Worthy of more numbers and a couple of extra letters behind our names. Medicine is obsessed with numbers! The glorified science of modern medicine. A fictitious safety net. We are often discouraged from relying on our brains to make decisions, especially in emergency situations. Criticism of human error and the human factors which lead to error are in abundance. What if I told you, your decision-making is far more complex than that? That, how I deal with an emergency also involve guts, prayers and yes, sometimes tricks. Does that make me reckless? A cowboy (girl) or a savant? Or am I just nudged by my unconsciousness. Are you? Whether you like it or not, how you deal with emergencies, how you deal with life is far more complex and unclear and uncertain than what quantitative science would like. Our brains are amazing and we need to embrace our whole toolbox when making decisions. There is literally way more between heaven and earth than what meets the eye and your unconscious mind is filling in the gaps. So hold on and follow me down the rabbit hole... Be inspired by a talk by MJ Slabbert on processing emergency decisions in Critical care.
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Intubation is one of the most important procedures that we perform. There are many immediate and bedside methods of confirming tube placement. Ben Smith and Jacob Avila present how to confirm endotracheal tube placement with airway ultrasound. There has been a bad trauma come into the Emergency Department. The patient has suffered a head injury with an obvious laceration. They are agitated and being physically aggressive to staff. To make matters worse, they are in a neck collar, and have little to no jaw to speak of. Although you will need to protect the airway of this patient it is going to be difficult. What’s more, you have no access to video laryngoscopy. How will you confirm the placement of the endotracheal tube? Physical examination to confirm endotracheal tube placement has poor evidence behind it. End tidal C02 is similarly problematic. Ben and Jacob propose adding another tool to you armamentarium. Airway ultrasound. Airway ultrasound has sound evidence supporting it. It has sensitivity and specificity in the high 90s. As such, it has been added to ACLS guidelines as the way to confirm the placement of an endotracheal tube. Join Ben and Jacob as they take you through the practical tips and tricks on how to perform this skill. As they will teach you, it is possible to use ultrasound to confirm endotracheal placement in the trachea and where it is in the trachea without having you worry about insufflating the stomach causing aspiration or vomit. You can use airway ultrasound in real time to guide the intubation, with excellent accuracy eliminating the need to bag valve mask ventilate a patient.
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A no-holds barred series of 6 provocative medical interrogations. We challenge the state of research, social media, pharmacology, social work, women in medicine, medicine in the developed work, and the health of healthcare workers. It should be novel, it may get heated, and it is not scripted. Sometimes to comfort the afflicted you also need to afflict the comfortable. This is why no prisoners will be taken, no topic is out of bounds, and no ego will be pampered. It may even offend: you have been warned.
SMACCForce: Bariatric Panel Discussion with Mark Forrest, Jason Van Der Velde, Phil Keating, Cameron O'Leary
Ashley Liebig passionately discusses medics in combat and post traumatic stress. Ashley got a tattoo recently. It was for a friend with whom she served in the army. Although this infantryman was tough, and cool, after a horrible injury he lost his leg and “gained a life full of trauma and scar tissue… and chronic pain and wounds” This left Ashley with grief, and anger. She slipped into an overwhelming sadness. Simple tasks and emails were piling up and she did not care. She was behind on her work. She was exhausted with the guilt. Work could wait. She needed to work through these feelings. This required her to be honest. Even if it made her feel vulnerable. She reached out to her colleagues to let them know what she was going through. In the medical world everyone paints the picture that they have their shit together. They paint the picture that they are on top of their game, always. The problem with this is that it makes it really hard to be honest when you need help. For Ashley, the moment came to reach out for help when she was so sad that she did not want to get out of bed. Her heart was broken. Ashley’s personal story highlights that even the toughest can be hurt, can have pain, can cry, and consider leaving their jobs. It also tells you that every time you are honest, it opens a window of opportunity. For help. For sharing. For healing. It is a powerful thing. Ashley will continue to remind all that will listen about mental health and wellness. She wants you to share the burden, and to not carry the cross alone. Join Ashley as she opens up about her deepest struggles, in the hope that you will too.
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Most people think it is easy to spot the paediatric emergency – and this usually holds true. However, this is not so in undiagnosed paediatric emergency cardiac disease, as Michele Domico explains. She delves into the practical points on recognising children over one month of age with life threatening cardiac disease. No child comes in and says, “I have chest pain” or in any way alerts the Emergency Department providers to include some type of paediatric heart disease in the differential diagnosis. This talk will review the most commonly missed cardiac “zebras”. Cardiac emergencies can masquerade as anything – fatigue, emesis, tachypnoea, septic shock, failure to thrive and abdominal pain could all point to a cardiac aetiology! Recognition is the key Recognition is the key Michele present five cases of paediatric cardiac emergencies to highlight the subtleties that can exist. Each case provides its own lesion and clinical pearl. A 7-year-old with abdominal pain and fatigue teaches us that a persistently tired child is not normal. A 5-month-old with respiratory symptoms highlights that when things do not add up, keep looking! A 4-month-old with tachypnoea since birth couple with peri-oral cyanosis teaches us that if something is abnormal, it is abnormal. Do not be falsely reassured by parents or other health care providers. A 3-month-old with tachypnoea and poor oral intake is a lesson in being aware of the quiet tachypneic! Finally, a 7-week-old with feeding problems shows us that failure to thrive is not always a gut problem – do not wear blinders when working these patients up. This presentation is meant to provide you with some helpful hints for when it is time to stray from the straight path and start entertaining a cardiac diagnosis in a sea of children complaining of respiratory, gastrointestinal, and other symptoms.
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Daniel Lichtenstein wants to make his past your future. Join him on a journey through the history of lung ultrasound in critical care and resuscitation. The scene is over 20 years ago in the desert of Mauritania. It is a noisy environment full of trucks and planes and motorbikes whipping up sand in a frenzy. You are attending a chest trauma and suspect a pneumothorax. However, in this chaotic environment, chest auscultation with a stethoscope is futile. Daniel describes a visual approach with a portable ultrasound in what was possibly the first extra-hospital ultrasound use. Daniel also has a passion for in-hospital point of care. This stems from a time he “borrowed” an ultrasound machine from the radiology department and reached a critical diagnosis. His journey with lung ultrasound in critical care and resuscitation was born. The usefulness of point of care ultrasound in critical care is far reaching. It is used for subclavian catheter insertion, searching for abdominal blood, and assessing the optic nerve or inferior vena cava. It is even used for assessing the “forbidden” area – the lungs. The use of ultrasound is now ubiquitous; however, this has not always been the case. During its rise to prominence there was a trench war going on and its proponents had to fight claims of ridiculousness! Daniel will highlight the utility of lung ultrasound in critical care, highlighting how proper use of the technology provides a holistic care approach to your patients. He will discuss multiple protocols he has been a part of developing and use them as an example of the philosophy of ultrasound. The ultrasound revolution is certainly happening, but the work that made it possible happened long ago!
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Emotion has a profound effect on decision-making. Chris Hicks demonstrates this as he discusses medical simulation and its ability to teach us skills to manage challenging emotions. As scientists and rational beings, we like to believe that we can control our emotions and make good decisions regardless of the context in which those decisions must be executed – The reality is, that is far from the truth. We rarely take the opportunity to deliberately examine how emotional valence can influence the choices we make, or how we sort and process information as clinicians. Simulation-based training often provokes strong emotions, both positive and negative, whether we intend it to or not. Simulation may be an ideal tool for eliciting challenging emotions – anger, fear, anxiety, joy, prejudice – and developing skills to manage them in real time. Chris highlights a number of strategies to make this process more effective. He recommends starting with developing a fiction contract. This creates by in and ensures psychological safety for all participants. Actors are used in a range of ways in simulation, dependent on the goal. When exploring emotion, Chris demonstrates the benefits of a nuanced character using a technique called immersive experimental roleplay. This creates an environment in which emotions can be really felt and explored. It plays to the idea that the goal of simulation should be to promote the transfer of knowledge to real clinical environments. The use of simulation affords the clinician and opportunity to experience how a rational mind often cannot over emotion. Healthcare is an emotive game. It involves high stakes scenarios under extreme emotional pressure. Recognise that emotion can be used as a heuristic way to make judgements, which is not helpful. Using exercises to provoke emotions better prepares the clinician to make better decision.
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What is New York City style resuscitation? Reuben Strayer and Scott Weingart honed their chops in public hospitals in America’s largest city, where patients come from every country, speak every language, and manifest every physiologic derangement on earth. Preferring to ask neither permission nor forgiveness, Reuben and Scott have long challenged emergency medicine and critical care orthodoxy and developed lateral (though sometimes divergent) strategies in their approach to problems that arise in the care of the sometimes unwashed masses who tend to avoid presenting to medical attention until they’ve fallen off the Frank-Starling curve. Topics that may be discussed (or argued) include the use of epinephrine, the use of noninvasive ventilation, the management of recently intubated patients, the use of ketamine as an induction agent with and without a paralytic, and decision-making in badly injured trauma patients. Ad hominem attacks will be defined and probably employed. Though Weingart has a physical and intellectual disadvantage against the bigger, stronger, quicker, younger, and better-looking Strayer, these disparities will be muted by Natalie May’s capable moderation.
Doctors are usually the ones who rule the resuscitation. They are the ones in charge, the boss, the person giving all the instructions. By design, doctors rule the resus. But what if they didn’t? In order to optimise teams to be seamlessly effective at resuscitation, we need to change the way that resuscitation is done. We need to challenge healthcare to embrace a new model. Ashley Liebig proposes five key concepts for effective resuscitation: 1. Ergonomics should rule the resus. Where are all the people standing? Where is the clock in the room? Where is everything placed? 2. Nurse-led codes should rule the resus. Let nurses run the codes, this is what they are trained to do and it is what they are doing up until the time that the Doctor arrives in the room. For physicians this means cognitive offloading, allowing space to think about the important things and to consider the differential diagnosis. 3. Assigned roles should rule the resus. The importance of assigned roles means that everyone knows what their job is and what is expected of them. 4. Communication should rule the resus. If you are unpleasant to work with, you’ve already changed the scenario. People will arrive at your resuscitation unfocused. Change this. 5. Briefing should rule the resus. Briefing, albeit difficult to coordinate, is important and means that everyone is on the same page. What if in just a few short hours we could take all that we have learned about resuscitation from FOAMed and apply it? What if we could turn an average community hospital ED into a high functioning team?
From DAS SMACC, Ashley Liebig delivers an inspiring talk on reinventing resuscitation teams.
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Haemostatic resuscitation of haemorrhagic shock by Wolfgang Voelckel Haemostatic resuscitation of haemorrhagic shock is an area great leaps forward can be made, as Wolfgang Voelckel discusses. Exsanguination and brain injury are the leading causes of death after major trauma. During the last decades, significant progress has been made in the fight against haemorrhage. Nevertheless, the window of opportunity is still small and the golden hour of shock more fiction than fact. Hence, the majority of trauma patients are still lost on the street and during the first hour after hospital admission. Moreover, trauma is an increasing epidemiologic burden worldwide. Pre-hospital emergency care plays an essential role when distances are long and immediate damage control is key. Since evidence of established interventions (such as fluid resuscitation and vasopressor use) is spare, Wolfgang presents his summary of currently available trauma care guidelines. Through this his team has collaborated best practice advice for massive bleeding comprising a five-step approach. First - Identification, on-going monitoring, and appropriate notification of the receiving hospital. Second - Control of haemorrhage by tourniquets and pelvic splints; and advanced interventions, such as emergency resuscitative thoracotomy and resuscitative endovascular balloon occlusion. Third - Target controlled fluid resuscitation within the concept of hypotensive resuscitation in order to prevent hypovolemic cardiac arrest during the pre-hospital phase. Fourth - Pharmacologic interventions employing vasopressor drugs and medication for coagulation management. Fifth - Avoiding mistakes in anesthetised and ventilated patients with critical intravascular volume status, as well as means to counteract inadvertent hypothermia. Finally - A minimum data set allowing retrospective analysis and system comparison is needed. In conclusion, code red protocols are key in order to reduce pre-hospital care to the max and to pave the way to major trauma care. Current concepts of trauma care with a strong focus on the C-ABC (Circulation-Airway-Breathing-Circulation) approach, hypotensive resuscitation, haemostatic resuscitation, and damage control surgery improve survival after major trauma.
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A no-holes barred series of 6 provocative medical interrogations. We challenge the state of research, social media, pharmacology, social work, women in medicine, medicine in the developed work, and the health of healthcare workers. It should be novel, it may get heated, and it is not scripted. Sometimes to comfort the afflicted you also need to afflict the comfortable. This is why no prisoners will be taken, no topic is out of bounds, and no ego will be pampered. It may even offend: you have been warned.
Leanne Hartnett is a massive fan of bedside ultrasound. Here, she tells a story of using ultrasound for the diagnosis of acute pulmonary embolus and the decision-making process for management. This is the story of a 65-year-old man who was brought into the Emergency Department with acute shortness of breath and chest tightness. This was on a background of motor neuron disease, due to which he was confined to a wheelchair. Despite this he reported a good quality of life. He enjoyed getting out and about with his wife, spending time with his family and reading the newspaper. In saying this, he was aware of the seriousness of his disease, and did not want any invasive treatments or CPR. The history and examination were unremarkable, although Leanne’s clinical suspicion of a pulmonary embolism was still high. She wanted to order a CT pulmonary angiogram. However her patient was sure he would not tolerate laying flat for that length of time. So, Leanne wheeled over the ultrasound machine. Despite the technical difficulties of the task, Leanne was able to obtain reasonable images of her patient’s cardiac structures and function. A parasternal long axis view showed a right ventricle doing not too much. A parasternal short axis view demonstrated a big right ventricle and small left ventricle. It also demonstrated an intraventricular septum that was flattening in diastole. Finally, an apical four chamber view showed a big hyperdynamic right ventricle and something flicking about in the right atrium. It was a cord like thrombus! Leanne was thrilled that she had been able to diagnose the patient using history, examination, and echocardiogram alone. Next, Leanne sought a colleague to discuss the situation and to review the literature of the different treatment modalities for right heart thrombus in transit. They determined that the literature suggested the best outcomes in terms of probability of survival was better with thrombolysis or embolectomy compared to anticoagulation. Armed with the correct diagnosis, and a evidence based treatment Leanne was able to successfully manage this patient. Her message is that patients who present with pulmonary embolism and right heart strain are high risk. Thrombolysis and embolectomy are both effective strategies. Finally, basic echocardiogram skills can make a massive difference to your patients.
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The arrested heart surgery patient is a unique beast in surgery and critical care. Dr Nikki Stamp gives a whirlwind tour of post cardiac surgery resuscitation. She will discuss how to spot the potential arrest, how to manage it and some special situations to be aware of in this special group of patients Post cardiac surgery resuscitation is complex. Nikki describes them as “brown trouser moments”. She highlights this with three cases. A15-year-old girl who exsanguinated on Day 12 after dissection repair in the community. A 40-year-old female arrested within an hour of a re-do aortic root procedure. A 72-year-old lady who arrested after a bradycardic arrest following an aortic valve replacement. Only one survived – this is serious business. Cardiac arrest post cardiac surgery is relatively uncommon. The survival rate is also quite high. This is due to it being recognised and treated early with a high proportion of reversible causes. The key is to think of these causes and treat them as a team. Nikki breaks the causes into four groups. Ischemia, mechanical, arrhythmia and unknown. It is important to recognise that cardiac arrest in this population is differs to a typical scenario of cardiac arrest. As such, there is a different algorithm. This hinges on assessing the rhythm in the first instance and consider defibrillation fist if appropriate. One should also consider the use of pacing wires if they are still in post-operatively. Nikki provides a great number of clinical pearls, discussing care of the right heart, use of chest compressions and cardiac massage, use of ECMO and considerations if a left ventricular assistance device is in place. Her take home points include being alert to these situations but not alarmed! Practice these resuscitations as a team. Shock early and pace early and remember most people should not die with a closed chest!
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Management of Status Epilepticus in Neuro Critical care Brandon Foreman talk about the management of status epilepticus in neuro critical care. What are seizures? Why is this important? There are 1 million ED visits due to seizures every year with a quarter getting admitted to the hospital. 1 in 10 people will have a seizure in their lifetime. It is common. Status epilepticus is defined as seizures lasting greater than 5 minutes or recurrent seizures without interval recovery back to baseline. Practically speaking, if the person is seizing when you walk into the room or they remain comatose after they just seized, assume they are in status epilepticus. A key point - the longer the seizure, the greater the mortality. So early and effective management is critical. The first line of defence is benzodiazepines. Give it however you want, give it fast and give it in the correct dose. Brendon stresses dosage is really important. This treatment is effective, with one study showing by following a status epilepticus protocol, 74% of status epilepticus patients had resolution compared to only 29% without adequate treatment. After 20 minutes, the patient is still seizing. Now what? This condition is now defined as established status epilepticus, and you must move to second line treatments. In this category there are a lot of choices. They are of course all intravenous drugs. They all have pros and cons so use what you have available and what you are comfortable with. Again, whatever you chose, use the right dose. If after 40 minutes you are still not winning, move to the next step. At this stage the seizure might look like it is controlled due to electromechanical dissociation. However, this is commonly non-convulsive seizure activity. Get started on the third line of defence… do not muck around with more benzodiazepines or second line agents. You now move to starting an anaesthetic and securing the airway. Use whatever is available and whatever you are most comfortable with. By treating and controlling status epilepticus in under 60 minutes and you have a real chance of reducing mortality and morbidity in these patients.
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Maaret Castren passionately delivers her take on how to improve outcomes from out-of-hospital cardiac arrests. Maaret brings resuscitation back to the basics. Using science, education and local organisation factored together, we can drastically improve the chance of survival in out-of-hospital cardiac arrest. Currently, the best systems in the world only garner 20% survival rates in these situations. Mareet explains that quite simply, education is lacking. She believes the first step is to know your patient. 50% of cardiac arrest patients have signs and symptoms in the preceding weeks before their arrests. However, there is no current sudden cardiac arrest risk prediction tool available! Maaret explains the concept of precision medicine – the idea that medicine practised in a one size fits all manner provides successful treatments to some patients but not all. One must consider individual differences in people’s genes, environments and lifestyles. In resuscitation medicine this can simply mean altering hand position based on a patient’s size. Developing a culture of excellence is crucial in improving survival rates. Maaret challenges you to make the decision to not allow anyone suffering a cardiac arrest to die. She challenges you to not accept failure – and if it is to occur then to scrutinise why. Maaret goes on to assert that while people have been trained and equipped with skills to deal with a cardiac arrest, health professionals have been found wanting research. Doctors and nurses have been shown to have less survivors when calling emergency numbers. She wants this to improve through ongoing education and training. Currently there is a huge variation in outcomes for cardiac arrest patients. Measuring your results makes it possible for you to know what to improve. Benchmarking shows you where you need to learn. You need to build a culture of excellence in your own system. Patients are not the same, so we need to also individualise resuscitation. Maaret implores you to make the jump from the current culture to the desired culture and in doing so improve the resuscitation outcomes from out-of-hospital cardiac arrests.
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Resuscitation is complicated, but the solutions don't have to be. Chris Hicks brings you four psychological strategies that will help you manage complex resuscitations. It is a fascinating time to be a resuscitationist with ROBOA, ECMO and EPR. Chris explains that as we learn more about critical illness, we learn more about the complexities of resuscitation. Therefore, we need ways to manage and constrain complexity and to simplify and organise problems that will see us through. Chris’s lessons are founded on a case. A 22-year-old female is brought into the Emergency Department. She was an unrestrained driver in a motor vehicle accident. She is agitated, has multiple facial smash injuries, burns to her torso and neck, a right sided flail segment, and a mechanically unstable pelvis. Also, when you ultrasound her abdomen, you realise she is well into the third trimester of a pregnancy. Chris discusses four strategies to cope in a complex situation. The first is grounded in habits. Habits have a lot to do with whether or not we succeed at a given enterprise. They can help break down complex problems into simpler parts. Once a habit has been practiced and rehearsed, it becomes harder to not execute the habit than it is to execute it. Next Chris advises to foster emergent organisation in the team. This is self-organisation in teams whereby individual simplicity can create organised complexity. During periods of high task loads it makes sense to create smaller teams to create divisional lines. This allows semi-autonomous teams to function independently towards a specific goal. Thereafter, try to factor down complex problems. Take a problem as you see it and lead it in a direction you’d like to see it. By simplifying a problem into a few sentences, you assert that you understand it, and you can then begin to manage it. Finally, Chris talks about limiting variability. This is in order to constrain chaos. Eliminate variables and thereby eliminate unnecessary steps. This can sometimes mean cutting down team size – Chris conjects most teams are too big! Join Chris as he takes you through four strategies to manage complexity in a complex resuscitation. Lean on habit. Foster emergence. Factor down the problem and limit the variables.
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Neurologic airway manipulation is unforgiving; errors lead to hypoxia and secondary injury. Managing the airway with an eye towards success, the first time, every time, without allowing sats to drop below 90% is the holy grail of neuro airways. Selection of RSI techniques, DSI techniques, and pharmacologic management is critical for success. The TBI airway with ICP issues and the post tPA airway present unique problems and the failed extubation in the neurologic patient is as common as the day is long. We will explore the latest theories and data (if there are any) and debunk some common myths together during this session.
Interprofessional issues in critical care
Meeting of the Tribes brings together clinicians from a broad range of health professions, including medicine, nursing, social work and physiotherapy, to explore interprofessional issues in critical care.
In addition to their clinical work, panelists have unique perspectives on education, simulation and resilience in healthcare.
In discussing issues related to tribalism and their implications for interprofessional practice, the panel explore what it will take to overcome a tribal mentality in the service of improved patient care.
Tune in to this discussion as the panel strive to:
(a) present a snapshot of the status quo
(b) explore key issues and their implications for clinical practice
(c) envision of future of enhanced interprofessional collaborative practice.
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Ronan O’Leary discusses reversing coagulopathy in traumatic brain injury. The PATCH trial was a trial look at the use of platelets to reverse the effects of aspirin and clopidogrel in patients with spontaneous cerebral haemorrhage. Ronan asserts that overall platelets are harming patients. Through his talk he highlights many studies that have been inconclusive about the benefits of giving platelets in traumatic intracerebral haemorrhage. As one study eloquently described, “It was not possible to determine if platelet transfusion was superior, inferior or not different from control interventions.” So why are platelets given at all? In haemorrhage, reduced platelet activity is associated with adverse outcomes. This is demonstrated with larger haematoma size in patients with lower platelet counts. So, it would make sense that replacing platelets should lead to better outcomes. However, this is not the case. Furthermore, as Ronan articulates, sometimes it just feels better to do something over nothing. The aetiology of the condition probably has nothing to do with platelets in the first place. Instead, non-traumatic intracerebral haemorrhages are likely caused by atherosclerotic disease, with changes in microvascular anatomy and brittle vessels leading to haemorrhage. Further, transfusing a patient with intracerebral haemorrhage with platelets may lead to secondary ischaemic change. Platelets have many proinflammatory and prothrombotic properties. So are the harms of platelets outweighed by the benefits… probably not. Ronan will go on to discuss the potential to extrapolate this evidence to traumatic brain injury patients. He concludes, probably not, mainly due to the mechanism of haemorrhage being the transmission of kinetic energy which is at odds with that of spontaneous intracerebral haemorrhage.
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The door to needle time for acute stroke in Critical Care is a key variable when striving for good outcomes. Rhonda Cadena answers the question - Who should pull the trigger on tPA for acute ischemic stroke? Medical management of acute strokes has changed dramatically over the years. We used to rely on clinical exams for diagnosis, prescribe strange medications and undertake interventions that were scary! This has changed in recent times. We have now evolved to advanced imaging techniques, new medications and interventions including endovascular treatments. These advances have dramatically increased the likelihood of positive outcomes in stroke patients. The new problem coming to light is time. All the modern treatments that exist do wonderfully well in achieving what they are supposed to. However, the longer it takes for a stroke patient to be get the treatment equates to more deficits and less chance of having a complete recovery. The process as it currently exists can take time. A patient will notice symptoms. They then call emergency service. An ambulance is dispatched, the patient undergoes an initial assessment and is then transferred to the hospital. Here they will be triaged, connected to monitoring, have bloods drawn, have a history taken, be examined… all taking time! Stroke guidelines say the door to treatment time should be 60 minutes or less. Rhonda explains that the focus should be on reducing the time that the process takes. She highlights that most of the time savings should occur before the patient hits the door. That is in the pre-hospital setting. We should be focusing on emergent treatment in the pre-hospital period. Rhonda runs through practical examples of time saving techniques utilising technology and a few simple changes to processes to cut time and improve outcomes. The basics of tPA are spelled out and Rhonda steps you through how a lot of the steps can be expedited along the patient’s early treatment journey. So, who pulls the trigger? Rhonda explains it does not matter! So long as we are saving time in the pre-hospital period, the door to needle time for acute stroke can be reduced and outcomes improved.
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Claire Park delivers a riveting talk, bringing military trauma lessons from MERT (Medical Emergency Response Team) back home. Claire tells two stories from her tours in Afghanistan. The first begins in the early hours of the morning when the MERT team is tasked on a job. They receive word of five casualties including two above knee amputations and one unconscious without a radial pulse. On arrival to the scene the paramedics leave the helicopter to triage and bring the casualties aboard to Claire and her team. They begin to take enemy fire. The second experience was delivering care to an Afghan national soldier with a gunshot wound to the neck. He was alert when he came onboard the helicopter but quickly deteriorated. Claire decided he need to be intubated. However, there was an expanding haematoma across his cricoid area with a deviated trachea. An extremely difficult airway in an extremely difficult environment. The lessons from her experiences as a part of the MERT? Do the basics well. This means prioritising the problems as a team. The hinderance here is becoming too tasked focus. That is why Claire alongside her colleagues developed a time out. With eyes up, they would ask themselves two questions. What have we got? What are our priorities? She advises – trust your clinical decision making in the moment. Experienced clinicians will have “blink” moments – where they make unconscious conscious decisions. The importance is learning from them in the aftermath. On that theme, Claire has experienced firsthand how different people remember events in vastly different ways. She calls them different black box recordings. This makes the debrief essential. Use it as an opportunity to learn from mistakes and errors. Finally, Claire speaks about passion. Passion can eliminate fear. It can turn threats into challenges. Her thoughts are if you do not feel and do not care – you should not be doing the job. Take these military trauma lessons from Claire’s time in MERT and use them to strive to do your best for your patients, every time.
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Join the debate between Bill Knight and Fernanda Bellolio as they go head-to-head, discussing diagnosing subarachnoid haemorrhage in neuro critical care headache. Should you rely on CT and lumbar puncture or, CT followed by CT angiogram. Why should you care? Acute headache accounts for 4% of all visits to the emergency departments. These patients will often describe the “Worst headache of life” – a phrase which can ring the alarm bells in the clincian’s mind. 88% of these will be from benign causes including migraine, tension and cluster. However 10% will have a subarachnoid haemorrhage, of which the vast majority are caused by an aneurysm. These are frequently missed - up to 51% of the time in all settings and 6% of the time in the emergency department. It is in face one of the largest sources of US litigation claims and settlements. So – what is the best way to diagnosis subarachnoid haemorrhage? Bill asserts that the lumbar puncture (LP) following the CT is the way to go. He stresses that the “miss rate” needs to be 0% for subarachnoid haemorrhage. He argues that with the combination of CT and LP the sensitivity for subarachnoid haemorrhage is 100% Fernanda on the other hand is a big proponent of using the combination of CT followed by CT angiogram (CTA). She discusses the very low incidence of subarachnoid haemorrhade and takes this into account when calculating the pre- and post-test probability for her patients. She argues that if the pre-test probability is higher for a patient, then a CTA can be utilised. Bill Knight and Fernanda Bellolio present a compelling case for both sides when identifying the best way to diagnose subarachnoid haemorrhage in neuro critical care headache.
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Prehospital high acuity transport by air rescue has the capability to deliver the sickest of patients to high quality, advanced care, and support. However, not all patients are transferred. Why? Per Bredmose tells the tale of Emma. Emma is a 12-year-old girl who developed a cough. She is admitted to local peripheral hospital, correctly diagnosed with pneumonia, and treated with IV antibiotics. Emma continues to deteriorate and is transferred to an ICU where she fails a trial of BiPAP and is intubated. She continues to deteriorate. She requires high pressure ventilation and vasopressor support – advanced, high end, specialist interventions. The truth… this never happened. This talk from Per is about all the future Emma’s. Someone in the hospital system (either the sending or receiving hospital) decided that Emma was too sick to be retrieved. Per challenges this notion of “Too sick to be retrieved”. He says it is rather a case of being in the wrong place at the wrong time. Or getting the wrong disease in the wrong place. Patients will inevitably be in hospitals that lack essential equipment or knowledge for a given condition. Small hospitals do have some deficiencies. Per advocates for the development of retrieval medicine teams and systems that can assist these patients and bring them to centres that can provide the best care. This requires a team including paramedics, pilots, flight nurses and yes, retrieval doctors who have high end specialist training and experience. The teams need to understand the system, the equipment and be able to calculate the risk-benefit ratio of retrievals. They need access to hardware – whether this be ambulances, planes, or infusion hardware. And they must be able to work within the system in which they are operating. Per advocates for a strong retrieval system, comprised of well support and trained happy teams. This leads to safe retrieval and transport and better outcomes for patients.
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Dr Suman Biswas is a UK based anaesthetist known for his musical talents. He and a fellow medical student began performing hilarious medical parody songs, perhaps the most famous is his 'London Underground song'. The two students were catapulted to fame as the "Amateur Transplants" but sadly parted ways in 2011. Suman works full-time as an NHS EnglandAnaesthetist. Here he performs live on-stage at the enormously popular medical conference SMACC (Social Media and Critical Care) in Berlin Germany 2017. The audience of over 2000 medical delegates goes wild. Tune in to hear some of your favourite songs masterfully re-purposed for Suman's medical parody. You are guaranteed to to laugh at the wit and irreverant humour.
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Clare Richmond discusses medical simulation and its ability to provide a safe working environment anywhere. Simulation is a tool which allows us to rehearse our skills and scenarios before they happen in real life, to real people, our patients. Many clinicians dislike simulation, they know it is good for them, but find it challenging to drop into a world of manikins, fear performing in front of their peers and find debriefs uncomfortable. This talk will consider the purpose of simulation and its role in providing a safe working environment for clinical care anywhere. As a junior doctor Clare always found simulation hard. A combination of talking to a plastic model, having to debrief, and trying to figure out the endemic of cardiac arrests in mannikins were all challenging. However, Clare now provides a useful overview to medical simulation and some handy tips into making the most of the simulation experience. The beginning, or pre-brief, provides an opportunity to improve learning. Here there should be consideration of psychological safety for the participants. It is a chance to immerse the learners for their improved learning. The scenario is where all the learning migrates from. It is central to the exercise. The case must come from reality. However, Clare cautions against a case that has truly come from real life. Instead draw from a real case a condition and cause, complications, and co-morbidities. Add to the case a sense of humanity, be it a husband, a child, a family, or a story. This reflects the complexity of real life. Do not forget to challenge participants to remove them from the comfort zone and into the learning zone. Every twist and turn must have a reason for being there. Keep it real and authentic and align it with the objectives of the experience. Keep the simulation somewhat real. This means real equipment and real collaborations with other health care professionals where possible. Also consider using humans as real patients. Lastly, debrief and reflect on the learning experience. This should be approached with curiosity. Re-run scenarios if need using the ‘pause, reflect, repeat’ model. Clare finally advises all to prepare for the expected and rehearse for the unexpected. Things do happen. Medical simulation ensures you will be as prepared as you can be.
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Michelle Johnston presents her thoughts on acute myocardial infarction, thrombolysis and haemorrhage. She delves into David Foster Wallace, evolution, and what do when the thrombolysis bisque hits the fan. Michelle’s interest into acute myocardial infarction, thrombolysis and haemorrhage began one day when she received a call from a peripheral hospital. A local farmer has presented to the Emergency Department with what turned out to be a big anterior infarct. As Michelle points out, he quite appropriately underwent thrombolysis. The gentleman’s symptoms and ECG trace began to settle and a transfer to Michelle’s hospital was arranged. Then he developed massive haematemesis. And to make matters worse, the gentleman turned out to be a dear friend of Michelle. Not to worry she thought… we will just reverse the effects of the thrombolysis. However, after a brief panic, a quick review of the guidelines, and consultation with the colleagues, Michelle realised that a massive knowledge hole existed! Even after getting the opinions of a haematologist, a neurologist, a respiratory physician, a cardiologist, an intensivist and an emergency physician on how to reverse thrombolysis – no clear and satisfying answer was forthcoming. Michelle was left with a big, fat, pile of questions. This led Michelle down the path of investigating how to reverse thrombolysis. This quest took her on a deep dive into the mechanism of tissue plasminogen activator (tPA), and the coagulation-fibrinolysis system. All this via the dinosaur museum, Carl Sagan, human evolution and irreducible complexity. She provides an entertaining and fascinating tour of what is known (or rather not known) about this human physiological mechanism. Through her pursuit of knowledge, Michelle comes to recognise that we either know an incredible amount or absolutely nothing. Michelle concludes that the future of thrombolysis reversal probably lies in not having to reverse it at all. Rather it would be better to have something that removes the clot more effectively and safely in the first place.
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A no-holes barred series of 6 provocative medical interrogations. We challenge the state of research, social media, pharmacology, social work, women in medicine, medicine in the developed work, and the health of healthcare workers. It should be novel, it may get heated, and it is not scripted. Sometimes to comfort the afflicted you also need to afflict the comfortable. This is why no prisoners will be taken, no topic is out of bounds, and no ego will be pampered. It may even offend: you have been warned.
For Trish Henwood, ultrasound use in resource limited settings is a perfect fit. Nowhere has Trish seen ultrasound have more of an effect on patient care and outcomes, and save more lives, than in resource limited contexts. Trish uses the example of a training program in Zanzibar to highlight the scope that ultrasound provides. Using ultrasound on a daily basis to the medical centre is able to screen for antenatal complications that may necessitate transfer to a setting with a higher level of care. Trish also leans of health professions recounting their experience with ultrasound. Fatma – a nurse/midwife – recounts her tales of finding many cases of molar pregnancies, placenta previa, eclampsia and ruptured ovarian cysts. Through the available resource of ultrasound, she has saved many lives (of both mothers and babies.) Gabin in Rwanda has taken the basic ultrasound training he received to diagnose a multitude of cardiac conditions in his centre and Olivier tells the story of a young man with an altered mental status on whom he diagnosed infective endocarditis using ultrasound. These real-world examples show a tiny fraction of the benefit of ultrasound in resource limited settings. Although there are challenges to initiating training programs including resources and equipment limitations, focusing on the bright spots is important. Similarly, the scale of need, wide burden of disease, and complex systems challenges can at times be overwhelming in the global health arena. Focusing on small wins and long-term investment is key to programmatic success and sustainability. Training clinicians in bedside ultrasound effectively uses the same human resources to help shrink the gap between the broad imaging needs of a population and limited consultative capacity of radiology. The result is enhanced patient care, provider empowerment, and improved job satisfaction. Growing point-of-care ultrasound trainees into trainers themselves allows for local solutions to ongoing education needs and helps develop and address the most relevant home-grown research questions, results of which may have broader international practice implications. Building broader networks for bilateral point-of-care ultrasound training and research opportunities will be of global benefit.
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Marcelo Amota makes the case for why driving pressures matter during mechanical ventilation in critical care. Sao Paulo, Brazil, experiences flooding every year. This exposes locals to Leptospira bacteria. The severe form of disease this causes – leptospirosis - sees patients end up on mechanical ventilators. These machines were traditionally complicated, with a huge number of settings and buttons. Marcelo Amato trained in this setting. He, alongside his colleagues, developed methods to halt bleeding in leptospirosis by manipulating ventilator settings. He calls it “protective ventilation”. It was not long before the same principles were being applied to patients suffering acute respiratory distress syndrome. Through research, Marcelo and his team concluded that driving pressures, above all other ventilator settings, were most important for patient survival. Driving pressure is the oscillation of alveolar pressure or variation of pressures inside the lungs. It is what your lungs are sensing. Although there is an obsession with tidal volume, which is displayed on ventilators, Marcello explains, driving pressures are easily calculated and more important. Marcelo discusses the increasing mortality with mechanical ventilation. The medical community, especially physiologists, are traditionally wrapped up in the concept of volutrauma. However, it is the gradient of pressures oscillating inside the lung (the driving pressure) that is causing lung injuries. So, the question became - would the lessons learnt the study on mechanical ventilation for leptospirosis be transferable to reducing risk in acute respiratory distress syndrome? Marcelo presents over twelve years of research. In doing so he highlights the changing dogma of the protective role of small tidal volumes. Research shows that the size of the tidal volume does not matter in terms of mortality. What matters is the pressure that is generated. The force with which the lung is deformed is much more important than the size of the deformation. The message: Do not look at absolute pressures, rather look at the swings in pressure. The only way a patient can survive is through a decrease in driving pressure, and not through a decrease in tidal volume.
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The healthcare ethics of alcohol related harm and driving change by Diana Egerton-Warburton Diana Egerton-Warburton talks about how to be a hero by championing healthcare ethics of alcohol related harm and driving change through stories and data. Have you ever saved a life? Many doctors and nurses have. But, how do you save a life without putting scalpel to skin or picking up a laryngoscope… or even having to go to a hospital? Diana Egerton-Warburton answers this question through the powerful tool of stories. Diana was put on the path of healthcare ethics over twenty years ago. She describes an emergency department shift that changed and shaped her. She sets the scene in the Western suburbs of Melbourne… Heroin bathed the streets and ocean of alcohol. One Australia Day sticks with her. In one Emergency Department shift, Diana saw seven separate episodes of alcohol related family violence. The stories still haunt Diana to this day. Broken bones, abdominal pain, an overdose, a cut lip – these were the faces and tales of the alcohol related violence that arrived in the Department that day. They were all survivors of domestic violence on Australia’s National Day. Through this experience, Diana was motivated to make a change. However, what she thought was a potent advocacy tool in research left her feeling frustrated and thirsty for more. Any one research project only applied to a small portion of patients. To make matters worse, policy makers did not listen, to the results, even in the face of clear data. There was just no traction in policy change. Diana’s answer? Use stories to make data real and to give it superpowers. This is the story of the ACEM Alcohol Harm (AHED) project. For the first time on a national scale the project quantified the level and effect of alcohol harm presenting to Emergency Departments (ED) in Australia and New Zealand. Over 100 EDs and more than 2000 ED clinicians have been involved. AHED provided an evidence base to advocate for measures to reduce alcohol harm through using evidence and clinician anecdotes. Through this strategy, clinicians are placed in a powerful position to influence culture and policy change The change in approach has yielded fantastic results in other areas. Needle and syringe exchange programs and naloxone prescribing Melbourne, decreasing blood alcohol driving limits New Zealand and data sharing amongst emergency providers to reduce alcohol related violence occurring in Cardiff have all been driven by individual clinicians with a story. So, the challenge is there. Draw your sword, raise your shield, and become everyday heroes through the power of stories and data.
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Annet Alenyo Ngabirano was enjoying the community medical placement in the 4th year of medical school. Placed 60km from the nearest hospital, in the lush hills of Uganda, the days were filled with vaccination drives, local outpatient clinics and lazing about. That was until a frantic nurse burst into the room and rushed the three medical students to the bedside of a severely sick and dehydrated infant. There was no doctor. There was no senior nursing staff. They no training, no equipment, no backup, and no resuscitation area - yet this small group of 4th year students were the only hope this small baby had. After trying to gain IV access for over 30 minutes, Annet felt exhausted, overwhelmed, under equipped, under resourced and alone. This is emblematic of where Emergency care in Africa has come from. Over 85% of the world’s population live in Low and Middle Income countries. Health statistics in these countries are characterised by numerous deaths from treatable time-sensitive illnesses and injuries resulting from inadequacies in health systems, particularly Emergency Care. However, across the world, Emergency Care continues to grow, and every country has a story to tell. There are similarities in our stories: the overwhelming sense of responsibility, the exhaustion and feeling of being undervalued. But there are also glaring differences in quality. Africa can be better and it should be. 2017 marks 10 years since the first Emergency Medicine Physician graduated in Africa. From one single Residency program in 2007, there are now 11 more in 9 of Africa’s 54 countries. 2009 saw the formation of The African Federation for Emergency Medicine (AFEM) supporting Emergency Care development across Africa. AFEM’s projects include: - The biennial African Conference on Emergency Medicine (AfCEM), the only scientific conference on African emergency care. - The Annual Consensus Conference that addresses various aspects and challenges of Emergency Care in Africa. - A quarterly international, peer-reviewed journal, publishing original research on topics relevant to Africa, freely available online and offering free publication support to African researchers through Author Assist. - Supadel, a peer-to-peer sponsorship program funds attendance of practitioners to AFEM-affiliated conferences on African soil, allowing them to network and learn valuable lessons in Emergency Care to improve systems in their countries. Emergency Care is a specialty that allows our humanity and compassion to touch and connect with people - not just patients, families, and communities but the whole of humanity. It brings us together. By recognising Ubuntu - the belief in a universal bond of sharing that connects all humanity – Annet knows that Emergency Care in Africa can, should and will be better.
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Trial design is the biggest problem with Evidence Based Medicine in the Intensive Care Unit. Paul Young wants to change that paradigm completely. He argues for research as we know it to change and to focus on clinical care with systemised and optimised treatments that reliably improves outcomes over time for all patients. Mortality measured at a particular time point (landmark mortality) is often regarded as the gold standard outcome for randomised controlled trials in Intensive Care Medicine. An important limitation of many Intensive Care Medicine trials is that they hypothesize large and potentially implausible reductions in absolute mortality. This is a major problem in trial design for two reasons. Firstly, it makes false negative trial results more likely. Secondly, the less plausible a postulated mortality reduction is the more likely that a statistically significant mortality difference will represent a false positive. This is because a p-value is defined as the probability of finding a result equal to or more extreme than that actually observed, under the assumption that the null hypothesis is true. This means that the greater the pre-trial chance or prior probability that the null hypothesis is correct, the lower the chance that a p-value below a particular significance threshold will represent a true positive. In Paul’s words, p-values suck! The biggest single problem with the current evidence base is that most hypotheses being tested have low prior probability. This leads to the two most likely results being 1) no difference or 2) a false positive. We need a new research paradigm to address this problem, particularly in relation to the fundamentals of Intensive Care Medicine. Paul argues for an approach based on the Bayesian approach, utilising big data sources about patients under current care and then randomising treatment in real time. Intensive Care therapy is fundamentally about providing supportive care, including airway support, oxygen therapy, ventilation therapy and haemodynamic support amongst others. These treatments can be uncertain. Under such conditions of uncertainty and idiosyncratic practice variation, treatment should be randomised. Randomised treatment is likely to be the best treatment is these situations due to inherent cognitive biases. Using this data, Paul stipulates that we will rapidly learn from every patient, ensuring improved outcomes for each subsequent patient. As knowledge grow, prior probability can be adjusted, skewing the randomisation process. This continues until the treatment has either proven effective, or been shown to be equivalent. Every patient contributes information that enhances the care of every subsequent patient. And, importantly, p-values no longer matter. Effective research is important. As Paul states, “Optimising ICU care is a priority for global public health.” By increasing the probability that patients will get the treatments that work even before we know what those treatments are the Intensive Care Unit can not only save money, but most importantly and critically, save lives. That is the way research should work.
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David Carr delivers an “old fashioned” talk, presenting his approach to the diagnosis and treatment of endocarditis in acute medicine. Whilst some may turn their nose up at what David describes as esoteric bedside medicine, the rare diagnosis of endocarditis is a bad diagnosis. It carries with it a mortality rate of between 15-30%. David attempts to rebrand endocarditis and make it sexy again. Who? There are four main suspects of getting endocarditis. If you turn up to David’s Emergency Department having had a cardiac valve replacement, the assumption is that you have endocarditis. 1% of these patient per year will develop endocarditis. A valve replacement plus fever or feeling unwell should raise the suspicion even higher. People who inject intravenous drugs are the second population of suspects for endocarditis.15% of people who inject IV drugs entering the hospital with a fever will have endocarditis. You must respect this population, and they need to come to the hospital in these instances. Marantic endocarditis (or nonbacterial thrombotic endocarditis) occurs in patients with active cancer – making this group the third group in whom you should consider the disease. Finally, lupus patients can develop endocarditis - Libman–Sacks endocarditis – related to their antiphospholipid syndrome causing a hypercoagulable state. Four patients, four suspects. These patients present with an association. David presents this as “fever PLUS one”. Fever plus any one of stroke, back pain, heart failure or arrhythmias should raise suspicions of endocarditis. So how should these patients be examined? Well first measure and confirm the fever. Secondly, dust of the stethoscope because up to 90% of patients with endocarditis will have a murmur. Forget the classical signs and look in the mouth at the teeth. Dental procedures in the two weeks prior to presentation is highly suggestive in the right patient. David concludes the talk with management principles. Blood cultures – three sets, three sites! Resist the temptation to give antibiotics in the first hour while you are doing this. Look up or ask colleagues about the blood culture results, and if the bacteria doesn’t fit the crime, be nervous! Lastly, managing endocarditis is a team game so involve the team early including cardiologists, cardiac surgeons, and the infectious disease doctors. Join David as he rebrands endocarditis providing you with the framework to identify the disease and avoid the pitfalls in preventing you nailing down this diagnosis.
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A no-holes barred series of 6 provocative medical interrogations. We challenge the state of research, social media, pharmacology, social work, women in medicine, medicine in the developed work, and the health of healthcare workers. It should be novel, it may get heated, and it is not scripted. Sometimes to comfort the afflicted you also need to afflict the comfortable. This is why no prisoners will be taken, no topic is out of bounds, and no ego will be pampered. It may even offend: you have been warned.
South pole...North pole, hot...cold, on earth...in space, below the sea...on Mount Everest, alone and far, far away. Gaynor Prince takes you to Union Glacier in the Ellsworth Mountain Range, Antarctica, to show you how useful ultrasound can be in extreme environments Gaynor relives the story of being in one of the most isolated places on Earth when she gets a Medivac alert. One of her clients, Jack, has become acutely short of breath. With her list if differential diagnoses including high altitude pulmonary oedema, heart failure and pulmonary embolism, Gaynor was presented with an enormously difficult decision. Whilst Jack’s safety was priority number one, in a place like Antarctica, no clinical decision is easy. With the weather closing in, and a huge amount of time and money having been invested in this journey by Jack and his companions, what was she going to do? The answer? Pull out her Phillips Lumify ultrasound machine. A thorough examination with the ultrasound satisfied Gaynor that her patient was safe and stable. Dry lungs, no elevated right pressures, and no signs of DVT of lower limb – meant Jack could stay at the South Pole. Not for the first time, the ultrasound saved Gaynor’s bacon and highlights why it helps her sleep easier at night. Ultrasound will make extreme environments less intimidating for the doctor by enhancing your diagnostic capability, honing your therapeutic management, and fitting into your pocket. This is a brief tale of a journey to Antarctica with a Phillips Lumify ultrasound. Find your passion and reach for the stars.
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Medical education and clinical programs are designed with four pillars - clinical excellence, research, education, and administration. These apply whether you build and design an ultrasound program or division, a simulation program, a toxicology or pre-hospital program or even an academic department Resa Lewiss describes the four pillars of medical education and clinical programs using a quirky anecdote of four tragic, dramatic and ridiculous stories of childhood dog deaths. Clinical excellence is providing good patient outcomes. Ensuring that staff are well educated and surrounded by working and necessary infrastructure to they can provide quality care. It is a strong and tangible pillar. Research is self-explanatory and demonstrates a program’s credibility locally, nationally and internationally. It is more difficult to uphold, including writing, grants, abstracts and writing manuscripts. Education is what the medical community does, occurring in a number of settings including the lecture theatre and bedside. It is fun, interactive and in real time. Administration is less glamorous, and involves making sure processes work, relationships work and things work. Through the stories of her four family dogs and their demise, Resa illustrates the four ways pillars of medical educational and clinical programs fail. They fail through silent, indolent process – cancer. They can be derailed by others, people and processes who do not want you to succeed – homicide. The clinical program can be the architect of it’s own demise, not publishing, not researching and not conforming to standards – suicide Finally, they can become stale, irrelevant and outdated – old age. Join Resa Lewiss as she remembers the tragic dog deaths of her childhood and what they taught her about medical education and clinical program design.
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In this quick, five minute talk, Brandon updates us on Sinus Venous Thrombosis. This includes what it is, what it looks like and how to diagnose it.
Brandon starts with a case – a 37-year-old woman, who is 8 weeks pregnant, presents with what she describes as the worst headache of her life.
She has a history of migraines, so this is Brandon’s first thought and possible initial diagnosis. But... it turns out to be more than just a migraine...
Brandon explains that what we should be looking for here is venous sinus thrombosis.
This is characterised by a sub-acute onset of a headache and risk factors. In this case, hormonal changes which are related to her pregnancy, making her at higher risk.
The key takeaway? A headache with risk factors (in particular anything that will cause a Hypercoagulable state) plus or minus seizures, usually means we should be looking for this condition.
Brandon suggests that we need to be suspicious of this condition and that we need to look for it. Even if it isn’t obvious at first.
Next, Brandon takes us through a second case which tells us that bilateral stroke usually means venous sinus thrombosis, until proven otherwise.
From DAS SMACC, tune in to an interesting and quick update by Brandon Foreman on how to identify and diagnose this condition.
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Fernanda Bellolio guides the listener through an approach to the treatment of wake-up stroke in neuro critical care. What time did the symptoms start? This is one of the most common questions that is asked when taking a history from a patient. However, what happens when this can not be answered. This is the case with “wake-up strokes”. A wake-up stroke is when a person goes to sleep without symptoms and wakes up with deficits. Similar problems in management arise when a person cannot accurately tell the clinician what time the symptoms began. Up to 20% of stokes are wake-up strokes and a further in a 10% of strokes the patient nor family can say exactly when it started. This presents a challenge as many therapies that currently exist are time sensitive and therefore not approved for wake-up strokes. Fernanda reviews the current evidence in the quest to answer three questions: 1) What is the evidence for tPA use in wake-up strokes; 2) Can endovascular treatments be used in wake-up strokes and 3) How can these patients be approached clinically? tPA has not been approved for this patient population due to the inability to know the time of the stroke. However, utilising advanced imaging techniques including MRI, it is possible to get a estimation of the temporality. Using these methods, studies have looked at the use of tPA and shown likely benefit, with acceptable rates of intracranial haemorrhage. Despite this, imaging techniques such as used in the studies are not widely available. Endovascular therapy has a wider window of availability, and the early research indicates this therapy can be beneficial. Thrombectomy similarly showed good outcomes in early trials when compared to tPA. Fernanda sums up the overall approach to the wake-up stroke presentation. Treat it as an emergency, get the history, send off labs and request imaging. Be guided by the stroke protocols that exist in your hospital. For management – at this stage Fernanda highlights that no routine therapy can be offered based on the evidence at the time of the talk. However, multiple ongoing trials will guide future treatment selection.
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Rinaldo Bellomo is here to cause some trouble! He says that critical care physiology in resuscitation has problems! Whilst the rest of the medical field has advanced and evolved over time (we no longer routinely prescribe oxygen for an acute myocardial infarction), critical care resuscitation still relies on malfunctioning physiological paradigms. Critical care clinicians can change physiology with a number of tools. They can repeatedly, often, and mercilessly change physiological variables. Blood pressure, cardiac output, cardiac filling pressures, glucose levels, positive fluid balance and countless other physiological parameters can be increased and decreased at will. This kind of “numerology” is attractive because the outcomes can be immediate, and clinicians feel powerful and effective. However, outside the obvious situations where physiology is so dangerously abnormal as to threaten life, such physiological manipulations have an unproven relationship with outcome. Importantly, patients do not care whether their cardiac output has been increased from 5L/min to 6 L/min. They only care whether they live or die, get out of hospital intact and return to their previous life. Thus, physiological gain is not patient centred. Moreover, all research focusing of the physiology of a specific intervention inevitably deals with the effect on a specific set of variables. For example, a fluid bolus may or may not increase cardiac output in the short term. However this effect is not sustained much past 20 minutes. Similarly, no studies examine the effect of such fluid bolus on anything other than haemodynamics. No one measures what the effect is on the immune system, cerebral oedema, the glycocalyx, interstitial oxygen gradient, pulmonary congestion, body temperature, haemoglobin, or white cell function. Thus, all physiological studies are “blind” to the broader effects of their intervention. Rinaldo claims that in critical care resuscitation physiology, the measurable is made important but the important may not be measured. Clinicians need to reflect on this before they become seduced by physiological manipulation. Rinaldo’s challenge to you? Look at the literature, consider biological plausibility, follow evaluated evidence, balanced, accept doubt with a smile and practice known medicine of the time whilst understanding that today’s medicine will be the source of derision in the future.
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Brandon Foreman gives a practical approach to the diagnosis and workup of neuromuscular disease in neuro critical care. Neuromuscular diseases are common and include chronic autoimmune disorders such as myasthenia gravis, acute demyelinating disorders like Guillain Barre, paraneoplastic disorders, and toxidromes such as botulism. The presentation of many neuromuscular diseases can be subtle: diffuse weakness, subtle swallowing difficulty, or double vision. Many patients do not present until its nearly too late, and timely diagnosis can lead to rapid stabilization of airway, autonomics, and other potentially lethal complications and expedited treatment of the underlying cause. Brandon’s first piece of advice pertaining to neuromuscular disease in critical care? You have to recognise it! There are subtle clues littered through the history and physical exam of a patient. A nasal voice indicates oropharyngeal weakness. This is important to recognise and can tip you off to the likely diagnosis. New onset eye complaints or proximal muscle weakness will likewise lead the clinician to consider neuromuscular weakness. If a patient presents with a history of difficulty rising from a chair or double vision think of disorders such as Guillain Barre or myasthenia gravis. A big question in the early management of patients with neuromuscular weakness is the need for intubation. Brandon advises throwing away some of the traditional methods of answering this question that rely on lung function testing and often involve a respiratory physician. Instead, he runs through a handy list of diagnostics, possible at the bedside to determine the need for mechanical ventilation in this population. Brandon discusses clinical pearls to hone in out what a patient is presenting with. Test such as Simpson’s test or the “ice bag test” are useful addition to any clinician’s toolbox. Finally, Brandon takes you through the initial workup of patients presenting with likely neuromuscular weakness, equipping you with the knowledge to start the process before calling the neurology registrar!
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Sara Gray works in the Intensive Care Unit and sometimes connects with patients. This was especially true for a lady who was in her unit intubated due to pneumonia. When this patient experienced a failed extubation, a tricky re-intubation and subsequent tracheostomy, Sara was kicking herself. She says we have all been there… Have you ever dropped your phone? What was the internal dialogue in your head at the time? Sara calls this out inner voice. She used to think that our inner voice did not matter to high level medical performance or resuscitation skills. That was until the evidence changed her mind. The inner voice is powerful. A negative inner voice can increase anxiety, raise the heart rate, and use up valuable cognitive processing power. So, when running a complicated situation, your inner voice matters! For Sara, the critical soundtrack of the inner voice was constant. Her question was – how do I change this? This led Sara to the concept of self-compassion. She explores how she trained the inner dialogue, which is a skill to learn and practice. Self-compassion has been shown to reduce the heart rate, reduce sympathetic surges, reduce stress induced immune responses and in practical terms make your hands shake less when is high stress environments in the ICU. Sara expands on the benefits. She suggests that once you are a competent clinician with good theoretical and procedural skills, it can be hard to take it to the next level. However, serious psychological skills are all part of excellent bedside resuscitation. When reflecting on her experiences in her practice, Sara highlights how medicine views calling for help as an act of weakness. In a profession where tiny mistakes lead to life and death consequences, staying silent can lead to shame and isolation. This in turn manifests as burnout, depression, addiction, and suicide. Everyone in healthcare is at risk. It is the price of a culture of silence. The answer to reverse this includes self-compassion. Self-compassion is not a light switch – rather it is something you must work at and practice. Sara tells a story that everyone in healthcare will relate to and walks you through examples of useful resources to assess and work on self-compassion. After this talk learn to listen to your inner voice, practice self-compassion and use skills and empathy to take care of yourself and your community. Self-compassion can make work performance and life better.
Resources to consider:
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www.Selfcompassion.org This is Dr Kristin Neff’s website, complete with a self-compassion quiz, and then exercises and resources for those who fail the quiz! She also has a book if you prefer that format.
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Pema Chodron. Fail, fail again, fail better. A short, and lovely commencement address with excellent advice for failing better. https://www.amazon.ca/Fail-Again-Better-Advice-Leaning/dp/1622035313
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Angela Lee Duckworth. Grit. A marvellous book about the essence of perseverance. Or if you don’t like books, consider her TED talk at https://www.ted.com/talks/angela_lee_duckworth_grit_the_power_of_passion_and_perseverance
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Brene Brown. The Gifts of Imperfection. A book about failure, and acceptance of failure. Again, if books aren’t your thing, she has a hugely popular TED talk about vulnerability: https://www.ted.com/talks/brene_brown_on_vulnerability and a website/online learning community: https://www.courageworks.com/
Rhonda Cadena explains the process of diagnosing and managing meningitis. It is a skill that involves rapid identification, workup, and treatment. In most cases, the diagnosis of meningitis is not a diagnostic dilemma, but the workup and treatment are not as straightforward. Meningitis is inflammation of the lining of the brain and spinal cord. This can be caused by bacteria, autoimmune process, drug reactions, viruses, and fungi. Rhonda delves deeper into bacterial meningitis. Worldwide there are over 1 million cases per year of bacterial meningitis. This equates to 135 000 deaths. Of the survivors, half will be left with neurological deficits. So, the swift identification and treatment of this disease process is crucial. Symptoms include fever, headache, nuchal rigidity and altered mental status with almost all patients having at least two. A lumbar puncture is absolutely necessary. Only insist on a CT first if you suspect a mass lesion or increased intracranial pressure. Otherwise, the delay in antibiotics can lead to an increased morbidity and mortality. Labs are next in the workup. All the common labs should be ordered along with a procalcitonin which can be diagnostic for a bacterial infection (although it will be positive with any bacterial infection so make sure it fits the clinical picture!) Likewise, fungitell can be useful in looking for some of the more common fungal infections. Blood cultures will guide antibiotic coverage. Steroids can be beneficial for prevention of neurological sequalae in patients who are infected with pneumococcal meningitis. They should be started in anyone with suspected meningitis. You can then cease if cultures come back negative for pneumococcus. Importantly steroids must be started before or during antibiotics. Finally Rhonda discusses prophylactic treatment. This is necessary for contacts of patients with Neisseria infections. Think household member, day care contacts, and anyone exposed to secretions. This scintillating talk addresses the challenges during the workup, which labs to send during the initial workup, and how specialized labs such as CSF lactate, procalcitonin, and fungitell may help in the workup along with helpful advice for management.
For more head to: codachange.org/podcasts/
Jonathan and his wife Anna thought they were coming to the emergency department for a routine sickle cell pain crisis. However, his illness takes him down an unexpected spiral of multi-system organ failure and critical illness. What was a routine patient encounter becomes a much more personal human interaction that causes the provider to question her perspective on chronically painful conditions and realise the effect our words and subtle actions have on our patients. Jessica Mason utilises the powerful tool of narrative storytelling, adapted to a live lecture format, to tell Jonathan’s story from his own perspective. In doing so, Jessica makes Jonathan the teacher. Jessica hopes you will remember the story and remember the medicine. In 2016 Jessica received an email from Jonathan’s wife. The email was to inform her of Jonathan’s death, from complications of sickle cell disease. He was 43. This stark note gave Jessica pause, and prompted her to reflect on her interactions with Jonathan and his wife and wondered what lessons could be learnt about how we view chronically painful conditions and the unconscious biases we carry. By reliving her interactions with Jonathan and utilising interview audio with Jonathan, Jessica highlights the struggles that face patients with painful, chronic conditions. They are often burdened by fear of judgement or fear of being undertreated when accessing medical services. Concurrently, healthcare providers can be afraid of turning people into heroin addicts or be fearful of having their compassion exploited. Jessica posits this is all driven by the stigma of opioid use in emergency departments. Jessica used to believe pain crises from sickle cell disease were relatively easy to manage. However, Jonathan’s powerful narrative provides a wonderfully effective teaching opportunity about sickle cell disease and other chronically painful conditions and how they are managed. Join Jessica Mason as she mixes medicine with the human condition to pass on valuable wisdom from the patient’s perspective. In the words of the Jonathan’s wife Anna, “If you don’t teach others about what you have, no one will know.”
For more head to: codachange.org/podcasts/
Trauma is an epidemic so what is the future for prehospital trauma resuscitation? The statistics are shocking – 14,000 people a day and 5 million people every year die from trauma. Injuries accounts for 9% of deaths worldwide and they are the biggest killer of under 40s across the world. Incredibly, these numbers are only rising. Dr Brian Burns describes what is largely a silent killer… many critical care doctors and nurses may never get the chance to see, treat or save the patient, because they often do not make it to the emergency department. Death often occurs in the first hour post trauma and 90% of trauma deaths are due to exsanguination. We pick up the story of Paul. Paul is driving alone when he loses control and crashes his car. There are no witnesses. No one to call for help. No emergency responders. Paul bleeds and dies. The emergency system that is currently used is not specific or sensitive enough – and we need to do better. The meercat is the animal world exemplar of the early warning system. Meercats knows where danger is, know how to look for it and on finding danger, they sound an alert that raises an immediate and appropriate alert from the collective. Brian applies the meercat model to Paul. Brian describes a new response, one driven by data, and fast and accurate access to that data. He draws parallels to the data gathering and sharing of Formula One teams. Brian takes a deep drive on predictive algorithms to calculate the likelihood of injury, automate the response and alert the dispatchers. He describes a response that utilises real time images, biosensors sending biometric analysis and the use of drones to deliver equipment ahead of retrieval teams – all while being supervised by a trauma team leader in a trauma centre. Brian re-tells Pauls tale in the future, the future of prehospital resuscitation. He describes a situation where technology is used to do better for Paul, and the countless others like him. Join Brian as he makes the case for computerised algorithms and decision-making assistance in medicine and implores the pre-hospital community to do better by utilising technology.
For more head to: codachange.org/podcasts/
Dying is not very sexy, but sometimes, dying is the right thing to do. Death is one of the many things that we only get one shot at. There is no second chance at death.
Dr Alex Psirides discusses death from a patient, family, doctor and economist perspective. 400 years ago, death was everywhere. Everyone was exposed to dying on a regular basis and people were encouraged to prepare for their death. Things have changed thanks to the intervention of the medical profession. Resuscitation teams, pain killers and the concept of “dying in comfort” have altered the trajectory of dying, leading to a mystique surrounding the concept.
Dr Psirides argues that death has replaced sex as the new taboo – and the result is a society removed from death. This has led to poor choices in medical interventions towards the end of life.
Furthermore, Inappropriate decisions made by medical teams are likely to delay death, decrease quality of life and cost money, all without changing the ultimate outcome… death. This sparks a discussion around a new perspective on “doing everything”. Medical Intensivists have been shown to be bad at knowing the outcomes of their patients. They also overestimate the benefits and underestimate the harms of the interventions they prescribe.
Alex discusses the affect that “doing everything” has on families. Families of patients that had received more life sustaining treatments towards the end of life had higher rates of depression following the death.
Finally, the financial cost of extending lives is explained. Alex questions the efficacy of spending greatly to advance life trivially. Underpinning these hard decisions around death is the enormous importance of early discussions of death and dying with patients and their families. Is doing everything the best thing doctors, families and society can do for patients? Alex asks you to give patients the death you would want and make dying great again.
Tune in to a discussion on The Ethics of Death by Alex Psirides.
For more head to: codachange.org/podcasts
Achieving excellence in healthcare communication requires multiple skills. When conflict arises we are programmed to respond with exasperation and negative judgment. In healthcare, this is especially dangerous. When your patient is in a critical state, the decision about whether to intubate before or after a trip to the CT is best reached with minimal conflict. Jenny Rudolph takes a refreshing angle on the practise of mastering yourself in difficult moments so that patient care is not compromised, and professional and personal relationships are not weakened. Conflict can be healthy when constructive. When making difficult decisions for patient treatment and care this friction or conflict can be even more important. This is because at this critical moment we should be sceptical about our decision making process, when we tend not to be. Equally, in a disagreement, we are often certain when we ought not to be. However, if there is too much prickly feedback and defensiveness on both sides, solutions are often difficult to deliver. When faced with such challenges in communication, Jenny discusses how to reset, and to reframe the situation and avoid reacting with negative emotion She explains the battle between judgement and curiosity when faced with difficult situations. They are both normal. It just so happens we are naturally curious about that which fascinates and interests us and judgemental about the irritating and appalling. By challenging listeners to get curious, Jenny explores techniques to manage conflict in high stress, time pressured, critical care conversations. She advocates for the efficiency and effectiveness of infusing positive regard into our interactions. Join Jenny as she guides you through reconciling curiosity and judgement, providing practical tips to use in the Emergency Department or Intensive Care Unit, alongside moments of catharsis!
For more head to: codachange.org/podcasts
Sarah Yong is an impressive person. Advocacy, Training, Representation and being a new fellow of the College of Intensive Care to boot.
Theres a lot to talk about when you sit down with Dr Sarah Yong. Let’s make it easy by focussing on three big issues;
Gender issues; Women in Intensive Care Network. www.womenintensive.org
Training issues; The Critical Care Collaborative and the Victorian Primary Examination Course for CICM. www.vpecc.com
Representation issues; New Fellows Rep on the Board of the College of Intensive Care Medicine. www.cicm.org
Where to start?
Women in Intensive Care Network www.womenintensive.org @WomenIntensive
If my sources are correct there pretty much the same number of women and men out there in the world. Further it seems that there are roughly the same number of women and men presenting to intensive care units. This pattern does not repeat itself in terms of the Intensive Care doctors.
Let’s talk about this. Let’s listen to the people that are raising awareness about this. The Women in Intensive Care are talking about it and publishing about it too. You may have heard about the Medical Journal of Australia article; “Female representation at Australasian specialty conferences”.
Darren Braude discusses the concept of Rapid Sequence Airway (RSA).
The evolution of this concept goes back to the start of the 21st century. Here, the practise of ‘archaic’ airway management was common. This involved getting that plastic tube down the patient’s trachea no matter what.
However, gradually, the risks of hypoxaemia during airway management become evident. This led to a movement towards extraglottic airways. If the oxygen saturation was dropping and there had been two failed attempts.
This movement continued to involve towards operators deciding to move to other methods when only one attempt had failed. This was largely due to the increased training and skill of clinicians. The thinking being if they could not get it in one shot, they probably weren’t going to get it at all.
This evolution was the catalyst for the movement towards faster airways, and less emphasis on intubation.
Rapid Sequence Airway is pharmacology and preparation as in RSI, with the planned placement of an extraglottic device, without any intention to intubate.
Moreover, in this talk Darren takes you through the advantages and disadvantages of RSA. It is a fast and highly successful technique with minimal airway trauma.
On the flip side, some patients are not good candidates for extraglottic devices. RSA necessitates a secondary procedure and it does not provide a ‘definitive’ airway.
RSA is an alternative airway management strategy that may be ideal for preoxygenation of hypoxemic patients as well for prehospital and in-flight use. Darren provides the ins and outs of Rapid Sequence Airway in this talk, as well as providing the data and his real world experience of using this concept.
Finally, for more like this, head to our podcast page. #CodaPodcast
Becoming competent in airway management requires good decision making and and technical skills. Ultimately what matters is how your clinical performance impacts patient outcomes. For this we need to have a clear understanding of what defines success ensuring that its more than just 'getting the tube'. Come to this talk and you'll experience a Canadian take on Guinness, adventure sports, flying a plane and how other factors including failure influence airway management outcomes.
Ellen O’Sullivan presents an outline of the Difficult Airway Society (DAS) Guidelines on airway management.
Airway management is a fundamental responsibility and skill of all involved especially for emergency physicians, anaesthetists and critical care physicians.
Ellen makes the point that mismanagement of airways leads to severe morbidity and mortality. She provides a few harrowing examples.
The 2015 Difficult Airway Society guidelines, published in the British Journal of Anaesthesia in December 2015, provide a sequential series of plans (A to D) to implement when tracheal intubation fails.
They promote patient safety by prioritising oxygenation and minimising trauma. Furthermore, they highlight the role of neuromuscular blockade in making airway management easier. The guidelines recognise the difficulties in decision making during an emergency and stress importance of human factor training.
The guidelines include steps to assist the anaesthetic team by providing a common stem of options (a simple algorithm) for maintaining oxygenation, limiting the number of airway intervention attempts, encouraging declaration of failure by placing a Supraglottic Airway Device and overtly recommending a time for stopping and thinking.
They emphasise the importance of considering discontinuing anaesthesia and waking the patient up (if appropriate) when tracheal intubation has failed. The guidelines recommend videolaryngoscopy and second generation Supraglottic Airway Devices. All anaesthetists, intensivists and emergency medicine physicians should be able to use these devices.
There is limited evidence relating to the management of the ‘can’t intubate can’t oxygenate’ situation (CICO) PLAN D. However, all anaesthetists should be able to perform a surgical cricothyroidotomy (and trained accordingly).
Join Ellen as she provides you with what you need to know for management of the difficult airway, in line with the DAS Guidelines.
For more like this, head to our podcast page. #CodaPodcast
Reuben Strayer presents a masterclass on airway management with laryngoscopy.
In the past two decades, airway management has been revolutionised by the development of video laryngoscopy, hyperangulated blade geometry, optical stylets, laryngeal masks, and a host of advances in airway pharmacology and technique.
The core skill of airway management, however, remains laryngoscopy. Reuben provides his take on how to perform this procedure with success.
Firstly, Reuben talks about positioning which is a critical step. This includes the common mistakes made in patient positioning. Reuben shares a proposed set of parameters that the provider can use to guide positioning that is optimal for laryngoscopy. He also guides you through his take on the grip to use throughout the procedure.
Reuben talks about the effect of the grip on the operator’s catecholamine production and what to do to avoid excess catecholamine levels which will be detrimental to performance.
Next, Reuben confronts one of the core principles of RSI, the delay between medication administration and commencement of laryngoscopy. He proposes an alternative approach that emphasises early laryngoscopy with deliberate slowness.
Reuben highlights the value of the jaw thrust – as performed by an assistant – during airway management. Then, he moves into a step-by-step analysis of laryngoscopy as the blade moves into the mouth, down the tongue and ultimately to the glottis.
Further, Reuben talks about the utility of suction. This is an under-utilised device in his view. He discusses the two most important intra-laryngoscopy optimisation manoeuvres. First, optimisation of the position of the head and then, optimisation of the position of the larynx.
Reuben concludes by discussing the value of using the gum elastic bougie for both difficult and routine intubations and describe pitfalls encountered when using the bougie (and how to manage them).
In this presentation, Reuben Strayer breaks down laryngoscopy into its discrete components and describes best practice techniques at each step.
For more like this, head to our podcast page. #CodaPodcast
Ross Fisher gives his take on how to make your presentations better!
Delivering a presentation is a skill like any other, yet few people are actually develop this skill. Instead, they merely copy those they observe and reach the same level of mediocrity.
There is more to a presentation than your slides.
Ross gives his three main elements of any presentation: The story, the media, and the delivery. In Ross’ view, these elements are all equally crucial to delivering a great presentation. He calls this concept ‘p cubed’ where each element is represented by P1, P2 and P3 respectively, and these elements are multiplied together to give the overall quality of the presentation.
The lesson here is that a small improvement in any area will garner and overall improvement in the presentation. Ross will guide you through practical tips for each of his key elements.
Firstly, your presentation needs to be grounded in an engaging concept in order for the audience to care about what is going on.
Moreover, Ross discusses the use of media and why slides of text are unhelpful and why PowerPoint sucks! Along the way he teaches you how you can utilise PowerPoint to you advantage to effectively get your point across and to avoid the strikingly common errors used.
Lastly, Ross gives his thoughts on the delivery and performance and how you can utilise these skills to improve your presentations. Ross will make you uncomfortable when he highlights the wrongs that we are all guilty of in giving presentations. The p cubed concept gives an understanding of presentation design that will change your presentations forever.
How to Give the Greatest Presentation in the World: Ross Fisher
For more like this, head to our podcast page. #CodaPodcast
Suman Biswas is an anaesthetist from London, however probably more famous for his satirical song writing career, gives a poignant talk about communication.
Suman provides his ideas about talking and communicating with patients. As everyone knows, anaesthetists do not need to talk to their patients!
Quite the contrary, as Suman divulges they indeed do. They need to establish rapport, gain trust and share information – much like every other member of the healthcare team.
Therefore, Suman will provide his musings on the use of language and the words we use when we attempt to succeed in these domains. Suman touches on the use of both verbal and non-verbal communication and the importance of nailing both when attempting to get a message across.
He similarly gives guidance on communication with patients who speak a different language to your own. This includes pointers on the use of interpreters. Suman moves on to communication with colleagues.
He talks about Anaesthetic Non Technical Skills (ANTS) – teamworking, task management, decision making and situation awareness. These are most prominent when under pressure, be that in a simulation or in an emergency.
They are all crucially important – as much as gaining a successful airway! Punctuated with some classic songs and delivered with his stand-up comic timing and panache, this is what SMACC is all about: an important message that could change your practice, delivered in a unique and unforgettable way. Language warning.
Communication in Healthcare (via Music): Suman Biswas
For more like this, head to our podcast page. #CodaPodcast
Jenny Beck-Esmay, Dara Kass and Stacey Poznanski tell the story of FemInEM and celebrate women in Emergency Medicine.
Jenny shares the story of Casey Drawert, a doctor who was tragically shot to death by her husband. This incident opened the discussion regarding how common domestic violence in physician relationships is.
In response to this incident, Esther Choo wrote "Intimate partner violence, a physician mother and our call to action" for FemInEM. Esther's post garnered a lot of attention and led to numerous women and physicians to come forward with their story of violence.
Dara talks about an incident regarding changing gender dynamics that led to the birth of FemInEM. A female physician received a call from her son' s school when he missed his class. This was despite the primary contact being specified as the stay-at-home father.
This incident motivated the formation of FemInEM. Even though there are multiple women organisations, women seldom know what is happening beyond the boundaries of such organisations.
So, they decided to take the fundamentals of FOAM and build upon it to learn how women survive in emergency medicine. Dara explains the data to prove that gender inequity exists in the field of medicine. Female doctors are only paid 64% compared to their male counterparts. She also points out the pipeline leakage where the percentage of women keeps decreasing as the job hierarchy increases.
Stacey talks about Dr Jullette Saussy who had to resign from her post as EMS and assistant fire chief in Washington D.C. This was because of the resistance that she faced at every level.
Stacey points out that FemInEM is not only about maternity leave and the gender pay gap. Instead, it is about providing support and connection to women, like Jullette, who try to make a difference in patient care.
By connecting with women through various platforms, they have been able to identify specific problems faced in emergency medicine.
FemInEM recognises the accomplishments of women in emergency medicine and has opened discussion on topics that were previously taboo. She believes that open access and open communication will have a positive impact on gender equity in emergency medicine.
The FemInEM Story: Celebrating Women in Emergency Medicine
For more like this, head to our podcast page. #CodaPodcast
Sandra Viggers delves into the art of learning medicine.
Sandra asks the question: can students choreograph their own education? On one hand, people believe students cannot choreograph their own education for various reasons. She calls such people behaviourists who push others back in line if they do not agree with their views.
Behaviourism is a top to bottom approach. The teacher is not a facilitator but an instructor. It produces MDs with knowledge that is not applicable to real life.
On the other hand, can students choreograph their own education? In educational psychology, these people are called humanists. In the humanistic approach students are active learners.
The problem with this approach is that it is dependent on intrinsic motivation. Hence, it is important to realise when the student is intrinsically or extrinsically motivated.
Sandra points out that both behaviouristic and humanist approaches fail to include the skill of reflection. While the humanist will expect the learner to self-realise reflection, the behaviourist does not even believe in the concept.
This causes the Dunning-Kruger effect, producing either over-confident or under-confident fools. Behaviourism trains people by correcting their behaviour. They are trained to work in an 'ideal world.' Therefore, they often fail to perform in unpredictable settings.
The humanist approach produces people who are interested in specific topics. The solution is realising that both a humanist and behaviouristic approaches are inadequate.
Students today are independent, love to learn but do not like to be forced. Importantly, they are aware of their needs and use connectivism. Connectivism believes in learning via social interaction.
According to Sandra all these theories are flawed. She believes that the solution is adaptive expertise. We want doctors to apply their knowledge to different situations.
To achieve this, we first must challenge or question everything that we have learnt. Make students aware that there is more than one solution to a problem.
The second step is to encourage reflection. Sandra endorses adaptive expertise via transfer of learning. She wants educators to create a playground where students can play, replay, fail, try and challenge themselves.
Sandra concludes by listing what she expects from her educators. She wants us to embrace learning as bidirectional and to encourage the art of reflection.
This will help students become creative, adaptive, lean mean machines of excellence.
For more like this, head to our podcast page. #CodaPodcast
Tom Evans wants to bring lessons from elite sport development and training to medical education.
Caring for the critically unwell is an important and difficult task. So, preparing our people to meet this challenge should be all about excellence. These are all true of sport – and Tom contends perhaps medical training!
Nothing happens quickly in sport. It takes time, often many years. There are a number of challenging tests along the way for an athlete to reach the pinnacle of representation. So hard are the tests that not everyone will make it to the end.
However, when one does make it, how the performance in those tests to get there has no bearing on how they will perform in the race or on game day. Standards are rigorous because there are no second chances. You do not get another go at the Olympic final.
Elite athletes often only have a handful of coaches during their career. Coaches are accountable for the performance of their athlete and talent will not rise on its own. Tom contests the medical training should look more like training for elite performance in sport.
He tells the success story of the Great Britain Olympic Team and how they managed to increase their gold medal tally from a single gold in the 1996 Games to 29 by the London games just sixteen years later. This was done by targeted spending by developing coaching and developing systems to identify and subsequently develop talent.
Too often, the structures and pressures that define medical training focus on competence rather than excellence. Competence is measurable. It can logged, assessed, and can be applied across big organisations. But aspiring only to competence limits us – our patients need more.
So can we learn from how other high-performance organisations train? For Olympic teams, aiming for competence just isn’t good enough. These organisations develop their athletes over many years – equipping them, ready to deliver an excellent performance under pressure.
Successful coaching relationships operate on an individual level. They are long-term. They are flexible. And they are measured not by exams or assessments, but by whether the person being coached can perform in the real world.
Join Tom and discover why he believes the paradigm should shift from medical trainers to medical coaches and how we should strive not for competence but excellence.
Lessons from elite sport brought to medical training by Tom Evans
For more like this, head to our podcast page. #CodaPodcast
This will be a panel discussion with a focus on the different styles of training and education in prehospital care.
Ross Hofmeyr divulges some stories from his experience of wilderness and expedition medicine.
In his words, wilderness and expedition medicine is the epitome of practical, pragmatic, minimalist and thoughtful care. Austere and extreme environments require special knowledge, critical thinking, innovative practice, and sometimes cunning improvisation.
Moreover, diagnosis in the wilderness relies heavily on clinical examination skills. Monitoring is limited and treatment options are determined by the individual practitioner’s hands-on skills.
Furthermore, the implications of extreme environments – high pressures and altitude, frigid and sweltering temperatures, hypoxia, and high-intensity endurance exercise – can provide us with great insight into the physiology of humans responding and adapting to critical illness.
Join Ross as he displays his deep love of the wilderness and nature, and the lessons he has taken from the outdoors. These lessons, whilst useful for medical practice, transcend medicine. His stories are funny and engaging and show a side of medicine rarely talked about!
He discusses lions, ships, dental procedures, meningitis and much more in this fast-paced talk. In this presentation, Ross shares trials and tribulations and draws on experiences from wilderness rescue, and expeditions around the world, which provide lessons for wilderness medics.
Evidently, we can translate these lessons into practicing better acute and critical care medicine in our day-to-day settings.
Lessons from Wilderness Medicine: Ross Hofmeyr
Finally, for more like this, head to our podcast page. #CodaPodcast
Kathleen Thomas describes her harrowing experience of a warzone whilst working in the ICU and ED of the Médecins Sans Frontières run Kunduz Trauma Centre (KTC) in northern Afghanistan.
Kathleen describes her work during a week where she found herself caught up in an eruption of war. The Taliban forcibly took control of Kunduz from the US backed Afghan Military.
This marked the beginning of a challenging week of heavy conflict in which the hospital was the only facility providing impartial medical care to war wounded civilians and soldiers from both sides of the conflict.
Despite the proximity of the rapidly changing front line, Kathleen believes that the hospital is the safest place. Both warring parties had agreed to respect the protection provided to us under International Humanitarian law.
Kathleen’s work in KTC came to a grinding halt when a US Gunship fired over 200 missiles into our hospital. This destroyed the main building and killed 42 people including 14 of her colleagues.
It was a scene of nightmarish horror that Kathleen will never forget. More than 250 hospitals in Syria and 130 in Yemen have been attacked. This shows a growing disregard for the rules of war. Despite the condemnation by the UN, the attacks on medical facilities continue, unabated.
Following an eyewitness account of the attack on KTC, Kathleen asks some important questions: Is international humanitarian law no longer respected by warring parties?
Are we entering into a new paradigm of war where hospital attacks are a legitimate military tactic?
What does this mean for the future of critical care delivery in war zones across the world?
Bombing of Hospitals in Warzones: Kathleen Thomas
For more like this, head to our podcast page. #CodaPodcast
Trish Henwood talks on all things point of care ultrasound (POCUS) in resource limited environments.
According to the World Health Organisation, 80-90% of all diagnostic problems can be solved by basic radiograph (x-ray) and ultrasound (US) examinations. However, the problem is that two-thirds of the world’s population currently has no access to imaging technologies.
From refugee camps in Greece, to rural clinics in Australia, to Everest Base Camp, POCUS is one of the most powerful diagnostic and procedural tools in any austere clinical setting. This transformative technology allows front line providers who have direct responsibility for patient care to rule in or rule out diagnoses rapidly. Moreover, it ensures safety in performing procedures with real-time image guidance.
For example, POCUS training can allow a midwife to identify a massive amount of free intra-abdominal fluid in a 30 year-old Ugandan mother presenting to gynaecology clinic with her third pregnancy and new abdominal pain. She can then notify the surgeon of her concern for a ruptured ectopic pregnancy.
This leads to patient survival in environments where they would otherwise die. Waiting for imaging facilities and specialists leads to delay in definitive care and poor outcomes for patients.
Ultrasound machines have become increasingly portable, user-friendly, and less expensive over the last decade. This is resulting in a growing presence in otherwise resource poor environments.
POCUS trained clinicians can afford imaging capacity to health facilities that may have very limited on-site diagnostics. There is no ionising radiation, nothing invasive, and it is cost-efficient.
POCUS provides the potential to quickly narrow differential diagnoses by facilitating a look inside the body during the patient encounter. Research studies support its use to solve information gaps in resource-limited settings.
Moreover, the potential for this digital technology to be shared – and to leverage global expertise and consultation – increases the range of application beyond one individual’s knowledge base.
Join Trish as she highlights the amazing capacity of POCUS with real world stories.
For more like this, head to our podcast page. #CodaPodcast
David Carr teaches you how not to miss the diagnosis of aortic dissection.
David breaks down the key pearls on history and physical exam that guide you into correctly suspecting a dissection.
Aortic dissection is a challenging diagnosis that you cannot afford to miss. The talk aims to give you the framework to avoid missing the diagnosis.
Firstly, David begins by teaching you what questions to ask in the history to raise the suspicion of an aortic dissection. These include onset, quality, and radiation.
As he explains, these simple three questions will raise the suspicion in the vast majority of cases.
If you do not ask these three questions, you may as well be flipping a coin! Secondly, David goes on to an in-depth explanation of the pain patterns that can present in an aortic dissection. He describes the concept of chest pain plus one. David delves into what he sees as the questions and considerations only a ‘master clinician’ will think of. He implores you to join this group.
Evidently, the physical exam provides vital clues to the diagnosis of aortic dissection.
In this talk, David breaks down the key points that he always considers in a busy and noisy Emergency Department to lead him towards the correct diagnosis.
Next is the diagnostics, where David will spend some time sharing his insights into the diagnostic tests of choice when ruling in or out an aortic dissection.
He discusses the plain x-ray which may or may not be useful, troponin, which need to be interpreted with care and d-dimer.
Finally, David concludes by giving some pearls surrounding the judicious use of imaging, how to begin the treatment promptly and how to become a champion in the diagnosis of aortic dissection.
Sit back and be ready to see dissections in a different light.
How Not To Miss Aortic Dissections: David Carr
For more like this, head to our podcast page. #CodaPodcast
This talk will look at current and previous pre oxygenation practices and some of the current research. It will also discuss the notion of commitment to evolution of practice, the breakdown of cognitive biases and how to move forward with adequate self reflected practice.
Peter Brindley explains why teamwork is the strongest drug in the hospital. Modern acute care medicine is eye-wateringly complex and potentially dangerous. It really can’t be delivered safely without deliberately addressing our teamwork (in both acute and chronic situations). Unfortunately, historically, human factors were commonly left to chance, and recently have been threatened by decerebrate checklists and meaningless ‘psychobabble’. Peter describes communication and its critical role in the effectiveness of any team. He compares the voice of a team leader to a drug. Like a drug, it can be a placebo or a nocebo, depending on its use. As such you must use the right drug at the right dose for the right patient and the right time! Moreover, other forms of communication play an integral part of any team environment. Peter discusses verbal, paraverbal, non-verbal and other forms of communication which all need attention. Rudeness, and its damaging potential is highlighted. Peter contends that rudeness alone will decrease both team and individual performance, impair diagnosis and impede procedures. Peter puts his message in to real world examples. Specifically, Peter discusses the management of airways – especially difficult airways whether that be anatomical, physiological or situation difficulties. In cases such as these, it is the clinician’s job to be understood when they communicate. Practical strategies to improve communication and teamwork exist and Peter highlights these in this talk. We have much to learn but must also avoid overly simple answers to exceedingly complex problems. It’s time to get back to basics. Come be part of a practical revolution and resuscitate by voice.
For more like this, head to our podcast page. #CodaPodcast
Richard will cover the rationale and evidence for prehospital blood product transfusion in trauma, look at the available current and future options, suggest best clinical practice and highlight areas of future research.
William Knight presents the considerations in the management of extra-cranial injuries in patients with traumatic brain injuries (TBI).
Patients with TBI often have concomitant systemic injuries that complicate the management of the TBI.
In this talk William presents his five top areas to think about – prognostication, suitability for the operating room, use of ventilators, pressure considerations and monitoring.
Prognostication becomes difficult when a brain injury is added to other injuries due to the long-term nature of neurological damage. This means that other clinicians can be unsure when managing extra-cranial injuries in such patients.
Adding a brain injury on top of other injuries tends to make people unsure, and enhances nihilism.
Intensivists in the neurological ICU tend to be very protective of their TBI patients. However, some simple measures and tests can go a long way to reassuring the treating team of a patient’s suitability for the operating room.
William describes the ‘lay flat test’, which is as simple as it sounds – laying a patient flat and observing the ICP. If it rises, then they are likely not appropriate. One must also consider the urgency of the proposed procedures.
William describes the ventilator as the single most lethal piece of equipment for a patient with a brain injury. The use of ventilators needs to be done appropriately and William describes the parameters to consider. Pressure is a broad category.
There are more acronyms than you can poke a stick at. William tries to make sense of them for you as he describes how he manages pressures in the TBI patient complicated by systemic injuries.
He makes the point that you need to remember other places of elevated pressure in the multi-trauma patients outside of the lungs and the brain. Consider your compartments including in the legs, arms, and abdomen.
Evidently, monitors do not save people; the use of monitors do. What does all the data mean, how do you monitor in the neuro ICU and how do you deal with contradicting data points. Using the data and taking in the whole picture in the TBI patient with extra-cranial injuries is complex.
Join William Knight as he attempts to make sense of this complex area of medicine!
Finally, for more like this, head to our podcast page. #CodaPodcast
Kieran Henry gives his insights into hospital handovers of major trauma.
He makes the comparison between prehospital care and the life lived in a Western movie.
Kieran stresses that he does not want you to behave like a cowboy, jumping off your horse (ambulance) as it is still moving into town, without much dialogue and with no one really knowing what is happening.
Instead, be the preacher man! Be cool, concise, and clear in your messaging. Prepare, practice and be professional.
Much like the preacher man, you will be listened to if this is how you carry yourself. You will then be able to convert the non-believers.
Delivering the handover message effectively and efficiently is crucial.
Tune in to Kieran to learn how to convert the non-believers into believers and do good patient handovers.
Hospital Handover of Major Trauma: Kieran Henry
For more like this, head to our podcast page. #CodaPodcast
Jo Anna Leuck discusses how to learn from error in paediatric sepsis.
Rory was a healthy 12-year-old boy, known for his smile and for standing up for others. A simple fall during basketball practice caused an abrasion on his arm. This is the suspected beginning of a cascade of events that led to his death from sepsis.
Rory was seen by both his paediatrician and a local Emergency Department and was sent home with a diagnosis of a viral illness.
He returned the next day in septic shock and died shortly thereafter. A review of the medical records revealed that there were errors that occurred during his emergency department visit.
This talk will attempt to move away from the controversy of the actual article and instead focus on how these common errors could have occurred during any busy shift and what we can do to prevent them in the future.
Jo Anna’s intention in giving this talk is to continue to use this case to raise awareness of both paediatric sepsis and common medical error.
When considering paediatric sepsis Jo Anna asks - Was this preventable? Were there clues? Why was this missed?
Jo Anna discusses what we can we do better. Recognition is the first step. Often procedures are used in this case. The Paediatric Sepsis Score is one such example.
Jo Anna talks about vital signs and how they are tricky in kids due to the changing reference ranges depending on age. Jo Anna recommends having easily accessed charts and stresses thinking twice about the size and age of the child in front of you.
The physical exam is as important as always. In kids, there are certain signs that should raise suspicion such as skin mottling. And in terms of treatment Jo Anna stresses rapid access, rapid fluid boluses and thorough re-evaluation alongside age-appropriate empirical antibiotics.
Lastly, Jo Anne touches on the errors that this case highlights. She provides some strategies to improve your practice.
Before discharge consider three main components. Vital signs, diagnostic studies, and communication!
Simple, but careful attention to these components of care will lead to the medical profession learning from errors and preventing them in the future.
For more like this, head to our podcast page. #CodaPodcast
Simon Finfer explains the future of sepsis treatment focusing on life after surviving sepsis.
Sepsis is the life-threatening condition that arises when the body’s response to an infection damages its own tissues and organs. It can lead to shock, failure of multiple organs, and death.
Organ failure and death are more likely if sepsis is not recognised early and not treated promptly.
Sepsis is the leading cause of death from infection around the world and contributes to or causes half of all deaths occurring in hospitals in the USA. Many people who survive severe sepsis recover completely and their lives return to normal.
But some people, especially those who had pre-existing chronic diseases, may experience permanent organ damage, the common problems that afflict those who have recovered from sepsis have been termed the post-sepsis syndrome.
Longer term effects of sepsis are extensive. They include sleep disturbance including insomnia and nightmares. People experiences hallucinations, flashbacks and panic attacks. Muscle and joint pain occur, which can be severe and disabling.
Similarly, functional impairments such as extreme tiredness and fatigue, inability to concentrate and impaired cognition occur. These effects even extend to a loss of confidence and self-belief.
The global medical community has improved sepsis survival. Because of that, Simon contends that all these long-term effects of sepsis must be paid attention. The current trials overwhelmingly look at survival.
The future of research therefore should include post-sepsis outcomes. For instance, Simon asks the question – are these long-term effects due to sepsis, or rather, are they due to being in the ICU.
Simon discusses the future of sepsis care. Specifically, he discusses the idea of post-sepsis care and follow up.
Much like there is respiratory follow up following an acute episode of respiratory disease, Simon believes there needs to be dedicated care for sepsis survivors.
As he explains, the acute treatment of sepsis is the beginning of the road.
For more like this, head to our podcast page. #CodaPodcast
Alistair Nichol explains the use of hypothermia in the treatment of traumatic brain injury (TBI).
TBI is a major cause of mortality and long-term morbidity. It leads to terrible outcomes and is a major cause of health burden across the globe.
Prophylactic hypothermia presents a promising treatment to address this hidden epidemic. The pathophysiology of TBI is exceedingly complex.
Evidently, one drug will likely not be the answer. This leads Alistair to discuss hypothermia as a treatment for TBI, which has huge potential benefit.
As Alistair explains, it acts in many different places, in many ways, across many time periods. Could this be the ‘drug’ to give?
The questions then become, when should you give it, how should you give it and how low should you aim?
Alistair recommends inducing hypothermia as early as humanly possible. In the case of TBI, this means at the roadside if practical. How low should you go?
Given the effect of hypothermia on coagulation, and the propensity for trauma patients to bleed, this is a tricky question. Alistair states that 32 degrees is ideal however this leads to further haematological complications.
To that end, 35 degrees is a sensible aim, to then go lower once bleeding has been excluded in the Emergency Department.
How do you do it? Ice is unfavourable, given the difficulty of controlling the temperature and the adverse effects including ice burns. Alistair also warns against the use of ice cold saline due to the effects of positive fluid balances in TBI patients.
Alistair explains the current methods, such as surface cooling pads and intravascular cooling catheters. It is not a risk-free treatment. Risk of infection rises due to effects on cellular processes. Propofol-related Infusion Syndrome (PRIS) is also being increasingly recognised as an adverse outcome.
Finally, the re-warming following hypothermia is risky. Alistair explains the complex process of re-warming.
Alistair concludes by explaining the current trials underway and the potential future for this treatment.
For more like this, head to our podcast page. #CodaPodcast
Ryan Radecki urges you to rethink the acute management of stroke.
The current way of thinking about stroke and the acute treatment has been around for decades. In this time, a lot has changed, new technologies have been developed and we have learnt a lot about the underlying physiology of stroke.
Endovascular therapy, CT perfusion, and patient-level predictive modelling are now all at the disposal of clinicians.
Moreover, Ryan wonders if we are using the current treatments – namely tPA – more safely or effectively. In acute stroke management there are two key factors to consider. Successful reperfusion and salvageable tissue.
To restore and save brain tissue one must successfully re-perfuse the tissue. The classic method for achieving this is by using tPA.
However, Ryan contends that this is akin to using a sledgehammer to fix a teacup. It is a dangerous drug, with many risks, and it is not appropriate for all patients. Salvageable tissue is the second key factor. If brain tissue is dead, it stays dead. It does not matter what drug you give.
Evaluating this tissue makes sense. To this end, Ryan believes that new technologies can be better utilised. As he sees it, some of the new advances in stroke care do not recognise the underlying pathophysiology of the problem. They just deliver pre-historic care, faster.
Further, he argues that the new advances do not individualise care. So, what should be done? Ryan explains that perfusion imaging makes sense, as every patient has unique cerebrovascular anatomy.
The goal should not be to give more patients tPA but to give it to patients who have the best risk-benefit ratio. He argues against expanding the treatment population for tPA against rational judgement.
Moreover, the goal should be to tailor evaluation to identify the patients that will benefit from this intervention and to identify patients who should be put onto a different pathway. Aim to individualise care with the available technology and investigations.
Finally, Ryan discusses the clinical trials underway, which may produce zero, subtle, or huge changes in practice.
For more like this, head to our podcast page. #CodaPodcast
In this entertaining talk, Ronan O’Leary discusses conflict in critical care.
Ronan explains how to make a team decision about whether or not to perform a decompressive craniectomy.
Undertaking a decompressive craniectomy is perhaps one of the most challenging decisions we face within critical care.
Ronan contends that we do not know if we should do the operation. As he explains, even if we think we should do it, we don’t know when, or even how.
Perhaps more importantly, intensivists do not perform the operation, the neurosurgeons do. However, we frequently put them in the position of doing the operation when we are at our wits end. Alternatively, they do the operation without asking us when we still feel we have space to play.
Ronan poses the question - how can we resolve this, in a workplace environment which is already fraught with competing interests, beliefs, values and approaches?
Evidence based medicine is not going to provide an answer soon and it is unlikely that a superficial approach to improving teamwork will either.
An important component will be the future structure of clinical training. Our current systems reflect the way hospitals worked decades ago and the specialties we now have exist almost independently of the training which leads to consultant posts.
Ronan posits that training should involve exposure to collegiate decision making and consensus building.
However, this will be difficult to achieve within our current nationally co-ordinated training schemes.
How to manage conflict in Critical Care: Ronan O’Leary
Finally, for more like this head to our podcast page. #CodaPodcast
Martin Smith persuades you that controversies in brain death should not, and do not, exist.
Almost fifty years since the concept of brain death was first introduced, some individuals and whole nations still struggle with its concept and justification.
Many controversies continue to surround brain death, although there is broad consensus that human death is ultimately death of the brain.
Martin provides a history of the concept of brain death. He describes how advances in modern medicine have made the concept of death, and specifically brain death, muddled. This has broad implications on the diagnosis of brain death – and provides the basis to the controversies that exist.
The concept of death as a process is explored. The idea, and in fact the truth, is that death does not happen at a discrete moment in time.
Alive or dead may be the only two states an organism can be in. However, the transition from one to the other is not instantaneous.
Martin contends that the process and the nomenclature has little practical relevance. What is important is the point of irreversibility.
He explains how we, as a medical community, can be confident of this point.
The main points are 1) fulfilment of essential preconditions, 2) exclusions of reversible causes and 3) clinical evaluation.
In his talk Martin elaborates on each and provides some important teaching points. As he explains, this is an important concept to grasp as it has implications for your patients as well as broader societal implications in the context of organ donation.
Martin’s talk will discuss the history and development of the concepts and diagnosis of brain death internationally. He examines current challenges and controversies and makes the case for an international consensus.
For more like this, head to our podcast page. #CodaPodcast
Hazel Talbot gives her insights from working in neonatal and paediatric retrieval.
She delivers her talk with all the passion and dedication that she brings to her work as a neonatal and paediatric transport consultant.
Equipment failure, rapidly deteriorating children and miscommunication are all common challenges that Hazel and her team encounter in their line of work. This is on top of the challenge of caring for neonates and children.
How are children different? They differ in physiology, in disease profiles and even the way they make clinicians feel! In this talk, Hazel focuses on physiology and disease. The large majority of young deaths in the UK, where Hazel works, are neonates – under 28 days old.
50% of these deaths are due to perinatal diseases. These include congenital malformations, prematurity, sepsis, and congenital heart conditions.
Children are small adults. Small airways, small necks, small lungs. Babies however are not small children. They use the majority of their physiological ability to survive.
When they breath they use most of their diaphragm, compared with an adult who will only use a small proportion. This leaves babies without much reserve. They have a high metabolic rate, and neonates have a right heart dominance with an inability to change their stroke volume.
Hazel urges you to consider this when faced with a sick baby. When thinking about neonatal and paediatric retrieval, Hazel has some key points. Practice, anticipation and knowing your environment and equipment is key to a success outcome.
Hazel drives this message home with a case presentation. This example highlights not only Hazel’s skill and knowledge, but also her ability of communication, leadership, and intuition.
Join Hazel as she gives an insight into her amazing work in neonatal and paediatric retrieval. Come along as she discusses her experiences and tells you how to ward of the Evil Transport Fairy!
For more like this, head to our podcast page. #CodaPodcast
Simon Finfer argues that the transfusion threshold should be 70 g/L. Simon first raises the Choosing Wisely Guidelines for Critical Care.
These state that one should not transfuse red blood cells in haemodynamically stable patients with a haemoglobin concentration of greater than 70g/L.
He continues to discuss the application of this specifically to patients with an acute brain injury. In doing so he will talk about evidence generally and how one must approach the use of evidence in specific patient subgroups.
Simon continues by raising further research to justify his position.
Oli Flower on the other hand will take the position that the transfusion trigger should be 90g/L. He makes the point that this is the easy position to take. Essentially, he is just explaining why the critical care community does what it does!
As Oli explains, haemoglobin plays a pivotal role in providing oxygen to tissue. In the case of a brain injury, to prevent further injury, one must ensure continued supply of oxygen to said tissue.
Oli will lean on animal studies, human studies as well as trial data to support his position. The transfusion trigger is remarkable heterogeneous around the world and even within individual institutions and this drives critical care professionals mad.
So surely there must be a “right” number. Unfortunately, there is not, which is where understanding all the relevant aspects to the argument becomes important.
Join Oli and Simon as they debate on this important issue.
When to Transfuse in Acute Brain Injury: Oli Flower & Simon Finfer
For more like this, head to our podcast page. #CodaPodcast
Myths persist because they are essential to the human experience and our development as a society.
They fill the gap between what we know and what we think we know.
Where does this gap hurt us the most? In our vulnerable populations, for example, in our care of children.
The “myth incarnate” in medicine: defective dogma. Not all dogma is bad – after all, dogma means “that which is believed universally to be true”. The problem with medical dogma is that our critical thought processes are curtailed by wholesale acceptance.
Medical dogma is a special kind of myth, because it’s difficult to define. We repeat defective dogma for three reasons:
“It is known”. Sometimes the dogma is all that is known on the subject, or it is simply the majority consensus. Be careful with this one – because there may be a reason for this specific teaching – not all dogma is bad.
Dogma is sentimental. We learned from our teachers who learned from their teachers. We want to honor those who taught us, and we get attached to some ideas. Sometimes – even subconsciously – we allow our attachment to an idea to give it more credence than it deserves.
The third driver of dogma is insecurity. “I know what I know”. In other words, “don’t make me reveal my limitations.”
Myth: “They’re all fine”
Remedy: Remember to look for the subtleties in children. Early warning signs are there, in the history or in the physical exam. If it doesn’t add up, investigate.
Myth: “Only pediatricians are experts”
Remedy: Don’t delegate decisions. You can do this. You sometimes are the only one that can.
Myth: “I will break them”
Remedy: Children are not another species. Use all of your skills for all of your patients”
Powered by #FOAMed – Tim Horeczko, MD, MSCR, FACEP, FAAP
Ffion Davies gives her take on how to spot the sick child in the Emergency Department.
Paediatric medicine is no doubt hard and can at times be scary. There is nothing worse, in Ffion’s opinion, than sending a child home who later represents to the hospital in a worse condition, or even worse, later dies.
So, how does one spot the sick child amongst the droves of children who will present with fever and vomiting.
In this talk, Ffion gives a lesson on how to spot the sick children in the ‘grey’ zone – those that are not clearly sick and not clearly well.
Ffion breaks her thinking into two main areas: physiology and psychology. Physiology matters. Scrutinising a full set of observations/vitals (in the context of the child’s age) will help avoid the feared crime of discharging a sick child.
Ffion discusses tachypnoea as a prime example of a simple physiological compensation to raise one’s suspicion of serious disease.
Similarly, psychology matters. Ffion talks in depth as to why she considers this to be true.
Talks on Paediatric Emergency Medicine are always popular because Emergency Medicine physicians are insecure about mismanaging a child. Are children precious? Are adults just big children? Therein lies the problem.
Less knowledge, less experience and perhaps less confidence. Compounding this is the complexities of having to deal with the stressed parents when you yourself are stressed because of the situation.
Ffion continues to talk about systems of thinking and decision making. She compares Type 1 thinking which is automatic and instinctive with Type 2 thinking, which is more considered. She explains the risks and benefits of relying more upon Type 2 thinking when considering the sick child in the Emergency Department.
Finally, Ffion concludes by talking about strategies to improve your own management of the paediatric population in the Emergency Department. She discusses improving your knowledge base, using resuscitation aids and checklists and training by using stress inoculation simulations.
For more like this, head to our podcast page. #CodaPodcast
In sub-Saharan Africa, where infectious diseases and nutritional deficiencies are common, severe anaemia is a common cause of paediatric hospital admission, yet the evidence to support current treatment recommendations is limited. The TRansfusion and TReatment of severe Anaemia in African Children: (TRACT ISRCTN84086586) is a 3x2x2 factorial controlled trial involving 3954 children (aged 2m to 12y) with severe anaemia (haemoglobin <6g/dl). The trial has been designed to address the poor outcomes following SA in children in sub-Saharan Africa, which is associated with high rates of in-hospital mortality (9-10%), 6-month case fatality (12%) and relapse or re-hospitalisation (6%) indicating that the current recommendations and/or management strategies are not working in practice. Hospitalised children will be enrolled at 4 centres in 2 countries (Malawi, Uganda) and followed for 6 months. TRACT trial is designed to answer 4 simple questions. Q1 and 2: which children should receive a transfusion (since current guidelines recommend transfusions only in children with a Hb <4g/dl (or <6g/dl if accompanied by complications)); and how volume to transfuse in each transfusion event?. Q3 and 4: Since the major factors related to poor longer term outcome are micronutrient deficiencies and sepsis would post-discharge multi-vitamin multi-mineral supplementation versus routine care (folate and iron) for 3 months and/or cotrimoxazole prophylaxis for 3 months versus no prophylaxis improve outcome and prevent relapse. Primary outcome is cumulative mortality to 4 weeks for the transfusion strategy comparisons, and to 6 months for the nutritional support/antibiotic prophylaxis comparisons.
If confirmed by the trial, a cheap and widely available ‘bundle’ of effective interventions could lead to, if widely implemented, substantial reductions in mortality in African children hospitalised with severe anaemia every year. The trial started in Sept 2014 and currently 2700 children have been enrolled. We expect the trial results to be available in 2017.
Alex Psirides discusses the problem with major hospitals and the systems that they use.
Throughout he uses a case example to highlight how and why things go wrong. Moreover, he suggests potential strategies to reframe the way care is provided in the hospital system.
As patients become more complex, the tribal systems we use to look after them remain stuck in the 18th Century. Back when the treatment for everything was amputation and, if you survived, leeches.
The large modern hospital is becoming a battleground of competing specialises, only concerned with their area of expertise. This leads to multiple single organ teams practising their art in a multi-organ (failure) world.
Many staff lack acute medical skills. Expertise is found far away from the ward in Emergency Departments, operating theatres, and ICUs.
Despite disease not knowing or caring what time it is, all hospitals operate with minimal nocturnal on-site expertise. As nursing & medical staff move more towards rotating rosters where no-one knows more than a single-sentence summary of their patient’s complex physiological, pathological & pharmacological needs, an ever-present vigilant family member may become the only hope of surviving any acute admission.
Compounding these issues is the medial education system that is not keeping up with what happens with patients. Advances in medical care and technology mean that patients who would have been cared for in the ICU 30 years ago are now being looked after on the wards by junior doctors with little training or experience in critical care.
Unfortunately, junior doctors often call for help when it is too late.
Join in to listen to a self-professed middle-aged intensivist rant about how things were so much better ‘back in the day.’
For more like this, head to our podcast page. #CodaPodcast
Anthony Baca provides a focused talk on prehospital critical care response to the active shooter.
Coming from the United States of America setting this is unfortunately not a rare occurrence.
Anthony will discuss the real-world violence that exists, and what are the most important considerations for first responders in such situations.
Anthony speaks about prehospital critical care team responses to mass shootings. He explores how emotional and physiological barriers run amok making the simplest logistical and clinical decisions extremely difficult.
Moreover, Anthony provides real world advice should you ever find yourself called to a scene with an active shooter. This includes the importance of staying “left of bang”, incident recognition, initial confusion, and the critical nature of incident acceptance.
Further, he reviews staff and patient safety priorities and basic concepts of tactical combat casualty care (TCCC).
Finally, Anthony concludes with thoughts about your role as care provider when on duty as part of a pre-formed team, and what to do if off duty facing an active shooter.
Today is the day to ponder actions you must take the moment an active shooter begins taking lives at an astonishing rate; that moment when the choices you make next will be the most important of your career.
The choices you make today will affect the milliseconds and millimetres that determine survival… patient survival, your survival, and the survival of those waiting at home for you to walk back through the door.
For more like this, head to our podcast page. #CodaPodcast
Scott Weingart discusses post-intubation sedation – a topic that tends to aggrieve him on a regular basis.
Scott explains in simple terms why he is bemused at the lack of understanding surrounding intubated patients who become agitated or aggressive.
How would you like a piece of plastic placed down your throat?
The problem, as Scott explains, is that sedation does not blunt pain. Sedation without analgesia leads to delirium.
In simple terms delirium leads to poor outcomes and death.
Moreover, concerningly, the early sedation strategy of intubated patients has long term and far-reaching outcomes during their course of critical illness.
So, what can be done? Scott explains that we need patients properly sedated, however not too deeply sedated.
The goal needs to be a patient who is oriented, safe and with a normal sleep-wake cycle. Paralysis is not the answer. What is the answer?
Scott walks you through A1 sedation – meaning analgesia first. Once pain is controlled, then sedation comes in to play.
Scott stresses with analgesia first, the sedation needed is less. He explains how he achieves this in practice in detail. He then provides some clinical examples and how he would approach them including which specific medications he uses in practice.
Scott’s main points are simple. Control the pain and very few patients will need a lot of sedation.
In addition, if you adequately control the pain, very few patients will have delirium in the Emergency Department.
Join Scott as he passionately discusses post-intubation sedation.
For more like this, head to our podcast page. #CodaPodcast
Katrin Hruska discusses the usefulness of biomarkers in Emergency Medicine.
All biomarkers are awesome predictors of badness. Elevated hS-troponins after non-cardiac surgery or an acute exacerbation of COPD are associated with increased mortality.
In seemingly healthy people, elevated D-dimer levels are associated with increased mortality. Similarly, NT-proBNP levels predict mortality in patients with end-stage renal disease.
A biomarker, in its broadest sense, is defined as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention” (NIH Biomarkers Definitions Working group, 2001).
This definition includes everything from laboratory tests to blood pressure measurements or an ultrasound scan. The clinical assessment in the Emergency Department is based on the subjective history of the patient and all available biomarkers (and their change over time).
If we assume that biomarkers are objectively measured, there is an overestimation of their individual importance.
As Katrin explains, over testing and over diagnosis have serious consequences. Not only for patients but also for the healthcare system. In a clinical context the ease of getting a laboratory test leads to a lower threshold for testing. This increases testing without affecting relevant clinical endpoints. Also, when a biomarker becomes part of the standardised workup for a certain symptom, primary care centres and emergency telephone services will refer patients to the Emergency Department for testing, even when the pretest probability is low.
Katrin contends this bias is not an inherent problem of biomarkers themselves, but of the decision-making process of clinicians. The human brain fears uncertainty. Anything that adds to the feeling of knowing is rewarding, which is the most probable explanation of over testing in settings where medico-legal risks for the clinicians are low.
There is an ever-increasing number of patients seeking to rule out serious conditions by relying on biomarker testing to provide certainty.
Finally, for more like this, head to our podcast page. #CodaPodcast
Chris Hicks delves in to how to optimise performance in a team environment in emergency medicine and critical care. When teams fail and fall apart, we are quick to analyse the performance. We pick it apart and see what went wrong, and why. Chris suggests that we should do the same thing for over-performing teams. We should analyse how and why they perform at optimum levels. In doing this, in reaching a higher understanding of elite performance, we can harness the techniques used, simulate and train them, and thus improve performance across the board. This is not a new concept. High performance in elite sport is driven by athletes searching to push themselves in new and more extreme ways during training. They do this so when they are faced with stressful situations in competition, they have seen it all before. High performers talk about being ‘in the zone’. This is a state of body and mind where optimum performance comes naturally and easily. Research suggests that when an individual is ‘in the zone’, areas of the brain go quiet. Your ego and your inner critic dampen down. Other more useful and helpful areas light up. These tend to be deeper areas and are related to information processing and linkage between ideas. They often are drawing on prior experiences. These are less conscious processes. Chris contends that conscious thought is expensive and time consuming and by tapping into this ‘flow’ state, you optimise performance. Chris then discusses how to utilise this research and methods used in other industries. He brings the lessons that are apparent from outside sources and describes how these can be implemented in medical training and simulation. He describes a method to play with perceptions. Rather than seeing situations as threatening, Chris highlights the benefits of embracing them as challenging – an opportunity to demonstrate elite performance. Further, he discusses a three-step process to practically implement the lessons he is talking about. So to improve performance whilst working in teams in emergency and critical care medicine, listen in to Chris Hicks discuss all things high performance.
For more like this, head to codachange.org/podcasts/
Adrian Plunkett describes how to learn from excellence in critical care. Learning from excellence is an initiative which began at Birmingham Children’s Hospital. Firstly, Adrian shares an anecdote regarding how the initiative begun. He sent a letter to the CEO of a hospital appreciating one of the doctors who treated him for cancer. The doctor unfortunately never received it. This caused Adrian to ask - is appreciation and gratitude undervalued? Evidently, noticing excellence will lead to two things: learning new insights and increasing staff morale. Adrian raises the question, why we do we not focus on the good things? We spend all our time improving safety and quality even though accidents and disasters are only a small percentage of what we do. Moreover, Adrian claims that people inherently have negative biases. This is evident in healthcare, so how can we combat this? The solution is to focus on excellent care. This led to the formation of a reporting system called Learning from Excellence (LfE), where people answer two questions: Who did something excellent? What did they do? LfE is a formal system for reporting and providing positive feedback and appreciation to the healthcare workers. It is a beneficial and constructive way of learning from excellence. Finally, Adrian explains, “Saying ‘thank you’ or ‘well done’ is the easiest quality improvement intervention of all.”
For more like this head to our podcast page. #CodaPodcast
Jo Anna Leuck discusses fatigue in critical care.
Is there a specific time during our shift when we are too fatigued to safely practice?
That was the question that led to Jo Anna’s research project comparing the clinical performance of providers during the first hour of a day shift and the final hour of a string of night shifts.
The providers were pulled out of their real-time clinical duties and video-taped while performing simulated critical care cases.
The hypothesis was that the day shift providers would out-perform the night shift, but surprisingly the opposite proved true. Blinded reviewers assigned the day shift providers lower performance scores. Furthermore, they noticed some surprising medical errors committed during these simulated cases.
Jo Anna examines how performance is impacted by practise, or lack thereof. She raises examples such as coming in to work after a few days off, or after an extended break and posits that performance will be negatively affected in these circumstances.
Perhaps clinicians, similar to others who are elite in their field, truly need daily practice or some type of deliberate exercise prior to a shift to perform at the highest levels of care.
How can we determine when we are not at our maximum level of mental sharpness during a shift?
Can we improve our abilities in real time?
Jo Anna concludes by suggesting some strategies to counteract these drops in performance. Allowing more time to get to work to reduce cognitive load, utilising mental rehearsal and taking advantage of checklists are all explored.
In this talk, Jo Anna discusses mental fatigue and critical care-based shift work. She focuses on techniques to recognise and potentially mitigate any clinical sluggishness and improve patient care.
For more like this, head to our podcast page. #CodaPodcast
Karin Amrein talks about the challenges for women working in the critical care world.
Incredibly, despite female prevalence, Critical Care is considered a man’s world.
We've all heard the notion, “big boys with big toys.” The false assumption is that men are more interested in the latest equipment and technology. However, Karin thinks that the “soft factors” like love, care and teamwork are what will make the biggest difference in the future.
Moreover, women are judged by their appearance and not their accomplishments. They are subject to questions like “Are you really a doctor?” or comments like “But you don’t look like a professor.”
Patients and their families are often insecure when a woman oversees their treatment.
Tragically, women are lost on their way to the top, captured by the “Glass ceiling.” One review showed that women have to be 2.5 times more productive to be given the same score in peer review. Another study showed that papers received better reviews when authored by a man.
Karin presents statistics regarding women in critical care with 31% of ICU trainees and 21% of ICU consultants being women. However, only 7% of the ICU editorial board members were women which was the lowest among all other departments.
Some things can be easily fixed, such as ensuring female speakers are on conference panels. She applauds SMAAC for having an equal distribution of male and female speakers, participants and organisers.
Karin encourages everyone to ask themselves the question “What would you do if you were not afraid?” and to do that without worrying about the consequences. Critical care is in fact, a great place for women.
For more like this, head to our podcast page. #CodaPodcast
Ashley Liebig is a senior flight nurse and helicopter rescue specialist with STAR Flight.
She talks with passion about her job, her vocation.
Ashley divulges a deeply personal and deeply traumatic story from the SMACC stage.
Pre-hospital medicine, emergency medicine and critical care are difficult jobs. There is a human toll to be paid when working in these areas.
Ashley wonders if the stress, the emotion and the trauma torments all listeners. She believes it does not matter. Because it affects some. And it has affected Ashley.
Ashley implores you to be nice. She wants her colleagues to understand her, communicate with her, and respect her.
She explores the physiological maladaptive response when humans experience trauma and relates this to her experience.
Ashley goes on to share how she has, and is, dealing with the chronic stress she is experiencing. It involved adaptation and behaviour changes.
She educated herself on the effects of chronic stress and engaged strategies such as exercise, laughter, and human touch to counteract these. She engaged in communication with her family, so they were aware of what she needed.
Moreover, she started having more honest conversations with her colleagues.
Through her brave relaying of her own experience, Ashley wants to convey the importance of being aware of chronic stress, recognising it in oneself and others, and continue to strive to face it and deal with it together.
Dealing with Chronic Stress in Critical Care
For more like this, head to our podcast page. #CodaPodcast
Nikki Blackwell provides an insight into critical care in humanitarian emergencies.
Through her experiences in hunger emergencies, epidemics, natural disasters and conflict zones, Nikki has gained a wealth of wisdom and lessons.
She shares these from the SMACC stage.
Nikki talks about some of the practical things she does when working in resource poor settings. It starts with hospital hygiene to reduce nosocomial infections, and often entails Nikki working alongside the cleaners due to resource limitations.
Hand hygiene is difficult without running water and Nikki champions using the WHO Handrub Formulation.
Other challenges include cold chain storage, blood donations, limited monitoring and food and nutrition.
Nikki also discusses the challenges of working in different environments. Invariable the environment will be too hot… or too cold!
On top of this, working in remote locations often entails living with the other medical professionals you are working alongside. This presents interpersonal challenges.
Moreover, Nikki touches on the personal dangers of working in some of the more politically unstable locations around the world. Training becomes hugely important in resource poor settings when you are dealing with complex medical and surgical cases. Especially with less-than-ideal resources and equipment.
Nikki expands on what is possible with good training, intuition, and a Swiss army knife. If you do not do anything stupid, and you have basic resources backed up by sound training, it is amazing what you can achieve and who you can help.
She concludes by touching the future direction of care in resource poor settings highlight the potential for technology to make huge changes and advances.
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Finally, for more like this, head to our podcast page. #CodaPodcast
Kathryn Maitland describes the challenges faced with oxygen therapy as an emergency intervention in critical illness in African children.
Where Kathryn works, in East Africa, there is no access to intensive care. Caring for critically ill children is all done in the Emergency Department.
70% of the global burden of disease and deaths from pneumonia occurs in Southeast Asia and Sub-Saharan Africa. The WHO has published guidelines as to what classifies as pneumonia, severe pneumonia, and very severe pneumonia.
These classifications rely on clinical signs. However, Kathryn in her research has discovered that these classifications are rarely correlated with the actual underlying disease process.
Clinical signs are non-specific for the diagnosis of pneumonia. Oxygen is recommended for severe and very severe pneumonia.
This has led to calls to prioritise oxygen delivery in African hospitals. However, it has not led to change from a health department or funding viewpoint.
There are also oxygen delivery practicalities to consider. Often there is only one source of oxygen on a ward (if at all) with patients clustered around it.
The production of Oxygen may only happen in a few places. Poor cylinder quality leads to leaks and therefore, low supply.
Concentrators are useful however they need regular servicing. They also rely on power, and in a region that experiences regular power outages, this can be problematic. When the power goes off, there is no oxygen available.
Kathryn asks – do all children actually need oxygen? There is still however a hidden burden of hypoxia.
Outside of Africa, Kathryn discusses the current state of equipoise on oxygen therapy.
Moreover, oxygen can be harmful if given inappropriately. This leads to concerns more broadly on the harms of oxygen therapy.
Kathryn concludes her talk by looking to the future. She discusses ongoing research and the implications for future practice in resource poor settings, and indeed the world.
For more like this, head to our podcast page. #CodaPodcast
Francesca Rubulotta argues in favour of the ICU being no place for the elderly.
She describes the ICU as a horrible monster, a very dangerous place. Furthermore, she suggests the ICU is on par with climbing a mountain in terms of risk and exposure to catastrophise.
She continues to make the point that once a person reaches adulthood, the healthcare system is a one size fits all model.
This extends to the type of treatment required – whether it be for an acute or chronic condition.
Whilst hospitals, and ICU specifically, may be suited to assist those with acute conditions, it is perhaps less appropriate to deal with chronic conditions that avail the elderly.
Francesca concludes that for the elderly, there needs to be a new model.
One reliable, dedicated to the older patient population and able to provide the dignity they deserve. Karin Amrein provides a counter argument. She bases this initially through a personal story of her grandmother. This provides the basis for her argument that advanced age does not predetermine outcomes in healthcare.
‘Elderly’ is a large spectrum and age alone is a poor individual determinate for health. At an individual level, age cannot tell one how a person will fare in the ICU, and it can be an appropriate setting for the right ‘elderly’ patient.
Karin contends that all patients are worthy of care in all settings depending on their personal context. Whilst with elderly patient one might consider conditions such as sarcopenia or dementia, this should not render them unworthy of care.
Karin suggests this is discrimination.
For Karin, age is just a number, and it is the person that should be treated – including in the ICU if appropriate.
Join Francesca Rubulotta and Karin Amrein as they debate whether ICU is a place for the elderly.
For more like this, head to our podcast page. #CodaPodcast
Darren Braude and Karim Brohi debate over the utility of hard cervical collars.
Darren argues that it is time to do away with hard cervical collars. He raises some assumptions.
The first being that movement of the spine is bad. As he explains, movement is not the problem.
Rather, energy deposition in the spine causes injury, not simply movement. With that being said, the problem is that the hard collar does not prevent movement!
Surely, the benefits of the hard collar outweigh the risks. Darren argues otherwise.
He discusses the effects of the hard collar on ICP and venous drainage of the brain. The issue here is that the patients with the highest risk of cervical injuries also carry the highest risk of concomitant brain injuries – and we as clinicians should not tolerate any increased risk to the brain.
Finally, Darren argues that the hard cervical collar impairs airway management which is the priority for any emergency situation.
Cervical collars are unlikely to help and can cause harm! Karim argues in favour of hard cervical collars. He contends that the lack of quality evidence in this field is problematic.
Furthermore, Karim believes it is easier to suggest harm than to prove harm.
Likewise, it is also easier to suggest harm than to prove benefit. With that being said, Karim concedes that some of the harm Darren raises are possible and can occur.
However, he states that no one recently has practiced medicine in a world without cervical collars. The improvements in spinal care therefore cannot be separated from the use of hard cervical collars.
He asks the question; do you want to mess with these improved outcomes?
Karim also points out, that patient complaints about spinal care are rarely about the cervical collar specifically. He goes on to discuss how to navigate patient concerns.
Tune in to this enthralling debate between Darren and Karim.
For more like this, head to our podcast page. #CodaPodcast
PRO:
Medicine is a complex craft. Acute medicine is more complex. Excellence is delivering effective acute care depends on recognising the broad base of basic sciences, clinical experience, and results of clinical trials. Central to all decisions has to be how these will benefit the patient – both in the short term as well and longer term so that survivors of acute illness are left with the best possible outcome for that patient, their caregivers and the community at large. This is a daunting concept under time-limited, information-limited conditions. Clinicians are often left with uncertainty about the impact of decisions and rely on short-term surrogate measurements to justify treatment options. Consequently, assessing outcomes are invariably confounded by associations that bear little relationship to causation or biological plausibility. Such confounders are often demonstrated in observational studies and RCTs with low levels of internal validity, particularly those conducted in single centres and/or driven by protagonists of a particular intervention. Carefully conducted RCTs with high levels of internal validity – those that produce believable results from rigorous study design and those that produce results that are generalisble to specific patient populations remain the only way to mitigate bias and produce clinically-relevant answers to improve patient-centred outcomes. Critical Care Medicine leads the way in producing high-fidelity RCTs that have fundamentally changed clinical practice, not only in terms of producing better patient-centred outcomes, but also by producing unequivocal evidence to stop or avoid using of previously harmful treatments that had been enthusiastically embraced by clinicians and guideline developers. Such examples of benefit include the CRASH-2 and ARDS-net trials, and of preventing harm, the SAFE, NICE-SUGAR, RENAL, CHEST, DECRA and FEAST studies among others. The net impact of these pivotal trials has been the prevention of millions of deaths and the saving of millions of dollars. Such is the basis of GOOD clinical practice and these trials must be seen as a source of knowledge, science and pride … that ultimately improve patient outcomes .
CON:
This speaker is pretty certain he is going to lose...but he's going to go down fighting. He will argue against the mighty Dr John Myberg (whom, incidentally, he admires mightily). RCTs do certainly matter, but clinical judgment and prompt bedside attention matters far more. Moreover, RCTs so often fail to address the questions that really matter. RCTs also commonly fail to improve quality, effectiveness, safety, and reliability in modern complex acute medical care. A vote against the blinkered focus on RCTs is a vote for better (not biased) patient care. Myberg and his myopics must be defeated...come join me!
Martin Smith and Mark Wilson debate whether neurocritical care improves outcomes in severe TBI.
Martin argues in favour of neurocritical care. He concedes that longstanding and established practices are not as efficacious or innocuous as previously believed.
Very few specific interventions have been shown to improve outcomes in large randomised controlled trials. With the possible exception of avoidance of hypotension and hypoxaemia, most are based on analysis of physiology and pathophysiology.
Further, the substantial temporal and regional pathophysiological heterogeneity after TBI means that some interventions may be ineffective, unnecessary, or even harmful in certain patients at certain times.
Martin however, contends that improved understanding of pathophysiology and advances in neuromonitoring and imaging techniques have led to more effective and individualised treatment strategies. Ultimately, this has led to improved outcomes for patients.
In particular, the sole goal of identifying and treating intracranial hypertension has been superseded by a focus on the prevention of secondary brain insults. This is done by using a systematic, stepwise approach to maintenance of adequate cerebral perfusion and oxygenation.
Similarly, multimodal neuromonitoring also gives clinicians confidence to withhold potentially dangerous therapy. Particuarly in those with no evidence of brain ischemia/hypoxia or metabolic disturbance.
Mark Wilson on the other hand argues there is no benefit in neurocritical care following severe TBI. The New England Journal of Medicine has published several articles that demonstrate no benefit from classic neurotrauma interventions (ICP monitoring, cooling, decompression). This is because factors such as ICP and CPP associate with bad outcomes by association rather than causation.
This debate will demonstrate that critical care just complicates things. Evidently, it is high time for the randomised trial between the very best neurocritical care and NOB therapy (Naso-pharyngeal, Oxygen and a Blanket).
Join Martin and Mark as they discuss the pros and cons of neurocritical care in the management of severe TBI.
For more like this, head to our podcast page. #CodaPodcast
Anthony Holley and Marietjie ‘MJ’ Slabbert debate the value of prehospital doctors in trauma.
Anthony argues that doctors in the prehospital setting add little value. He does so with the upmost respect for prehospital doctors and having worked in this setting himself. He makes the point that across the globe, the employment of doctors in the prehospital setting is a rarity.
Working in this environment is diverse and every situation encountered requires a different skillset. This presents a logistical challenge.
Anthony continues to discuss the evidence, or lack thereof, in this space. He raises the point of competing interests from paramedics, flight nurses and doctors themselves.
This leads to apples being compared to oranges most of the time.
Anthony goes on to suggest all the advanced clinical interventions that are necessary in prehospital situations can be competently undertaken by paramedics.
MJ argues for the negative. In doing so, she concedes that the evidence base for prehospital medicine is scarce.
This is due to inherent biases, the difficulty of gathering data and the issues with methodology. However, MJ believes that care provided outside of the hospital should be of the same level as care received in hospital.
This provides a seamless patient journey from the prehospital setting into the hospital and improving the chain of survival.
Furthermore, MJ posits that prehospital doctors not only improve care of patients outside of the hospital, but care for those in the hospital and clinics too.
Prehospital physicians add value wherever they practise. They bring leadership, knowledge, additional skills, and training as well as innovation and collaboration.
Tune in as Anthony and MJ debate over the value of prehospital doctors in trauma.
For more like this, head to our podcast page. #CodaPodcast
Resuscitation of the critically ill trauma patient involves a myriad of high-stakes, time-sensitive management decisions. The landscape is shifting rapidly: new evidence on hemostatic resuscitation and component therapy in hemorrhagic shock, peri-arrest point-of-care ultrasound, novel approaches to resuscitative thoracotomy and trauma RSI have at once clarified and muddied the waters. In this rapid-fire, case-based session, Petro and Hicks will debate some of the recent and potentially practice changing literature to assist with key inflection points in the care of the sickest -- and sometimes deadest -- trauma patients, and engage in some trauma dogmalysis in the process.
Alex Psirides and Sara Gray debate over whether ‘Do Not Resuscitate’ (DNR) should be the default choice for all patients. Alex contends that application of ‘CPR-for-all’ is the ultimate evidence drift. A treatment that is completely appropriate for dropping dead whilst running a marathon has almost no place in acute healthcare facilities where chronic irreversible complex co-morbidities abound. 90% of doctors would not choose CPR for themselves, yet 100% are trained in how to administer it to patients. Defaulting to ‘CPR-for-all’ removes a patients’ ability to provide informed consent for assault whilst they die from another disease. Remember – 2 weeks in ICU can spare you 5 minutes of difficult conversation. Sara on the other hand argues that DNR should not be the default position. Across the globe, patients are assumed to be full code to allow for prompt resuscitation, until code status can be discussed and clarified. There are numerous excellent reasons for this. Can you imagine if our systems decreed that DNR was the default? “Let’s not shock that VF, until we can clarify his code status.” Or, “let’s not resuscitate that child, after all, DNR is the default and her mother isn’t here yet!” Making DNR the default is not a good solution to ICU or hospital over-crowding. Let’s not mandate DNR, let’s mandate having reasonable code discussions early and often. Join Alex and Sara for a stimulating, engaging and entertaining debate!
For more like this, head to our podcast page. #CodaPodcast
In a 2 min rant about medical tribalism, Dr. van der Velde questions which medical specialty, if any, owns prehospital physician response. What is more important: skillset or specialty? Is there a role for tiers of physician response? Is there a future in a stand-alone specialty?
Marietjie (MJ) Slabbert describes the unseen enemy, fatigue in critical care medicine.
MJ does 24 hour shifts every other day with just three to four hours of sleep.
Though many would claim that this is more than enough, MJ thinks otherwise.
Physicians are killing themselves while trying to save others because fatigue kills. MJ points out that sleep is one of the basic necessities in Maslow's hierarchy of needs.
Fatigue often affects the go getters or type A personalities. Among doctors, the critical care and emergency doctors are at a higher risk of being fatigued.
MJ points out the dangers of being fatigued. Driving while tired is as dangerous as drunk driving or speeding. Fatigue also puts patients at risk as it increases medical errors and safety compromising behaviour. Studies show that the response time of anaesthetists increased twenty times when they were sleep deprived.
Fatigue is the number one problem faced by doctors and MJ wants us to wake up. Doctors are at a higher risk of getting cancer and this has led WHO to consider shift work as a carcinogen.
Sleep deprivation increases the risk of developing obesity, depression, compassion fatigue, diabetes, wrinkles due to collagen breakdown, heart attacks, strokes, arrhythmia and even early onset Alzheimer's. It makes people weak and angry as they become less capable of handling stress.
According to MJ, there is no one size fits all solution to dealing with fatigue. However, the first step is to acknowledge the problem and to change the "tough guy" medical culture.
Doctors have to realise that they are part of the human race and need to rest. Doctors must help themselves so as to help their patients better. Taking breaks must be acceptable.
MJ encourages taking naps during free times at work. She wonders if doctors ever notice if their team is tired. She asks if it is measures or if hospitals have fatigue policies.
MJ ends by asking everyone to fight the battle against fatigue by waking up and going to sleep.
For more like this, head to our podcast page. #CodaPodcast
James Tooley discusses the sheer terror that comes with the challenge of managing children in the pre-hospital environment.
As James explains, although many clinicians may think that they do not need to (or may not want to) think about the paediatric population, it is something that every clinician would do well to mentally prepare for.
James shows a video clip of a large-scale paediatric trauma and challenges you to consider being dispatched to the scene. How do you prepare for that?
Simulation, as usual, is key. Through simulation one can discover knowledge gaps, limitations of equipment and guidelines, and coping strategies.
James takes you through some specific pointers regarding equipment that one should carry when anticipating dealing with pre-hospital paediatric emergencies.
Next, James discusses pressure and how it degrades performance. A clinician should be aware of where their pressure limit is. The importance lies in recognising when you reach your cognitive overload.
Once you recognise this point you can be aware of it, deal with it and train to prevent it.
James continues to talk about simple ways to approach the pre-hospital paediatric emergency. The primary survey does not, and should not, go out the window in paediatric cases.
Similarly, simple analgesia can be a fantastic starting point to take control of a situation.
Lastly, James points out that just because young people are small and can be moved off scene easily, does not always make this the right choice. Stabilise, and then move is his message.
James contends that clinicians train and prepare for adult emergency situations and he challenges the audience to treat paediatric emergencies in the same regard.
Challenges in pre-hospital management of children
For more like this, head to our podcast page. #CodaPodcast
Flavia Machado and Paul Young present the top 10 ICU trials of the recent past SMACC style. Their list of trials includes a number that challenge dogma and establish interesting new lines of scientific enquiry. In addition, they also include all the recent clinical trials that should change your practice. If you want to know what’s new in critical care then this is the talk for you.
Anand Swaminathan and Iain Beardsell debate the use of thrombolytics in the treatment of submassive pulmonary embolism (PE).
PE is a spectrum of disease. Patients should be treated differently depending on where they are on the spectrum.
Subsegmental PE may need no treatment at all, whereas massive PE is unlikely to improve without thrombolytics.
Anand argues for the use of thrombolytics.
Evidently, time is critical when dealing with patients and Anand posits that thrombolytics gives the physician control over time.
Submassive PE can deteriorate, leading to massive pulmonary embolism. A proportion of these patients will die. The data is not conclusive for the use of thrombolytics in terms of mortality, however long term outcomes do improve.
Finally, Anand concludes by suggesting that the decision to use thrombolytics relies on sound clinical reasoning and decision making, informed by the available data. He argues for nuanced treatments and use of these drugs.
Iain takes a different approach in his reply.
Some of the most difficult topics in medicine attract considerable debate. The use of thrombolysis for submassive PE is one of these.
In this argument Iain attempts to highlight some of the most pertinent evidence against the use of thrombolysis. And he does so through song!
Submassive PE should be Thrombolysed: Anand Swaminathan and Iain Beardsell
For more like this, head to our podcast page. #CodaPodcast
Ryan Wubben discusses the standards in Helicopter HEMS.
He asks the question, what standards?
The development of Helicopter EMS (HEMS, or as the Federal Aviation Administration recently coined it: “Helicopter Air Ambulance” or “HAA”) services in the United States has taken a different path in recent years compared to other countries.
The widespread use of single engine, VFR only aircraft, owned and operated by for profit companies is a uniquely American phenomena. This is at odds with most other countries who have developed HEMS programs around the world.
This has resulted in significant direct competition between HEMS programs. Additionally, it has drawn attention to highly questionable billing practices.
Ryan examines the origins of this development. This includes the use of the US “Airline Deregulation Act” to prevent states from regulating HEMS programs.
More recent efforts in the US to tie reimbursement and program accreditation to the levels of care provided and minimum standards of equipment are still nascent at this time.
Efforts by the US National Transportation Safety Board (NTSB) to mandate improved safety equipment standards have been met with resistance by the industry and the FAA. This has resulted in wide variability in US HEMS programs. Moreover, it has resulted in the adoption of IFR standards, mandating NVG use, twin-engine aircraft and risk assessment strategies.
There is also increasing scrutiny being placed on appropriate utilisation criteria in the face of skyrocketing bills and questionable billing practices by for-profit companies.
The Standards in Helicopter EMS (HEMS)
For more like this, head to our podcast page. #CodaPodcast
Natalie May & Roisin McNamara discuss a young person’s experience of critical illness.
They are joined by Ema, an 11-year-old girl who had a scary time when she was diagnosed with tracheitis. Experiencing critical illness is scary for anyone. However, when you are a young person, this terrifying experience is amplified.
Natalie and Roisin tell us what we as clinicians can do or think about differently to provide a better patient experience.
Although she is young, Ema provides some salient points about what doctors and nurses do well and what they can do better.
The main take away boils down to clear communication. Medical professionals often think they are explaining things thoroughly. However, the words they use, and the speed of the delivery of those words, leaves a patient feeling confused and scared.
On top of that, a patient's experience of critical illness leaves them exhausted, in pain and unable to effectively communicate.
Bringing one’s awareness to this can assist when we are deciding how and when to discuss the ongoing treatment. Ema’s mother also provides insights into the experience of the family. The broad themes include the feelings of isolation, fear, and overwhelming concern.
Encouragingly, there are simple things that clinicians can do to alleviate these feelings. Whilst the fear and concern for one’s young child will never abate, simply taking the time to listen to all worries and ensuring understanding can go a long way towards improving the experience for both the patient and their family.
Similarly, ongoing communication regarding the tests, procedures, and treatments that are planned to be undertaken is highlighted as critical in eliciting the support and buy in of the family.
Critical illness in a young person will never be easy for the patient or their families. Listen in to this discussion to discover how to make it more bearable.
For more like this, head to our podcast page. #CodaPodcast
Maxime Valois and John Christian Fox argue the role of POCUS in critical care.
Maxime makes the case for POCUS being a problem. POCUS changes everything. It has helped physicians throughout the world to make easier, more accurate and faster diagnoses.
It has contributed to enhance the diagnostic possibilities in resource-scarce environments However, as it gains more widespread acceptance, its use is becoming more and more common.
Maxime contests that this poses a problem. No longer is ultrasound only in the domain of specialists and technology-eager early adopters of the technology. He proposes that this will lead to difficulties as non-specialists take up the technology.
Maxime warns against being hypnotised against the seductive nature of ultrasound. Research and use of fancier, new or more advanced applications are likely to help the global advancement of POCUS and even medicine in general. But as POCUS enters fully in its stage of normal science, this will inevitably induce some degree of scientific esotericism.
This has been the case of all past scientific revolutions.
Point-of-care ultrasound is already generating some important difficulties. If these go unattended, Maxime believe POCUS itself might rapidly be a problem.
John on the other hand claims in no way is POCUS a problem. It is maybe only a problem for the radiologist holding down their turf in a small hospital that has been shielded from the world wide web.
John argues that POCUS is changing the way medicine is practiced for the better. John makes the point that ultrasound makes the clinician better, faster, and stronger. It does so without exposing patient to harmful radiation.
Furthermore, John contends that POCUS enables the physician to bridge the gap between patient and doctor in increasingly complex healthcare system. It allows him to spend more time at the bedside and in doing so deliver better care for his patients.
John makes his point with a range of clinical situations, driving his point home that POCUS certainly has a place in the future of medicine.
Is Point of Care Ultrasound (POCUS) a problem?
For more like this, head to our podcast page. #CodaPodcast
Scott presents the argument that whilst Emergency Physicians are amazing, as it stands, Emergency Medicine is failing.
Scott presents the system as it should be.
This involves stabilising the critically ill before admission to the ICU, seeing sick patients in appropriate time and seeing the less sick patients as you can.
The issue as it stands, is when this system breaks down. He talks about the ‘boxes’ which now includes the ‘not sick at all’ patient. This leads to Emergency Physician’s not doing what they are trained to do.
Scott discusses the issues with the outcome measurements of Emergency Departments. Hospitals measure patient satisfaction and wait times.
Moreover, Scott argues that a trip to the ED should be the worst day in a patient’s life and measuring their satisfaction is misleading.
A good medical outcome should be the indication of success. Scott also discusses the issue of Emergency Physicians not dealing with emergencies for most of their practice. This, in Scott’s eyes, leads to cognitive dissonance, where ED doctors are not doing what they are trained to do.
Simon argues that Emergency Medicine is not a failed paradigm. Emergency Physicians are trained to help people, when people feel that they need to be treated.
He claims that doctors in this speciality want to treat a wide variety of people across a wide spectrum of disease.
Evidently, Simon discusses a ‘revolution’ in Emergency Medicine. An increasing number of people are attending Emergency Departments across the world. The generalist approach of Emergency Medicine is critical in triaging, treating, and helping these people in their moment of need.
The skills, breadth of knowledge and wisdom and ability to work across a range of specialties and in uncertainty is what makes Emergency Medicine and the physicians who work in it special.
Join in the debate as Scott and Simon argue for and against the place of Emergency Medicine.
Finally, for more like this head to our podcast page. #CodaPodcast
Ashley Shreves:
There are nearly 100 billion stars in the Milky Way – and almost that many articles published every year. Luckily for you, we read them all – or, at least, the ones in the domain of EM (Emergency Medicine). Catch up with where the new literature is leading you, leading you astray, or just plain bonkers. Sit back and let us inspire you to take your own deep dive into all the great foundational science. We'll swing through new stroke treatments, the ketamine blow-dart, the best medications for reanimating the dead, and many more!
Ryan Radecki:
It has been exciting and surprising year in the EM literature. We'll be hitting all the highlights and letting you know what's hot and what's not. Topics to be addressed include, but are not limited to, abscess management, medications for renal colic, imaging for subarachnoid, new anticoagulant reversal agents, use of opiates, and the diagnosis of PE
Ben Shippey discusses the important anaesthetic considerations in bariatric surgery. Obesity surgery can induce a strong response in healthcare professionals. These biases must be overcome to facilitate efficient and safe services. Evidently, Bariatric surgery provides many challenges.
To begin with, healthcare professionals can associate negative thoughts with obesity. Secondly, these patients present complex respiratory and cardiovascular physiology that must be considered. Ben highlights three important considerations when preparing for, and delivery anaesthetics in the bariatric population. These are Attitude, Assessment and Act.
Attitude - Encompasses the attitude of the physicians, theatre team and the patient themselves. One must recognise and change their thinking about the obese patient. Ben’s team does this by realising the complex psychological background these patients invariably have.
Assessment - Furthermore, a multidisciplinary team must undertake a broad assessment. Specifically for the anaesthetic team, there is a complex decision pathway, especially with managing the airway. The broad principle should be to shorten the time between the awake, vertical, spontaneously breathing obese person and the supine, anaesthetised, intubated and positively pressure ventilated patient.
Finally, Act - As Ben states, the previous two points are null and void if it does not change practice. The key element to act is to plan! This involves having a clear action plan for the intubation of the patient and failing that, clear points at which Plan B, C and D will be initiated. He encourages his theatre staff to alert him when a cut off Sp02 is reached so he can move to the next course of action. He comes prepared - for example, by having the cricothyroid membrane marked out. Furthermore, it is important to consider putting the patient to sleep and waking them up. As Ben puts it – pay attention to the take off as well as the landing! Lastly, the post-operative care is significantly important. Remember patient positioning in bed (not slumped) and encourage early mobilisation. These patients need to be up and moving, as well as having the appropriate DVT prophylaxis in place. The obese patient presents unique challenges to the anaesthetist.
For more like this, head to https://codachange.org/podcasts/
John Carlisle asks the big question – what is the risk of surgery?
It is a big question that holds implications for everyone involved in caring for patients. Like John, patients want to live a long and happy life. They would like to know whether the chances of living a long and happy life are enhanced by having surgery or not. They do not generally care whether they will be alive in 30 days or not. John explored whether or not we can accurately answer the question – what are the risks of a given surgery? Prognostic models based on a single surgical cohort are very vulnerable to chance and variation. This is even the case with large cohorts. The reason is that mortality is not that common. Therefore, the range of uncertainty in any one model is big. John explores this concept in the context of surgical intervention for abdominal aortic aneurysms. He highlights the perils prognosticating by describing the trials that influences the treatment guidelines for abdominal aortic aneurysms. John describes the current data, and the flaws in the recommendations currently being offered. John then describes a tool he has developed relating to this particular question. The tool also explains how one piece of research has been misunderstood, a misunderstanding that has resulted in two general mistakes: surgeons operating on aneurysms when they should not; surgeons not operating on aneurysms when they should.
For more like this, head to https://codachange.org/podcasts/
Karim Brohi gives an insight into his mindset as a trauma surgeon, drawing on lessons from Zen philosophy.
During this talk he discusses how we can develop the self confidence that helps us cope with stressful clinical situations.
The word confidence is often talked about in a negative context, in terms of overconfidence or arrogance.
Karim however uses this talk to highlight the importance of self-confidence. Self-confidence is important for you, your team, your department, and your healthcare system.
Karim will teach you how to use this confidence to handle whatever is thrown at you. Zen philosophy draws on the notion of water. Water, mind like water, heart like water and core like water. How do you adopt a heart, mind and core that is like water?
Water takes the shape of whatever environment it is in. In a glass, a vase or a lake, the water fills the space. It mimics its environment. Extending this analogy, water in its resting state is calm and still.
However, throw a stone into the water and you create ripples and waves. Thereafter, the stone disappears, and the water once again becomes calm. Karim draws parallels between the properties of water and one’s mindset.
At a trauma scene, panic and confusion can spread rapidly amongst all present without that panic or confusion every being named. However, if a calm and reassured team leader arrives, everything else stills around them. Like water they react to a challenge, an external stimulus, accept it, deal with it, and then return to a resting state.
A trauma surgeon or team leader reacts appropriately to its environment, and then becomes calm again. This, Karim posits, is how a trauma surgeon, or team leader, should behaviour.
The notion of the Zen Garden is another useful analogy from which to draw inspiration. Zen gardens are defined by their attention to detail. This extends to medical practice. Attention to detail enables you to be prepared and deal with anything that comes through the door.
Again, it allows you to foster confidence. Compounding this, is the quality of the gardens that enhances the minimal. They are perfect not when there is no more to add, rather, when there is no more to take away. In a medial sense, Karim draws comparisons to medical imaging.
What is important? What is unnecessary? The gardens are meticulously planned.
Karim highlights the importance of planning is his practice that has helped him instil confidence in himself and his team to deal with all scenarios. Using the art of Zen you can be ready for anything and teach the mind to deal with change with confidence.
For more like this, head to our podcast page. #CodaPodcast
Haney Mallemat discusses the treatment for PEA cardiac arrest.
Patients who present with pulseless electrical activity (PEA) arrest have a high mortality. The treatment of PEA requires finding and reversing the underlying cause; therefore a simple and rapid approach is required.
Traditionally we were taught to use the H’s and the T’s, but this diagnostic tool is cumbersome and of questionable utility overall.
Haney discusses the problems with the traditional H’s and T’s as well as focusing on newer approaches to PEA arrest. Haney makes the point that PEA is not a diagnosis, but a ‘waste basket term’ for a lot of possible diagnoses.
Rather than assisting a clinician in the assessment and treatment of a patient, it acts on to lead to pontification.
To that end, Haney wants us to do away with the H’s and T’s. The problem with the algorithm of diagnosing a PEA, as Haney explains, is the reliance on feeling a pulse. It lacks sensitivity and specificity, largely linked to using fingers.
They should not be used in resuscitation scenarios – as the guidelines say we should.
Haney makes the point that despite all the advances in medicine, resuscitation has stayed essentially the same for decades. He describes two ways in which he thinks we can advance our care.
The first involves the QRS complex. Ask the question – is the QRS complex narrow or wide. Narrow (< 0.12 seconds) leads you to consider mechanical problems, such as tension pneumothorax or tamponade. If it is wide (> 0.12 seconds), then consider metabolic problems such as hypokalaemia.
If the QRS is narrow, and you are thinking a mechanical problem then there is electrical activity, and the heart is still beating underneath. The step should be to use ultrasound immediately to find the focused cause. If it is wide, and you are considering metabolic causes, this is more aligned with a true PEA. Calcium bicarbonate should be considered in the first instance.
Haney describes the limitations with the algorithm that includes the trauma patient or those with underlying cardiac conditions.
Next Haney describes a second algorithm - PREM (pulseless with rhythm and echo motion) and PRES (pulseless with a rhythm and echo standstill). The use of ultrasound is central to this pathway. In PREM the left ventricle is not strong enough to produce a pulse. Does this patient get adrenaline or chest compressions?
Haney discusses the options. In PRES there is electrical activity, but the heart is not squeezing. Maybe these people should get adrenaline and compressions!
The ECG should still play a part in this algorithm. Haney puts it all together for you and takes you through the algorithm he uses when faced with a patient with PEA.
He includes some tips for using the ultrasound probe during cardiac arrest resuscitation scenarios.
A Revised Algorithm for PEA Cardiac Arrest: Haney Mallemat
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John Greenwood takes a broad view on pulmonary hypertension and explores the heart-lung interactions that occur in this disease process. Pulmonary hypertension commonly occurs when managing a patient with an acute critical illness. Pulmonary hypertension has a devastating impact on cardiac function. Whilst we recognise the disease itself, we don't recognise the ‘upstream’ effects. John explains how it is these effects that may be causing the patient to crash. John, in this talk, helps you to understand the clinical heart-lung interactions affected by pulmonary hypertension and the effect on the right ventricle. He educates you on identifying patients at high risk for pulmonary hypertension, and finally he discusses critical management strategies for patients with pulmonary hypertension. In the ICU, causes of acute pulmonary hypertension are evident daily. Microcirculatory of the lung has a strong impact on what the pulmonary pressures are. Therefore, conditions such as pneumonia, ARDS and pulmonary oedema will all lead to pulmonary hypertension. The condition can then be exacerbated by the treatments offered – namely mechanical ventilation! This brings John to the right ventricle. John explains why he feels the right ventricle is too often overlooked. He describes the form and function of the right ventricle and how it often fails in the case of pulmonary hypertension. The pumping function of the muscle does not have the necessary components to overcome high pressures as they are encountered in this disease. Finally, John provides his thoughts on the management of pulmonary hypertension, keeping in mind the importance of the right ventricle. Through his presentation he will convince you that pulmonary hypertension is common. By remembering that the right ventricle is sensitive, by judicious use of echocardiography and by proper resuscitation, John will help you treat patients with pulmonary hypertension.
Finally, for more like this, head to https://codachange.org/podcasts/
Michele Domico presents a talk on the pitfalls of common paediatric resuscitative manoeuvres in paediatric cardiac patients. Emergency and critical care physicians are all well accustomed to items such as oxygen, bolus adrenaline, intubation and cardioversion. However, as Michele explains, these ‘go to’ interventions may in fact be harmful for the paediatric cardiac patient presenting to the emergency department in extremis. Due to the physiology of certain complex congenital heart diseases, the usual resuscitation manoeuvres may in fact kill the patient instead of helping. Supplemental oxygen can worsen the pulmonary to systemic blood flow ratio in single ventricle patients and cause them to have rising lactate levels and cardiac arrest from low systemic cardiac output. Intubation and positive pressure ventilation may impede pulmonary blood flow in patients with a Glenn shunt and the patient can become more desaturated. With increasing PEEP and higher respiratory rates, the patients will continue to deteriorate and desaturate. Regular dosing of adrenaline boluses in patients with single ventricle physiology who are nearly arrest, can worsen their systemic output by increasing systemic vascular resistance and promoting pulmonary overcirculation. Cardioversion of a previously healthy paediatric patient might be tempting when you see what looks like a stable ventricular tachycardia. This wide complex rhythm has fooled many people into shocking it. You might in fact be dealing with something else and can make the patient infinitely worse by shocking. In her talk, Michele highlights the importance of understanding the physiology of your patients. This particularly applies to paediatric cardiac patients. In this population, the change from typical physiology means standard models of care are harmful. Tune in to hear what not to do!
For more like this, head to https://codachange.org/podcasts/
Deirdre Murphy presents everything that can go wrong in cardiac surgery. Deirdre will impress on you that cardiac surgery is by no means a safe procedure! Murphy’s Law stipulates everything that can go wrong, will go wrong. Subsequently, Finagle’s corollary will tell us, it will be at the worst possible moment. In this talk Deirdre attempts to prove these theories in the world of cardiac surgery. Cardiac surgery can vary from being routine elective surgery to time-critical emergency surgery. The term encompasses a broad range of procedures carried out on patients from neonates to nonagenarians. In the 63 years since the first open heart surgery was performed using cardiopulmonary bypass enormous advances have been made in the field such that an average person presenting for coronary bypass grafting in 2016 can expect a very low chance of peri-operative morbidity or mortality. When things go wrong however, they can go badly wrong and at the worst possible moment. The list of problems that occur is extensive. Deidre steps through some of the more common issues that arise post cardiac surgery. She describes pneumonia, mediastinitis, haemorrhage, ischaemia, and neurological issues, amongst others. Along the way she provides clinical pearls as to what to look for, what not to miss and what to do about it. Through her extensive experience, Deidre has seen more than her fair share of post-cardiac surgery complications. She provides a number of clinical scenarios she has encountered, and in doing so gives useful insights to be aware of. Her top tips are to prevent complications if possible. If not possible, recognise the complications early and finally train for ‘avalanches’ – those critical and scary situations that will put your patients at immediate risk of demise.
For more like this, head to https://codachange.org/podcasts/
The practice of emergency medicine is no longer a one size fits all approach. Furthermore, most of your patients are not usually 'average' as described in journal articles. With more data, newer analytic techniques, and a better understanding of pathologies, we can isolate the exact and most appropriate therapies for our individual patients. We're already doing it, but we should be doing it better. Learn how to be systems thinkers and become better providers.
Using examples from emergency medicine, I will show how a comprehensive approach to patient care can be beneficial for guiding theories and therapies tailored for an individual. This concept of precision medicine allows us to incorporate all knowledge and processes in to one picture rather than segregating medical care in to buckets. We will also discuss some of the challenges in this type of thinking and best practices for translating in to your every day work.
When was your last paediatric/neonatal life support course update? Did it include the latest recommendations from the European Resuscitation Council (2015)? NO?! Well, let's have a look at the very latest consensus recommendations for the resuscitation of children in cardiorespiratory arrest and for neonates at birth - and explore any controversies therein.
Peter Brindley explains how burnout affects us all. It affects the cost, quality of care, organisational culture, performance and patient outcomes.
Burnout is fatigue, loss of ideals, purposelessness, presentism and the sense of being under-appreciated. It is not tiredness, exhaustion, boredom, mid-life crisis, depression, PTSD, perfectionism or narcissism.
Moreover, burnout involves the 4 C's: cutting corners, cynicism, callousness, and contempt. Peter explains when and why, and to whom a burnout occurs. A major reason for burnout is the difference between expectations and reality. This drives the thought, “this is not what I signed up for.”
Furthermore, he presents the 12 steps which lead to a burnout. It begins by the need to prove yourself by working harder, neglecting your needs, avoiding issues, and losing friends or hobbies. This leads to denial, withdrawal, behavioural changes, depersonalisation, inner emptiness, depression and finally burnout.
Peter suggests a few things that we can do to prevent burnout. He recommends purposeful imbalance and dividing career into thirds: learning, earning, and returning.
Evidently, burnout is a chronic condition, and although it cannot be cured, it is manageable. It might take years to manifest and hence, we must always be on the lookout for the signs.
Finally, for more like this head to our podcast page. #CodaPodcast
Francesca Rubulotta talks about disproportionate care in ICU. Disproportionate care is disproportionate in relation to the expected prognosis. Moreover, this can lead to moral distress among clinicians who think they are offering inappropriate care. There is mounting research and evidence pointing to the existence of disproportionate care. Furthermore, stress and burnout cause increased miscommunication and lead to low performance and concentration. Stress leads to absenteeism or in many cases, presenteeism. Presenteeism is when someone just shows up for work but does the bare minimum. Francesca shows the financial burden caused by absenteeism across various countries. Francesca points out that only 14% of employees feel engaged in their jobs. Moreover, data shows that companies which keep their employees engaged have higher rates of performance. Such companies have managers who are more engaged and approachable. Francesca discusses various studies that look at the appropriateness of care in ICU. She talks about the CONFLICUS, APPROPRICUS and DISPROPICUS studies, all of which point to the moral stress experienced when clinicians are forced to give inappropriate care. We must ask whether inappropriate care occurred and why. The three major factors influencing the perception of inappropriate care are client related situations, work characteristics and personal characteristics. 27% of healthcare providers (HCP) report at least one of their patients are mismanaged per day. Furthermore, 63% say that inappropriate care happens all the time. There are multiple reasons for disproportionate care taking place. Studies show that nurses associated inappropriate care to interpersonal factors while physicians ascribed it to prognostic uncertainty. Francesca discusses the methods used and results obtained in the DISPROPICUS study and self-awareness and individual development in ICU. According to her, these future studies will help to find solutions to the problems regarding disproportionate care. Evidently, authentic leaders, who can inspire others, are the need of the hour.
For more like this, head to https://codachange.org/podcasts/
Karin Amrein highlights the importance of bone health in ICU. Karin asks – do fractures matter? If the presentation is a hip fracture for elderly patients, then the answer is obviously, yes! However, Karin will describe why this answer should be a resounding yes for all patients who are admitted to the ICU. Critical illness affects bone. It is not a stretch to conceptualise this. However, Karin wants to impress on you that bone affects critical illness also! Bone is an endocrine organ, the largest endocrine organ. Fragility fractures are associated with substantially increased mortality and morbidity. One year post hip fracture, 50% of the patients are either dead or in a nursing home. Prevention is crucial! After an ICU stay, patients have a largely elevated risk of fractures – up to 65%. However, this risk factor is not recognised in the literature. If you survive critical illness and get home, you have done well. If you then sustain a fracture, you are almost back to square one! Karin attempts to explain this association. The ICU population is getting older, and the very nature of an ICU admission means they are predominantly sedentary – that much is true. However, there is likely more factors at play. Inflammation, endocrine alterations, increased osteoclastic activity, hypercatabolism leading to muscle breakdown (and in turn bone breakdown), malnutrition and drugs are all likely implicated in the increased risk. Karin takes you through each factor in turn in detail. So, what can be done about the increased risk of fractures in ICU patients post discharge. Addressing each factor in turn is difficult, however Karin shows some viable options to consider in this patient population. Karin demonstrates how poor bone health, leading to fractures, produces poor outcomes. In turn, she discusses how treating the bone health, and reducing the fracture rate, leads to improved morbidity and mortality! Karin concludes with some recommendations for ICU patients providing some tangible and practical takeaways.
For more like this, head to https://codachange.org/podcasts/
Natalie May gives you the break down of paediatric trauma.
Paediatric trauma is relatively rare but terrifying. However, there are many ways we can think about paediatric trauma to make these challenging situations easier to face.
Children are inherently portable. This means that they often turn up at peripheral, non-paediatric centres that are not major trauma centres.
This highlights the importance of all physicians knowing how to deal with these cases.
Anatomy and physiology of children is different to adults. Their ability to compensate is remarkable. This means the index of suspicion of serious injury should be higher.
For instance, their ribs are a lot more pliable than those of adults, meaning hollow viscous organ injuries are more common following trauma.
Similarly, their vital signs can be more confounding. Tachycardia could simply mean fear or pain.
On the other hand, it could indicate a major internal bleed. This leads to children being under and over triaged at a high rate.
Teenagers also present challenges. Does the surly, teenage girl with limited verbal responses have a serious head injury..? Or is she being a stereotypical teenage girl?
The mechanism of children trauma differs from that of adults. Polytrauma is rare in children without adult involvement, such as a motor vehicle accident. However, as children develop through adolescence, the mechanisms of injury begin to resemble those of adults.
Quad bike accidents, stabbings and even shootings become more common. Isolated thoracic injuries become the second most common cause of trauma in adolescents 16 years and older.
Toddlers by comparison get isolated limb injuries more commonly. They are mobile, curious and have no sense of danger. Their height to the ground is less, making head trauma less common, and less serious.
Under one’s however are more often carried by adults and lack protective reflexes making skull fractures more common. Polytrauma in this age group should also raise suspicion of non-accidental injury. External factors often need to be involved for more serious polytrauma.
Natalie suggests being suspicious of horse-riding children!
Once a child is in your department, the assessment differs slightly to that of an adult. Specifically, scanning protocols are different with less use of pan scanning and more focussed scanning. CT for heads and penetrating chest trauma and abdomen, and plain films for C-spine, limbs, pelvis, and blunt trauma to the chest.
Natalie concludes by discussing the differences in management of injuries, comparing children and adult interventions. She also discusses the outcomes of children with major trauma and the vast implications on the child, the family and society.
For more like this, head to our podcast page. #CodaPodcast
Confined Space Airway Management in Emergency and Critical Care by Ross Hofmeyr
Ross Hofmeyr discusses the ins and outs of managing an airway in a confined space.
He details the challenges, the potential solutions and his top tips when faced with an airway in a less than ideal setting.
Ross defines confined space airway management as airway management in an environment where access to the patient, normal positioning, and use of airway equipment is limited by physical constraints.
Ultimately, these situations are endless. An icy crevasse or on a mountain top. Inside a cave. Motor vehicle crash scenes. War zones with bullets flying overhead. The inside of a helicopter or the back of an ambulance.
Even inside tight Emergency Departments, cath labs or operating rooms that are full of advanced equipment. These are all scenarios in which one may find themselves faced with confined space airway management.
Ross contends that all airway clinicians have the possibility to have to handle these situations. In this presentation, Ross addresses the locations and difficulties which can be anticipated, and then discusses the options, techniques, and evidence available for managing airways in constrained places. Learning to cope (and then excel) in abnormal fashions and positions makes us better at managing airways in both emergency and routine situations.
Ross discusses the specific techniques, equipment and alternatives that can assist a clinician in tight situations. He backs up his thoughts with literature which demonstrates which techniques may be considered.
Moreover, his primary piece of advice to managing an airway in a confined space is, don’t do it! His first tip – get the patient out of the confined situation!
Evidently, this may not always be possible. If that is the case, Ross recommends a Supraglottic device. Otherwise, a channel laryngoscope is his next go too.
Failing that, Ross stresses that a clinician must be prepared, mentally and physically, to proceed with a surgical airway. The more skills, knowledge, and flexibility the clinician has means the better they will be able to cope with confined airway management.
Confined Space Airway Management in Emergency and Critical Care
Finally, for more like this, head to our podcast page. #CodaPodcast
The Role of the Immediate Responder in Mass Casualty Trauma
Christina Hernon describes a traumatic experience in gripping detail.
In doing so, she shares her deeply personal insights into what it is to be an Immediate Responder. Christina suggests that the medical system must change to support these people.
After a major formative experience at a life-threatening mass casualty incident, Christina felt incredibly unprepared despite over two decades of training in emergency and first response.
Christina reflects that all the training that students undergo does not prepare them for every scenario. The standard approach to emergency care, is this scene safe? is completely inadequate for those present the very moment an incident occurs. These people are then amidst and surrounded by an unsecured and potentially unsafe scene.
After her experience Christina had an acute stress reaction exactly like after rough calls in prehospital Emergency Medical Services.
However, Christina wasn't offered the usual support given in these circumstances. She felt somehow betrayed, but unsure who to be mad at. Therefore, Christina tried to understand why she felt so unprepared and overlooked.
In deconstructing and reflecting on the experience, she self-identified neither as bystander nor first responder. Instead she was an on scene, immediate responder, victimised rescuer. Realising that she did not fit into any already existing category, she uncovered an undefined time period that we need to give attention to.
The Disaster Gap is the time between the moment an incident occurs, through the first call for help, and until the clearheaded First Responders arrives. In this definable time gap, the only available rescuers are people who are on scene when the event happens. These Immediate Responders, who are traumatised by their experience themselves, take immediate action to help another person or make the situation better.
They are present at virtually every scene and have been for all of time. However, we know very little about them, their actions, their safety, their impact, and their recovery.
By trying to understand the Disaster Gap and Immediate Responders, we can improve training, preparedness, resilience, and recovery.
The Role of the Immediate Responder in Mass Casualty Trauma
For more like this, head to our podcast page. #CodaPodcast
Natalie May brings the lessons she has learnt from Sydney HEMS training and teaches you how to apply them to your practice.
What can hospital specialties learn from teaching and training in prehospital and retrieval medicine?
Natalie, a self-described medical education enthusiast, gives you her thoughts on the application of educational theory to the challenges of the prehospital environment.
Evidently, Natalie will discuss three domains of medical education – Induction, Competence and Culture.
Firstly, Induction How do you welcome new staff to your service? In Sydney HEMS there is a week-long full team training.
This teaches new clinicians to contextualise pre-existing knowledge into their new environment. Here, they combine teaching tools including demonstration, simulation, discussion and debriefs. This is often in stark contrast to in-hospital inductions that can consist of a cursory department tour and online modules.
Moreover, Natalie discusses the medical education principles that provide the basis of the importance of a well-rounded induction. Inductions are crucial to ensure that new clinicians can safely learn how to operate successfully in their new environment.
Secondly, Competence Competence is necessary for good outcomes. Training is essential in the development of competence. Natalie discusses the proven theory of spaced repetition to embed new skills. This involves regularly practicing alongside skilled clinicians – as is done in the HEMS program.
Furthermore, In-hospital, simulating cardiac arrest scenarios regularly can dramatically improve junior clinicians’ competencies and highlight deficiencies in competence that can be addressed.
Thirdly, Culture Natalie describes the methods of culture building that exists in Sydney HEMS. These include ‘Coffee and Case’ meetings, fortnightly clinical governance days and interactive lectures and journal clubs. These all acknowledge the higher order thinking processes that is involved in the care the services provided.
Natalie recommends fostering a culture of learning from practices and providing open non-judgemental clinical governance days in the in-hospital setting.
Finally, Natalie wants you to use what you have learned to inspire, teach, and motivate others.
For more like this, head to our podcast page. #CodaPodcast
Sara Gray tackles the controversial topic of disaster ethics in critical care. Most hospitals develop a disaster plan, but few jurisdictions develop a plan for triaging or rationing scarce resources when the existing supply is overwhelmed.
Rather than leaving individual health care workers to make these decisions, we should work together as a community of experts to develop ethical, practical and appropriate policies for triaging scarce resources during a disaster.
Healthcare resources are finite. In the case of large-scale trauma with large numbers of casualties, such as a disaster scenario, how do you decide who gets what?
Sara discusses her guiding principles when thinking about disaster triage. First and foremost, avoid having to triage or ration scarce resources. Have a plan and make first part of the plan to be “Never use the plan”. Mitigate all the risks and possibilities that would see the plan being enacted. This involves sharing with partner hospitals, urgently reordering supplies and repurposing what is available.
The second guiding principle relates to the ethics. Normal circumstances dictate offering the best for every individual patient. In a disaster, a shift to the utilitarian philosophy – the greatest good for the greatest number – is necessary. This means not everyone is going to get what they need, which is a difficult concept for people.
Thirdly, Sara stresses the importance of developing a disaster plan in a public way. This stops a plan being “sprung” on staff, the public and stakeholders. It encourages buy-in and engagement which makes it a smoother process should the plan ever be enacted. Sara next discusses the inclusion and exclusion criteria when dictating who should receive the finite resources of a hospital in a disaster. This, she admits, is the tricky part. She backs her thoughts up with the available data. Sara concludes with some points regarding the implementation of disaster plans.
Making these plans is tough, however not having them is tougher. Hospitals and health authorities should have a clear criteria for when a crisis is declared. This needs to come from the hospital level, if not the health region or government.
It is not an individual decision. Next a dedicated team should review de-identified patient files to allocate resources according to the inclusion and exclusion criteria. This team needs to be multi-disciplined and received adequate support. This is a tough job.
Finally, for more like this, head to our podcast page. #CodaPodcast
Liz Crowe believes that love can revolutionise the way we approach critical care. She wants every doctor to become love ambassadors for their critical care community and share love like nothing is holding them back.
Liz believes that work life balance does not exist because we spend most of our time at work. Therefore, it is essential to love and be passionate about the work we do.
Liz compares the feeling of being a novice in critical care to first being in love.
Initially, there is fear and excitement doing new procedures. However, as days go by, you lose the rhythm. This is how relationships evolve, both in life and in critical care.
Relationships with critical care is all about hanging in there and, love. Love helps to sustain it. She discusses the role of love and leadership in critical care.
Liz demonstrates that great leaders always lead with love and compassion. Leading with love does not make them weak or indecisive, instead it creates a climate of trust and intimacy that makes individuals and the team feel emotionally and physically safe.
This in turn promotes robust conversations and conflict which is beneficial to the patients. By being kind and compassionate, a leader inspires their team to work better and achieve higher standards.
According to Liz, a good leader is supportive, genuine, works hard, apologises when they are wrong, has a good sense of humour, creates an environment of trust and acts as a human shield for their team.
The most stressful thing in an intensive care is not death but being unappreciated. Being loved and supported leads to increase in brain capacity and the ability to make difficult decisions.
Liz strongly recommends having a work spouse because family and friends do not understand what critical care workers go through. The people we work with are our support and community. Love builds innovation and creativity and not the brain. She quotes the example of the three doctors whose passion made the SMACC conference a reality.
Liz discusses the role of love in dealing with patients. She believes that beginning a conversation with a patient with love, respect and compassion makes things easier because they will believe that we care about them. She feels it is as important to teach newcomers about love and compassion as it is to teach them about having boundaries.
The more we care about patients, the less likely we are to be burnt out. Liz explains the concept of Ikigai which says that you can achieve bliss if you can combine passion, mission, vocation and profession, which according to her most doctors can.
Though there are times when this job can leave you heartbroken, it is also quite rewarding and important.
For more like this, head to our podcast page. #CodaPodcast
For Ross Fisher there are things that scare him. And he knows there are things that scare you too.
Ross discusses the purpose and effect of fear in medicine and surgery. Whoever you are and whatever you do, there are things that you are afraid of. It is not stress, it's fear, it's real and it affects us.
Ross wants you to know, it is okay to be afraid. Being afraid is recognising a threat and realising that there is a limitation to your ability, and that you have reached that point.
Ross describes three moments in his career that he has felt fear. Real fear, that was different to stress.
Moments before operating on a preterm neonate of 29 weeks.
Believing he had transected the common iliac artery in a haemorrhaging 9-year-old during a removal of a Wilm’s tumour.
And being reported for malpractice by a colleague.
In each situation, Ross felt fear. What does fear do to a person? It is different to stress.
Stress in critical care medicine is part of the job. In fact, it is necessary to reach a performance state.
Fear on the other hand is when an individual is way into the “red zone”. Your hands shake so much that you cannot perform tasks. Your head pounds from tachycardia and hypertension. You breathe so fast it is like you have just finished a run. Your focus is directed at one thing only and you can no longer appreciate your surrounds, nor any inputs from your senses.
You cannot think, you cannot remember, you cannot calculate, and you cannot make decisions. That is what it is to be afraid.
Fear affects us acutely. However, it also affects those around us. Similar to how a yawn will spread person to person, fear can spread through a group.
This is particularly true when the person showing fear is a senior person or leader. The reason things go wrong in stressful situations is not because of a lack of knowledge or training. Rather it is due to poor performance as a result of fear.
So, Ross wants us to acknowledge our fear. He wants us to recognise how common it is, and how we can confront our fears and no longer be fearful if we stand together.
For more like this, head to our podcast page. #CodaPodcast
Resa Lewiss gives her insights into leadership. Through her experience training and working in Emergency Medicine and Critical Care, Resa has collated a series of pearls, pitfalls, and lessons shared by leaders.
For Resa, there are leaders, and there are follows – more often than not, people know good leaders. Resa firmly believes that leaders look like leaders. She affirms that it is neither a male nor a female trait – despite what some may assume.
Resa shares her lessons on leadership.
1) There is never a need to publicly embarrass someone Public embarrassment serves a purpose, however this purpose is often misguided and can be better achieved in other ways.
Resa has experienced the embarrassment firsthand and knows of its detrimental impact. A good leader will give a person an out and speak to them in private. This is much more effective.
2) Make a decision Being indecisive can be perceived as worse than making the wrong decision. Leaders need to be confident in their decisions.
3) Know your strengths and build on those Also, know your weaknesses. For what you are not good at, reach out and bring people into your circle to complement yourself and your team.
4) “People may forget what you say, they may forget what you do, but they will never forget the way you make them feel.” Maya Angelou Leadership is not about hierarchy. Leaders should make their subordinates feel respected, welcome and part of the team.
5) Ask Leaders need to get over their imposter syndrome. This allows them to advocate for themselves and for their team. Never be afraid to ask for what you need.
Resa concludes by sharing ways that everyone can improve their leadership skills.
For more like this, head to our podcast page. #CodaPodcast
Medical journals have many possible functions, but the main one for most is publishing science. They are actually better at campaigning and agenda setting, rather like the mass media. Journals are now beset with problems, including failing to include data, publishing lots of poor quality material, being slow to publish, publishing research that is either not reproducible or fraudulent, encouraging waste in the system, failing to be transparent, and exploiting academics. New ways of publishing science are appearing, and a better system would be for the grant proposal, protocol, and full data to be published on a database with the whole process transparent.
Antibiotic Use for Sepsis in Critical Care: Steve McGloughlin
Steve McGloughlin presents his thoughts on antibiotics and their use in sepsis and critical care.
Steve discusses the ABC of sepsis… the trouble is after A for Antibiotics there is not a whole lot else! In sepsis and severe infection, the goal is to change the trajectory of the patient, away from death and to a more favourable outcome. The tools that are currently on offer in critical care are pretty simple.
There are things to support the patient such as fluid and ventilators. In addition, we consider goal directed therapy. In terms of definitive therapy, the list is quite small. Perhaps only antibiotics and source control can be turned to.
Antibiotics are a powerful tool. So much so that the number needed to treat is around four. They are also very commonly used. 70-80% of patients in the ICU will get antibiotics – far higher than nearly all other treatments. Steve has some basic advice for the use of antibiotics to enhance their effectiveness.
Go early as possible when prescribing and administering. In saying that, he cautions to move beyond simple antibiotic prescribing regimes. Whilst we need early antibiotics, we need the right antibiotics.
Why? Alexander Fleming warned against drug resistant bugs when developing penicillin. There has been reports of pandrug resistant organisms (bug against which no known drug is effective) in multiple countries and 214 000 neonatal sepsis deaths per year are attributed to resistant pathogens.
Steve concludes with a discussion on what more we need when considering sepsis. We need more than antibiotics. As it stands one definition covers all categories of sepsis.
The result is a homogenous treatment protocol. In reality, the source, the bug and the pathology all change the disease and all call for an individualised treatment regime. That is the future.
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Per Bredmose discusses the use of inhaled nitric oxide (iNO) in retrieval medicine and critical care. He explains why iNO is useful for retrieval and transport of the critical respiratory failure patient.
iNO is not a magic bullet, but rather a bridge that will help you get to where you need to go when treating a patient.
Furthermore, it can be useful in both pre-hospital and in hospital care.
What is nitric oxide? It is an endothelial derived potent short acting vasodilator mainly found in the pulmonary system. It also exists in other areas of the body. When nitric oxide is delivered via the inhaled route it has local effects only, with no systemic effects.
Most people will be familiar with the use of iNO in persistent pulmonary hypertension of the newborn.
However, there are other uses which are more “off label”. For instance, take the case of severe ARDS lungs in pre-hospital settings. These patients present challenges in retrieval for several reasons, including the retrieval ventilation systems being inferior when compared to hospital systems.
Of course, you could turn straight to ECMO. However, setting up ECMO takes time and is complex. It requires a large amount of equipment, skilled operators, and room. Nitric oxide can act as a bridge.
Per stresses, iNO is a tool to get the patient to the right place. Nitric oxide is simple to use. It is an extra gas that goes into the ventilatory circuit. It is accessible, can be used in any vehicle, is easy to transport, and fast to grab and use. Much faster than a big ECMO set up or retrieval.
A lot of places have stopped using iNO and it has gained something of a bad reputation. The main reason for deleterious effects appears to be kidney injury. Per posits that this may be due to an increased length of time using the drug. Therefore, he advises caution.
Per concludes by explaining other conditions where iNO may be used as an adjunct to standard therapy. These situations include pulmonary hypertension, non-thrombotic pulmonary vasoconstriction, and pulmonary emboli.
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In Critical Care we deal with death on a regular basis and although it seems an ‘on or off’ issue where you are either dead or you are not, nothing is more true. Not only physicians but scientists, philosophers, writers and theologians have been debating about the subject for as long as we have become aware of the concept of death.
To try to create order from chaos I divide the deceased in 5 categories:
The soon to be dead,
The reversibly dead,
The irreversibly dead
The walking dead (although this group I will leave to Hollywood to educate us about)
and the most curious group
The reversibly, irreversibly dead.
They are the patients of whom we think they are irreversibly dead, we stop our resuscitation efforts, and then they have return of spontaneous circulation. This is known as the Lazarus phenomenon and although many case reports have been published about this phenomenon over the years, presumably it’s only the tip of the iceberg.
In providing Critical Care we sometimes need to make immediate decisions on who’s dead and who’s not. Yet decisions about whether further treatment of patients is futile or not can only be made when one is aware of the limits of extremes in physiology that are survivable. Although not every patient should be treated up to these physiological limits, knowing these extremes can help in making an informed decision of whether to continue treatment.
How do you diagnose death? In Critical Care we deal with death on a regular basis and although it seems black and white, that is often far from the truth.
Patricia Gerritsen discusses what it means to be dead and how that knowledge can aid you in stopping a resuscitation effort.
Patricia presents the degrees of death in her eyes as: 1. Soon to be dead 2. Reversibly dead 3. Irreversibly dead 4. Reversibly, irreversibly dead
Changes occur following death that can be proof of death. But not always. Pallor mortis, algor mortis, rigor mortis, livor mortis and decomposition can all indicate someone has died.
There are other clues that can indicate a person is either dead or will soon be dead – with minimal chance of any life saving intervention. The varying ways death presents itself poses a challenge for the clinician. This is especially true when deciding when to stop a resuscitation effort.
Consider the reversibly, irreversibly dead – also known as the Lazarus phenomenon. These patients achieve return of spontaneous circulation AFTER the resuscitation effort has been stopped. There are over 50 cases in the literature, with a wide and unpredictable array of clinical situations.
Therefore, the question becomes - what are the limits that can be survived? Patricia suggests that we must know the extreme limits in order to make an educated decision about resuscitation.
Patricia details some of the most extreme stories of survival in the literature. Submersion has been survived after 66 minutes in a child. An individual survived being in an ice stream after 40 minutes, with a recorded temperature of 13.7 degrees. A man with a potassium of 14 mmol/L made a good recovery.
There is a case of someone with a pH of 6.33 recovery fully and someone surviving a CO2 level of 375mmHg.
Patricia highlights these extreme examples to show what is possible whilst acknowledging the decision to stop resuscitation is a difficult and nuanced one.
When to Stop Resuscitation in Critical Care: Patricia Gerritsen
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Diagnostic medicine is not simple – Casey Parker discusses the finer points of the diagnostic process in critical care.
Diagnosis is not black and white. The world is not black and white. It is all shades of grey and about probability.
One tool that clinicians have to deal with probability is Bayes’ theorem. Since it was first described in 1763 Bayes’ theorem has been applied, rejected, and rediscovered in many fields. Its use in medical diagnostics is a relatively recent phenomenon.
This talk will review the history of Bayes in medicine. Since 1763 the medical world has made dramatic leaps forward. However, Bayes’ theorem still has its place. It has been made more accessible with nomograms and more recently handy clinical decision-making tools in the form of smartphone apps.
Casey helps you put all this together by elaborating on the diagnostic process. Firstly, is the pre-test probability – how likely is a disease in any given population. Not all populations are the same. Therefore, depending on where you work, you need this into account when assessing patients. How do we arrive at pre-test probability? Casey details the three ‘G’s. Gut feeling, gestalt, or guess work.
Secondly, are likelihood ratios. These exist independently of the population and can be described as a marker of signal to noise. For example, when a radiographer tells you there is a PE on a CT, this is not strictly true. Rather there is a chance of a PE. Next Casey discusses choice of tests. He stresses - do the test with the highest diagnostic yield.
For instance, in a young female with abdominal pain you may consider a diagnosis of appendicitis or pelvic inflammatory disease. Blood tests and ultrasound will not help you in this case. A laparoscope is the diagnostic tool of choice in this case.
Finally, the post-test probability – where the rubber meets the road. Where probability is converted into action. Consider the threshold to treat.
This should be determined by three factors: 1. How bad is the disease?
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How good or bad is the treatment?
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How bad/dangerous is the test?
Join Casey as he challenges you on diagnostics in critical care.
Diagnostics in Critical Care: Casey Parker
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Kate Prior conveys the lessons she has learnt working as a doctor as part of the Medical Emergency Response Team (MERT) in Afghanistan.
“Unexpected survivors” are those patients who, according to their injury severity score, should die of their injuries but they survive against the odds.
The years of conflict in Afghanistan saw increasing numbers of these grievously injured patients surviving to live a fulfilling life. How was this achieved?
As Kate explains, it is sometimes necessary to reorder the ABCDE. In the case of a major trauma with catastrophic bleeding, stopping the bleeding needs to be prioritised above all else. Kate describes the methods she used.
Secondly, she discusses the importance of taking the hospital to the patient. Kate talks about the capability of the Chinook helicopters she worked in.
In her words ‘helicopters become flying Emergency Departments’. This enables advanced assessment and interventions to be delivered on scene. This includes IO access, blood transfusion, RSI and high-quality analgesia.
Kate goes on to discuss the important of training and rehearsal. For her role, many months of training are essential, to prepare for the unpredictable nature of a warzone.
This extends to being extremely familiar with all protocols, equipment, and machines, so that it becomes second nature in all situations.
Finally, Kate touches on the human impact of the patients she treated. Although you cannot save everyone, there is a need to learn a lesson from every patient.
Learn from them and disseminate the knowledge. In this way, you can continue to get better. This is highlighted by the improved mortality rates in Afghanistan.
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Peer review is at the heart of science. Yet, as Richard Smith explains in this talk, there are many problems with peer reviewed research. As Richard argues, peer review is not an evidence-based process, but rather a faith-based process. Is it time for something different? Peer review has two main functions: 1) Quality assurance and 2) Improving what is published. However, with that in mind, there is no evidence of effectiveness of peer review, and lots of evidence of its ineffectiveness. This is along with peer review being slow, expensive, wasteful, inefficient, prone to bias and being largely irrelevant! Richard discusses a few of the main issues as he sees it. For example, studies in large journals are more likely to be wrong when compared to smaller journals. Some argue that the vast majority of research is a waste of time. Similarly, replication is also a major problem, as Richard explains. A huge number of studies cannot be replicated, raising questions about the initial research. What is published in journals should not be taken to be truth but rather “provisional truth”. Richard tells the tale of planting errors in articles and seeing if they are picked up by peer-review. Far more often than not, they are not! On top of this, there is fraud and theft that occurs in the peer review process. Bias exists both positively and negatively. To top it off, much of the time the process does not pick up the errors (or fraud) in papers. A lot of problems and few answers. And it is not necessarily a case of it being the least “bad system” for this process anymore. There has been attempts to improve peer review. Blinding of reviewers to authors has been shown to be ineffective. An open system did not make much difference to the quality of opinion. Checklists and training have likewise been trialled and moved past due to ineffectiveness. Finally, the process has been made as open as possible, and in real time where possible. Richard argues that we may no longer need peer review. In the age of the internet, why would a peer review process be needed when an enormous number of people can access and critique the evidence simultaneously. Journals may be yesterday’s way of publishing data.
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The exposure of fabricated numbers in published papers by eagle-eyed readers has been due to sporadic serendipity. I am going to describe a semi-automated method that you can take away with you to do some sleuthing. I am going to describe what I found when I analysed over 4500 papers.
Jeff Drazen delivers a powerful message on the use of medical evidence in critical care. Medicine is powered by knowledge, but how do we know what is true and what is not? How do we deal with uncertainty in a setting where outcomes are not closely related to known variables? For example, although there are a few people who have survived jumping or falling from an airplane at high altitude, it is a rare event. Thus, a test to determine how to prevent death from such a disaster would only take a small number of participants to see if a particular method works. In contrast, when considering a medical condition where a large fraction of people might seemingly “recover” without treatment, such as tuberculosis, how does one determine if a treatment is effective? In this talk Jeff discusses the trials surrounding blood glucose control in the Intensive Care Unit (ICU). The way we have dealt with increased blood sugar levels in critical care has changed over time. Whereas once upon a time there was little thought given to high blood sugar levels, this changed in the 90s. One single centre paper was the catalyst for a move toward tighter glucose control for patients in ICU. Due to the novel question and well-designed study, this paper was published in a prestigious journal – even if there were questions surrounding its validity. Larger, multi-centred papers were not published until many years later due to normal logistical and financial constraints. In the interim, the initial data had informed policy. Therein lies the problem. Join Jeff as he highlights the benefits and potential pitfalls in medical research by telling the story of tight blood glucose control in the ICU.
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Medicine is powered by knowledge, but how do we know what is true and what is not? How do we deal with uncertainty in a setting where outcomes are not closely related to known variables? For example, although there are a few people who have survived jumping or falling from an airplane at high altitude (http://zidbits.com/2010/12/can-you-survive-a-freefall-without-a-parachute/), it is a rare event. Thus, a test to determine how to prevent death from such a disaster would only take a small number of participants to see if a particular method works. In contrast, when considering a medical condition where a large fraction of people might seemingly "recover" without treatment, such as tuberculosis (http://www.who.int/mediacentre/factsheets/who104/en/print.html), how does one determine if a treatment is effective? In this talk, I will examine how we gained knowledge about tuberculosis as an example of a disease where a combination of observational scientific findings and clinical trial data are linked to advance knowledge. I will also discuss other examples of clinical trials challenges and the solutions to these challenges.
Michael Perlmutter guides you through the prehospital diagnosis and treatment of sepsis.
Sepsis is a difficult diagnosis to make. Even in the hospital, where a plethora of tests are available to assist the clinician.
The diagnosis remains a challenging one, due to the very nature of sepsis. A shadowy shape-shifter notorious for its ability to hide in plain sight.
For now, even in-hospital, there is no test with perfect sensitivity or specificity for sepsis.
This is especially true in the prehospital environment, where we must rely on tools we can bring into the field: physical exam, point of care tests (lactate/venous gas), assessment of end-tidal CO2, and ultrasound.
The aim of prehospital sepsis care is two-fold – early diagnosis and early treatment. First, early diagnosis of cases ranging from early sepsis to septic shock. Point of care testing is essential.
Measurement of EtCO2 serves two purposes: as a reasonable surrogate for lactate and providing an accurate respiratory rate. A vital sign that is notoriously poorly assessed.
Respiratory rate plays a key role in both SIRS and SOFA/qSOFA criteria for sepsis, making an accurate count essential. Ultrasound should also play a pivotal role in prehospital sepsis management.
Much has been made of the prehospital FAST exam, however, the ability of POCUS to gauge fluid responsiveness and cardiac function is far more useful.
Assessment of the IVC may aid in determining the value of volume resuscitation by helping to identify patients who are responsive to volume and those who would be better served by early initiation of vasopressors.
Similarly, assessment of cardiac function may prove extremely useful in selecting a pressor. POCUS may also assist in differentiating sepsis from other aetiologies by identifying a source, such as pneumonia. The second fundamental aim is treatment equivalent to that available in-hospital. This includes judicious administration of balanced IV fluids guided by POCUS and clinical assessment of fluid responsiveness, early pressors, and early antibiotics, particularly where transport times are significant.
When sepsis is diagnosed by EMS, a “sepsis alert” should be communicated to the receiving hospital, to facilitate ongoing early, aggressive care upon arrival of the retrieval team.
Advanced prehospital diagnosis and treatment can produce dramatic reductions in mortality from sepsis.
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Endothelium was once thought to be an inert organ. However, it plays an important role in multiple functions. These include coagulation, inflammation and determination of vascular permeability.
He then gives a brief overview of the endothelial arrangement, function of the glycocalyx layer and how an injury causing a loss of the protective layer results in holes in the endothelium. The inflammatory cells enter via these holes and causes oedema in the affected organs leading to multiple pathologies.
Danny then explains the role of endothelium in controlling cell barrier function. Activation of cortactin protein and the myosin light-chain kinase (MLCK) enzymes activate stress fibres resulting in pulling of endothelial cells thereby increasing its permeability.
Danny discusses the role of endothelial dysfunction in acute respiratory distress syndrome (ARDS) at macrovascular, microvascular and molecular levels. Macrovascular thrombosis is related to an increase in severity of ARDS, pulmonary hypertension, and mortality.
At a microvascular level there is a loss of vascularity and increased blood vessel thickness. At a microscopic level, endothelial cells appear swollen and damaged in ARDS. Endothelial dysfunction drives organ dysfunction and mortality. Changes in various endothelial markers like increased von Willebrand factor (vWF), decreased protein C and increased pulmonary dead space correlate with increased mortality.
Studies show that endothelial dysfunction is a more specific and sensitive method to predict mortality of critically ill patients when compared to SOFA score, SAPS 2 score and WCC. Danny discusses ventilator strategies for endothelial cells in ARDS patients. Lowering the tidal volume of ventilators and employing recruitment manoeuvres are such strategies.
Both of these cause a decrease in oedema by reducing endothelial permeability. He then shares the various potential pharmacological treatments for treating endothelial damage. These include statins and spingosine-1-phosphate (S1P). Different studies on the effect of statins in ARDS show contradicting result.
However, targeted therapies can be designed by studying the phenotypes and molecular basis of ARDS in each patient.
The role of the endothelium as a mediator of critical illness by Danny McAuley
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Bill Knight explains the concept of death by neurological criteria and the complexities surrounding organ donation in such situations.
Bill discusses the process of dying, the definition of death, how to approach the neurologically dead patient and how to consider organ donation.
Death is a complex topic. Due to advancements in medical technology and processes, the definition of death is a challenging one.
Bill talks at length about the definition of death by the neurological criteria. Dying is an active process, whereas death is an event.
The acceptance of death by the neurological criteria is often challenging as Bill will highlight. Bill talks about the care of the dying or dead patient.
There is a point at which care will transition from supporting the patient to supporting the organs. This is still good care. There is an alignment of parallel intentions – first and foremost resuscitation of patients and then failing that, proceeding to considering and actioning organ donation. This is important due to the shortage of viable donor organ worldwide.
The donation process itself is complex. Bill provides his thoughts. He insists that an intensivist be involved as this has been shown to increase the number of viable and healthy organs made available.
The timing is also important. Available evidence does not support the need for immediate procurement after brain death. Taking time to optimise perfusion and allow recovery and cardiac function is appropriate and should be done.
Bill also discusses other treatment options at the time of death such as optimising endocrine function.
Finally, Bill will provide some practical considerations when communicating with the dead patient’s family. This involves being clear on your messaging. You are supporting organs, not life.
To reinforce this point, Bill suggests not examining or talking to the patient. He also recommends using all of the available hospital support services.
Similarly, it is best to not introduce the topic of organ donation to the family yourself as the treating clinician. Utilise the Organ Procurement Organisations (or similar services) and get them involved early to speak with the family.
Join Bill Knight in his talk on the North American perspective on Organ Donation, brain death and management of the brain dead donor prior to organ donation.
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Greg Kelly focuses on transferable skills from adult practice applicable to the collapsed neonate, taking us first through a systematic approach to the common underlying causes and the physiology behind them. He outlines a comprehensive approach to the clapped out baby even when the underlying cause isn't immediately clear and reassures us that there are plenty of simple interventions we can undertake.
Allow me to introduce to you this extraordinarily talented doctor. John Hinds became involved in our motorcycle racing medical team as a medical student and progressed to inspirational teacher and natural leader. He had a burning passion for improving the care of the injured and on qualification it was evident he was destined for greatness within the world of critical care. In his role as Delta 7 for the Northern Ireland Ambulance Service and as a travelling doctor at motorcycle races in Ireland Doc John brought the highest standards of care and compassion to the most unfortunate at their hour of greatest need. I took this young man as my pupil teaching him the role of motorcycle doctor and quickly realised this exceptional doctor was truly special. In truth the pupil quickly became the master and I had the privilege of 15 years of working alongside him as his wingman.
Where does the abdominal assessment occur when you manage a paediatric trauma patient? Warwick Teague challenges us to stop just leaving it to the paediatric surgeon as he talks us through his approach to the abdomen in a paediatric trauma, including the key aspects of assessment and treatment - so simple, he says, even a surgeon can do it.
Trish Woods guides you through some clinical pearls in the intensive care management of neonates.
The complex physiology of the transitioning required in the journey from foetal life to neonatal presents many challenges and scary moments.
Trish helps you to navigate these challenges and to unlock the key to providing quality neonatal intensive care. Many things can go wrong in the neonatal period as babies transition to life in the real world. Trish highlights her thoughts on the use of positive end expiratory pressure (PEEP), how deep to intubate, when to clamp the cord and the use of ultrasound.
When babies arrive early their lungs can be full of meconium or fluid. Due to this, Trish recommends using PEEP – without which there is distal airway collapse and fluid accumulation.
Aeration of the lungs is vital. To this end, how deep should intubation be aimed? The depth may not be overly important. This is because regional lung aeration triggers widespread, global increase in pulmonary blood flow.
There is little definitive evidence to guide clinicians on when to clamp the cord – early or late. Trish recommends considering the physiology of clamping the cord.
After clamping the cord there is a massive drop in cardiac output. Ventilatory support will turn this around – something to remember.
In a compromised baby, perhaps we should aim to clamp the cord sooner and then initiate ventilation.
Finally, Trish highlights the utility of ultrasound. Viewing the heart and lungs provides crucial information for the clinician.
Furthermore, Trish discusses actively looking for aeration, collapse, consolidation and pneumothorax in the lungs and thorax.
Overall, don’t forget the essentials. Trish reminds you to keep life sweet, warm, and tempting and help neonates to transition into the big world.
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Deirdre talks ‘bad blood’ – the complex world of critical care haematology. Critically ill patients frequently have activation of inflammatory and clotting pathways. These are likely adaptive responses in the human. When they run riot, or the fine balance between pro- and anti-inflammatory states is shifted, there can be significant morbidity and mortality. Deirdre presents three patients to highlight these issues and what you can do about it. This acronym-busting talk will focus on some acquired haematological disorders in critically ill patients. Platelets make up a tiny percentage of blood – just 0.01%. However, they have a crucial role to play. A low platelet count can be due to reduced production or increased destruction. Disseminated Intravascular Coagulation (DIC) is a clinical and laboratory diagnosis that affects about 1% of hospitalised patients. At the most severe end it is associated with bleeding and/or thrombotic complications. Disorders such as thrombotic thrombocytopenia purpura (TTP) and other forms of micro-angiopathic haemolytic anaemia (MAHA) will also be described including the role of ADAMST13. The knowledge of what is what, is critical, as it will dictate treatment. Heparin-Induced Thrombocytopaenia (HIT) is an uncommon but important condition which is difficult to diagnose in a critically ill patient. It is a heparin dependent pro-thrombotic disorder. There is no good test for HIT. Have you always wondered about NETs (neutrophil extracellular traps) and their importance? If so this whistle-stop tour of non-malignant hematology in the ICU is for you! Deirdre drives home the message that low platelets are common in the critically ill and the causes are multifactorial.
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Mervyn Singer discusses the use of biomarkers in critical care. Multiple biomarkers - physiological, biochemical, biological - can prognosticate early in critical illness, even in the ED. These biomarkers are numerous - lipids, progesterone, troponin, thyroid stimulating hormone, inflammatory cytokines, mitochondrial dysfunction… so on and so forth! Prognostication can happen as early as the Emergency Department. Studies from the States have found high levels of inflammatory cytokines can predict death, separately from clinical presentation. Therefore, we can predict when critically ill patients are destined to die. So, does this mean that we are just prolonging the life of those destined to die in critical care? Perhaps. Mervyn discusses this being the possible reason for many failed ICU studies. Concurrently, the only progress in critical care in the past 20 years may be due only to less iatrogenic harm. Furthermore, he explains his experiments with rats demonstrating the use of cardiovascular parameters, cytokines, troponins and even cholesterol being accurate prognostic biomarkers. Then, Mervyn goes on to identify the use of steroids in sepsis. He talks about research that demonstrates a benefit to steroid use, but only in those patients predicted to die using the aforementioned biomarkers. This could be a key to selecting an appropriate patient group to allocate a specific treatment too. Furthermore, we examine treating sepsis with beta blockers. Giving beta blockers to everyone has no effect at best and a harmful effect at worst. However, giving beta-blockers to those who were predicted to die conferred benefit! In conclusion, we can predict outcome early in disease. This may allow better selection of patients for certain treatments! We thus need to adopt a completely different strategy for such patients predetermined to die. This also applies to trial design, especially where survival is the endpoint.
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Jim Manning presents the how and why of adrenaline in cardiac arrest. The use of adrenaline in cardiac arrest resuscitation has been popular since the 1960s. Laboratory studies and anecdotal experience showed improved rates of return of spontaneous circulation (ROSC) with the use of adrenaline at small dosages. This led to the widespread adoption of adrenaline administration during cardiac arrest into every resuscitation guideline for decades to come. Extensive laboratory studies characterised the beneficial physiological effects of adrenaline during cardiac arrest and closed-chest cardiopulmonary resuscitation (CC-CPR). Adrenaline administered during CC-CPR results in peripheral arterial vasoconstriction that raises the aortic pressure. Particularly during the relaxation phase of CC-CPR. This increase in aortic pressure results in an increased aortic to right atrial pressure gradient that drives blood flow to the myocardium during CC-CPR. This pressure gradient is known as the coronary perfusion pressure (CPP) and this correlates with ROSC in laboratory investigations and clinical studies. During the 1990s, the use of “high-dose” adrenaline showed increased rates of ROSC compared to “standard-dose” adrenaline. However, larger doses of adrenaline did not result in improved survival. Recent meta-analyses have raised serious questions about the value of adrenaline. Notably, showing a benefit for achieving ROSC but no clear evidence of improved long-term survival. Controlled clinical trials to address this question are now underway. However, there is another important issue that needs to be addressed: the “route” of administration. With the growing interest in endovascular resuscitation, the use of intra-aortic adrenaline titration offers a means of rapidly and effectively delivering adrenaline to peripheral arterial effector sites while providing arterial pressure and CPP monitoring to guide titration of adrenaline doses to achieve an optimal hemodynamic effect while avoiding excessive adrenaline doses.
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Congenital heart disease isn't just diagnosed in the antenatal period and during post-natal examination. Nick Pigott takes us through the three main presentations of congenital heart disease (shock, cyanosis and heart failure) and reassures us that treating these patients is simpler than we think, urging us to consider cardiac disease in the sick newborn. He covers duct-dependent lesions, structural obstructive lesions, immediate resuscitation, the usefulness of physical examination, a deeper dive into hyperplastic left heart syndrome, the known cardiac patients (and what to do with them) and the paediatric cardiology wonder-drug: Prostaglandin infusion.
Working in a Paediatric Emergency Department that has 52,000 attendances per year, means that at this point I have fallen into almost every possible pitfall associated with communicating with children and their parents, whether it be the seriously ill or the efficient disposition of the worried well and everything in between. The art of appearing to take all the time in the world whilst managing large volumes of patients can be challenging at times. It can be difficult to separate your emotional response to a patient and their parents from your professional assessment. I hope that by hightlighting mistakes I have encountered along the way that others will learn from them.
John Glasheen discusses the importance and challenges of trade-offs in prehospital critical care.
Every Pre Hospital and Retrieval Medicine (PHARM) mission involves a series of complex decisions. These are made rapidly in a high-pressure environment.
Excellent PHARM clinicians are invariably expert decision makers. The ability to identify, accept and manage trade-offs is a key skill in prehospital and retrieval medicine.
Some of these trade-offs are obvious, and the best options are clear. For example, aircraft and crew safety cannot be compromised regardless of the clinical situation on scene.
Other choices are far more complex. These require rapid and accurate cognitive appraisal of a dynamic and often incomplete information set.
Moreover, interventions performed on scene, involve a balance of the patient’s immediate requirements against time and risk.
During a mission, each decision to do something leads to how and where it should be done. This often results in a trade off between principle and preference.
Decisions on which team member should perform a particular procedure must balance competence, training opportunity and the concurrent performance of other tasks.
Every mission is a continuous efficiency-thoroughness trade-off, and each individual decision must be made to positively affect overall patient care.
Furthermore, there is often no single ideal solution to these trade-offs. We must tailor decisions to circumstances.
The way in which the clinician manages these trade offs is vital both for effective patient care the overall performance of the mission.
Excellence in PHARM is a function of training and experience, with expert clinicians operating within a robust system that allows for flexibility. Protocols are powerful but individual insight is indispensable.
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A demonstration in the ECMO-CPR process and then going back to basics, to understand the need for such a process and how to design and develop it from scratch using simulation to cut lead time and highlight and remove issues prior to rolling out on the patients. Making E-CPR both possible and safer.
Sara Gray presents an incredible case highlighting the importance of resuscitative hysterotomy. The story is full of drama, moments that went well and moments that went poorly. It demonstrates the key points when considering this emergency lifesaving procedure. The case is a woman who is eight months pregnant and has an out of hospital cardiac arrest. The call comes in advising of an imminent arrival. This is where the preparation for a perinatal resuscitation and resuscitative hysterotomy begins. The first thing to consider is a Code OB – a maternal cardiac arrest code. This will bring neonatal doctors, obstetricians, specialist nurses, airway specialists and all the specific equipment required to the department. A Code OB can be a life saver – if you do not have this, Sara implores you to implement it. Next, you must consider which room will be used for the resuscitation. The room should have two beds and lots of space. As you are organising this, mental preparation should begin. The uncommon and serious nature of a resuscitative hysterotomy makes it a highly stressful situation. This leads to hesitation. Moreover, mental preparation in this situation is tremendously valuable. This is because it makes hesitation less likely, and appropriate action more likely. That appropriate action is the resuscitative hysterotomy which is lifesaving for three reasons. Firstly, it relieves aorto-caval compression allowing better venous return for the mother. Secondly, it improves pulmonary mechanics by allowing free and unobstructed movement of the diaphragm. Lastly, it reduces maternal oxygen demand once the baby and placenta are delivered. This leads to a maternal survival benefit of 32% and a neonatal survival benefit of 50%. Furthermore, in relation to timing, the well promoted 4-minute rule is a myth. Recent data shows maternal survival out to 15 minutes and neonatal survival out to 30 minutes. Mean time for resuscitative hysterotomy is 16 minutes. This does not mean that time is not of the essence, it absolutely is. However, it does mean that 4 minutes is not the cut-off. The aim should be to do it as soon as possible. The procedure itself is not complicated, aside from the fact that a resuscitation is still ongoing concurrently. Sara talks you through the procedure and the required equipment. This talk is a dramatic and fascinating 101 on the resuscitative hysterotomy. Sara wants to let you know – you can do this!
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David Halliwell presents the science of cardiopulmonary resuscitation. Resuscitation means lots of things to different people – compression, CPR, mouth to mouth, ventilation, return to normal and reanimation all come to mind. But how and why does resuscitation really work – let David explain. This talk uses a case study approach to discuss why resuscitation practitioners should focus upon technical accuracy when resuscitating, focussing on all the facets of a resuscitation, compression, decompression, trans-thoracic impedance. Two points David would like you to take away: 1) Blood flows from high to low pressure even when the heart stops beating and 2) Blood doesn’t flow through the heart during systole. David talks about the two big theories of cardiopulmonary resuscitation. The first is the heart squeeze theory – that being chest compressions will pump blood out of the heart and around the body. This is as opposed to the thoracic pump theory which states blood flows due to a pressure gradient and by changing the pressure in the thoracic cavity you enable the blood to continue to move. This is enabled by the papillary muscles and valves failing to work in an arrested heart. The truth is probably that both theories hold merit and a combination of both enables a successful resuscitation. David calls this the lung pump theory. After discussing theory, David moves on to the more practical aspects of CPR. Firstly, compression – compressions clear the heart out. Without compressions, the right ventricle fills with blood (due to the pressure gradient) that cannot move through. This splints the right heart against the collapsed left heart. Secondly, ventilation. David warns of the complications caused by improper and inappropriate ventilation which will decrease venous return and make your compressions futile. Finally, defibrillation. There are a few important points here. The critical mass is the left ventricle, so get the pads as close to this as possible. Prepare the skin (which involves knowing how to use the razors in the defibrillator kit) and place the pads appropriately. David concludes with some technical issues that need to be remembered, performed correctly, and watched out for. These include chest compression depth, compression rate, hand placement and consistency.
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The child with the reduced conscious level presents a unique challenge to the Emergency provider - how can we recognise normal sleepiness versus pathology? Natalie May reminds us that, even if it's after bedtime, we have to take the time to wake children up fully as part of our routine assessment. She then explores the common pathologies - 5MF! - we need to consider in children with a reduced conscious level and how we can figure out which one is in front of us.
Pierre Carli expands on the prehospital and critical care responses to terrorist attacks.
For retrieval medicine specialists and prehospital care providers, terrorist attacks are a new and unique threat. As Pierre impresses on you, terrorist attacks are not accidents. They are a targeted human activity whose purpose is to kill, injure, and inflict the maximum amount of human casualty as possible. They do this with the intention of disrupting society, spreading feelings of fear and panic and inflicting feelings of insecurity in the population. Terrorism is not blind.
Terrorist attacks involve organised strategy that is much more complex than any natural or technological disaster. To oppose an aggressive strategy a static plan is not enough. Pierre highlights the need for a counter strategy, comprehensive and adaptable enough to counteract this and deal with a multitude of scenarios. This begins with effective leadership, combining the expertise of the Police, Rescue and Emergency. Prior preparation will allow the best possible emergency response. Terrorist attacks raise the possibility of multi-site, multimodal attacks.
To face such complex situations requires a coordinated response. Pierre discusses improvements of prehospital and in hospital organisation and protocolisation for massive casualties. Alert shared by all services, close coordination between Rescue Police and Emergency care, backup on a regional basis is crucial. Similarly, strategic allocation of resources and keeping reserve for the next attack are some of the options that may be extremely helpful.
Next, there needs to be consideration toward improvements of care for injuries related to military weapons. Injuries that are common in terrorist scenarios are major penetrating trauma and major haemorrhage. These are the results of powerful bombings and assaults riffles. Management of these victims is very different of the care of a multiple trauma patients after traffic accidents. Pierre also discusses adaptations of the principles of the military “damage control” to civilian practice. From the scene to the operating room and the critical care unit, all actions must be coordinated to prevent the death triad - hypothermia, coagulopathy and acidosis.
Finally, Pierre talks about resilience. The action of Health Care Services is not limited to medical care, it is also the first step of resilience. By maintaining the quality and the organisation of care despite surprise, violence and aggression you oppose directly the objectives of terrorism.
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Ciaran McKenna discusses 3D printing of high fidelity simulation equipment. Simulation training is useful, but it is often a costly exercise. However, according to Ciaran McKenna, it doesn't have to be. Ciaran shares his experience of using 3D printing to create simulation equipment. According to Ciaran, anyone with basic computer skills is capable of making their own 3D solutions for simulation training. For example, he demonstrates how to design and print a basic mackintosh blade using 3D modelling. Training for rare procedures can be very costly using the traditional simulation methods. However, training for such procedures shouldn't be avoided. Therefore, creating low cost, high fidelity SIM equipment is key. Furthermore, Ciaran explains how 3D scanners can be attached to iPads to take accurate facial contours of a person. Ciaran demonstrates how to make a mould of a person’s neck and then 3D print it. This mould is re-usable and cost effective. Ciaran discusses the benefits of 3D printing and how it is an excellent alternative to expensive simulation equipment that is often out of reach for many facilities. Ultimately, 3D printing of high fidelity simulation equipment is a good option. Ciaran is hopeful that more people will reap the benefits of 3D printing in the future.
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Diana Badcock begins the talk by discussing her decision to take up the role of Chief Medical Informatics Officer (CMIO).
Diana was optimistic about taking this job. However, she left the job after a year. Though she failed in the job, Diana thinks she learnt a lot about failing with fortitude.
Diana next talks about the death of her father who was very healthy throughout his life. Three months before his death, he went for a check-up as he was not feeling well. However, he was reassured by the doctor that everything was fine without conducting any tests.
Diana, therefore, feels that both she and the system failed her father. Doctors today are overwhelmed with the volume of patients who are older and have more complex conditions, morbidities and mortalities.
Many feel that technology is the solution to the problem. However, the amount of money spent in health IT does not reflect the value of the product.
This happens because the design of the technology does not match the user experience. Therefore the role of CMIO, CNIO or CCIO is very crucial because the end user has to be there when the technology is being developed.
However, Diana feels that CMIO does not get any support either from their colleagues or the organisation. While her peers expected her to help them with their daily IT tasks like opening emails or changing passwords, the organisation treated her like a child or a mere token.
This is because a clinician is naïve in the ways of governance, politics and project management. The solution is to involve clinicians in the planning, delivery, improvement and evaluation of clinical ICT systems. Clinicians should be responsible for clinical documentation, single sign on and medication management while the project manager should only manage the project and not the people.
Technology should be the enabler, not the driver for health IT. Diana thinks clinicians should focus on bringing about clinical intra-operability to have a simple, standardised way of managing common conditions.
Roles like Chief Medical Informatics Officer, Ideas Officer, Innovation Officer, Improvement Officer will be coming up in the future and clinicians should take up these posts to improve the system from within.
In conclusion, we need to learn to respond and respect the other silo business of health so that we can work together to analyse, dissect and transform healthcare.
Medical Informatics improving healthcare outcomes
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Resa Lewiss tells you how ultrasound improves resuscitation outcomes in critical care. Ultrasound helps you make more accurate diagnoses. It allows you to perform procedures with fewer complications, and ultrasound enables you to be more time and cost efficient. However, there may be more to ultrasound - Resa enlightens you.
The ultrasound allows the clinician to interact with their patients. Further, Ultrasound enables patients to be integrated into their own care and it allows for an element of creativity.
Moreover, Resa explores the idea of reciprocal illumination – the process of exchange and education between clinician and patient. It is the dialogue that occurs between the two and allows for different and deep thinking.
Evidently, what underpins these thoughts is the idea of creativity. Resa asks you to consider how you are creative with your hands. It may be gardening, knitting, playing a musical instrument, writing, or even washing the dishes. Working with your hands is the gateway to creativity. Working with your hands in an intentional and purposeful way, on a regular basis elevates your mood and decreases stress and anxiety. The science supports this.
Furthermore, a hand-brain interaction is stimulated, fostering creativity. In bringing these ideas back to the Emergency Room, Resa explains that by using your hands through ultrasound, you are enabling creativity and open communication with your patients.
Moreover, Reciprocal illumination – enhancing both care and outcomes. Resa describes the evidence behind this idea. Patient’s overwhelming welcome ultrasound at the bedside in the Emergency Department. They agree that it improves patient care and increases efficiency of their treatment.
Finally, Resa concludes by pondering the idea that ultrasound may also lead to great benefits for the clinicians themselves.
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'"Think of the danger while things are going smoothly." Chicago's own Lisa McQueen picks apart the challenges of identifying those children who genuinely need sepsis resucitation in the "pre-shock phase" and explores the pathophysiology and treatment of shock in children.
Two simulations for prehospital care - tactical and motorcycle pit crew with a panel discussion debrief following. Demonstration and discussion of the medical response to these incidents.
Haney Mallemat informs you how technology is improving healthcare. Haney’s talk is grounded in a patient experience. Jim is a gentleman from a small farm in a rural area of United States. His farm is everything to him and his wife and daughter. When Jim got seriously sick, he had to have an extended stay in a major tertiary hospital. As a result, he and his family lost their farm, which was their world. Could Jim have been treated locally with the utilisation of technology? Haney thinks technology may be the way of the future in medicine. Through the utilisation of technology which already exists, patients such as Jim can stay in their communities and have more holistic outcomes. There are three areas Haney discusses. Telemedicine Defined as medical information exchanged though electronic telecommunications to improve a patient’s outcomes. Traditionally telemedicine is big, bulky, and complicated. This brings with it resistance to use. However, with the advent of lighter and faster computers, telemedicine becomes more and more possible. It is also being compacted into our smartphones making the possibilities endless. Patients are not opposed to telemedicine – surveys show the opposite. They would prefer to not wait endlessly in clinics and travel unnecessarily. Robotic surgery This technology is truly remarkable. Fine movements are possible with precise control. This translates to improved patient outcomes. These include smaller incisions and shorter recovery times. Compounding these benefits, surgery can be performed from another continent. The possibilities for under resourced areas are endless. Mobilisation of products and services Drones are becoming ubiquitous. They have medical applications when thinking about the fast and efficient delivery of supplies, vaccines, and medications. This provides great benefits for hard to access areas, whether that is in developing countries, or across city in peak hour traffic. On top of this, ‘paramedic drones’ have been developed, delivery equipment and telecommunication hook-ups to medical professionals rapidly to accident scenes. Let Haney Mallemat educate you on the future of technology in medicine!
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Flavia Machado gives you the ins and outs of a day in the life of an ICU doctor working in Brazil. She addresses healthcare inequality, ethics, and the challenges she faces in a developing country. By sharing a blow-by-blow account of a day at work, Flavia demonstrates the challenges and inequality that exists. And whilst poverty is shocking, Flavia believes inequality is worse. Flavia’s day begins in the morning with a ward round. Critical bed shortages mean that the clinicians have to make impossible decisions – which patients will get allocated one of the scarce beds? At 07:00am every morning, Flavia and her colleagues in the ICU have to play God. Inequality is plain to see. It is graphically depicted when looking at a map of the distribution of ICU beds across Brazil. In the north, an area of greater disadvantage, there are far less ICU beds per capita. Flavia continues her day, but the challenges do not stop. She checks WhatsApp later in the morning and is inundated with issues pertaining to medication shortages and equipment supply issues. The issue of a broken defibrillating is upsetting, but not unexpected – to the point of her staff using humour to cope with the desperation of the situation. Later in the day Flavia has clinical decisions to make. However, she cannot rely solely on her clinical reasoning and skill as a doctor. There are external pressures that exist – from judges, from industry, from scientist and researchers – and she feels all of them. Sometimes, Flavia feels the strain of operating in these challenging conditions in a middle-income country. Sometimes she feels the futility of it all, like pushing a stone up a mountain, or filling the impossible to fill vessel. That being said, Flavia can see the progress that is made and at the end of the day, she and her team remain happy in doing what they do!
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Dr Anne Creaton talks about the healthcare capacity building in Fiji. Fiji was struck by Cyclone Winston in 2016. It caused widespread devastation and the impact will be felt for a long time in the future. The most important thing that Fiji has taught her is faith, patience and persistence. Anne begins by talking about the three Rs that are essential in trainees who want to work in Fiji or similar situations. The three Rs being: Realistic, Resilient and Resourceful. Emotional intelligence is also very important. Most of the people are highly trained, but always in a high resource environment. Dysfunctional systems in places like Fiji, can impact the clinician’s welfare and performance. Critical care systems are made up of multiple building blocks with doctors playing a small part. Anne compares critical care systems in Fiji to a game of Jenga. This is because multiple blocks that are essential for critical care systems are non-existent. Anne divides the Jenga blocks of a critical care system into three: a pre-hospital block, a hospital block, and an administration and governance block. The pre-hospital block consists of scene care, transport care, communication, hazmat, decontamination and retrieval. The hospital blocks consist of factors like triage, medical assessment, equipment, drugs and patient flow. The administrative and governance block provides data, audits, leadership and human resource activities such as training, recruitment and retention. All these blocks put together form the critical care system. This illustrates how when the different blocks in critical care services are removed, it makes it very difficult to successfully treat a patient. She explains how doctors face multiple difficulties like faulty equipment, untrained staff, lack of timely transport vehicles, inaccessibility to interventional cardiology, lack of risk management and quality improvement. They also lack hazmat, decontamination, personal protective equipment (PPE), proper communication. Anne then gives an example of using the three Rs technique to reduce VF arrest by early defibrillation. Realistic: Automatic external defibrillator (AED) for all health facilities. Resilient: Placed all AEDs in pelican cases. Resourceful: Acquired the AEDs via Twitter. Anne ends by saying that life is about expectation management and you need to understand that there will be a gap between the type of care you want to provide and what you will be able to provide in situations like Fiji.
So, are you ready to play critical care Jenga?
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The paediatric airway terrifies many of us: at the smaccMINI paediatric critical care workshop, Fran Lockie explores some real-life examples of airway challenges and considerations. He takes us through the concept of the "airway bundle" and how teamworking and communication is key to improving paediatric airway care, emphasising the concepts we can borrow from adult practice to offload some of our cognitive burden and outlining the key components of first-class post-intubation care, with pitfalls and pearls of wisdom from his experiences as a prehospital clinician. Phil Hyde follows on with the nuance of assessing paediatric ventilation, starting with simple interventions and exploring the factors that make big differences for children in respiratory distress.
Andrew Chow gives a rapid breakdown of malignant cerebral artery (MCA) infarction and the utility of decompressive craniectomy. An MCA infarction is an ischaemic stroke, affecting the total or subtotal area of the MCA. It involves the basal ganglia (at least partially) and may involve the adjacent territories. The incidence is 10-20 per 100 000 and there is a high mortality rate of up to 80%. Early clinical symptoms of MCA infarction are contralateral hemiparesis, gaze deviation and hemisensory neglect. A malignant infarction will then progress to severe headache, nausea and vomiting, papilloedema and reduced consciousness. The pathophysiology underlying these clinical signs is complex and involves a failure of sodium pumps, leading to cellular swelling, metabolic failure, tissue necrosis and breakdown of serum products. So, how do you predict who progresses to a malignant MCA infarction? Andrew will guide you through the three domains to consider: Radiological, clinical and pathological. From there, the management. Medical management is grounded in methods to reduce the intracranial pressure. This includes admissions to a stroke unit, high dependency unit or intensive care unit. Elevating the head to greater than 30 degrees and maintenance of normal clinical variables are other considerations. Surgical management involves decompressive craniectomy. This procedure first described in 1935. It is not a benign treatment and there are a number of complications. Andrew discusses the risks, and the preferred methods of the procedure to enhance outcome. He also describes the risk benefit analysis that should be undertaken before recommending this treatment to a patient with a malignant MCA infarction. In doing so, Andrew takes you through the landmark trials looking at the use of decompressive craniectomy.
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Natalie Thrutle educates on the critical issue of lead poisoning in developing countries. Critical care means different things to different people. In the context of lead poisoning, you may or may not think of developing countries such as Nigeria. The response to the Zamfara state, lead poisoning outbreak, in Northern Nigeria, is unprecedented and requires a nuanced interpretation of ‘critical care’. In 2010, 400 children died from lead encephalopathy in the largest lead poisoning outbreak ever recorded, affecting more than 5000 children in Zamfara. The outbreak is ongoing. Children were presenting with intractable seizure and coma, not responsive to treatment for malaria and meningitis. 50% of these children were dying. Environmental poisoning was considered early on, due to the high levels of artisanal gold mining in the area. This increase in mining was a major economic boom to a remote and rural population much in need. MSF had never dealt with a lead poisoning outbreak before… neither had the Nigerian government. No one had ever dealt with a lead poisoning outbreak in the world before. It had never been seen. Initially there were three main aims. Chelation, remediation, and safer mining practices. Whilst chelation worked, it would have been futile without an effort to clean the environment (remediation). This in turn was futile without considering safer mining practices. The solution to the problem required by in and input from all parties. Herein lay the challenge. Parallels with the Ebola outbreak in Guinea can be drawn. In this instance there were attacks on both healthcare workers and quarantine facilities. Zamfara did not see such extreme reactions although there was certainly a feeling of animosity and resistance coming from the mining community. In this talk, Natalie highlights the successes and the ongoing challenges of facing this issue head on. Progress has been made, and challenges still exist.
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Nikki Blackwell tells her story of the emergency response to the Ebola outbreak in Nzerekore, Guinea. She chronicles the enormous challenges of providing care to some of the most vulnerable people in the world, in one of the most under resourced and challenging environments.
The Ebola virus was first isolated in 1976. Between then and 2013 there were twenty outbreaks of Ebola. However, the outbreaks, although vicious, were relatively small and in isolated areas. This outbreak was by far the most complex, with a mortality rate of up to 40%. The fruit bat is the natural host and reservoir of Ebola. They transmit it to other animals, and ultimately humans. Human to human transmission occurs from body fluids, mucous membranes, and sexual contacts.
Nzerekore, Guinea has a terrible health service and infrastructure stemming from a long period of conflict. This is further exacerbated by the scarce number of doctors. Further, what compounded the problem even more was the delayed recognition and action from the international community.
Eventually, Nikki and the Médecins Sans Frontières (MSF) had funding to launch a project, providing care to the region that was dealing with a devastating epidemic. What followed was an eye-opening experience for Nikki and her team. Nikki highlights the endless challenges she faced in delivery care in her role as Medical Director on the project. These include hot, dusty conditions with the constant stench of chlorine. Heavy, thick biohazard suits that take 30 minutes to get into and can only be worn for one hour due to the extreme nature of the dehydration and exhaustion they cause.
Lastly Nikki describes the technical and emotional difficulties of providing care to this population of people with grave illness, constantly surrounded by death, all heightened by the real fear of the staff falling ill.
Finally, Join Nikki as she tells her incredible tale of the Ebola outbreak in Nzerekore, Guinea as Medical Director for the MSF.
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In this podcast, Mervyn Singer talks about the link between stress and multiple organ failure. Often, the organs involved in multi-organ failure show no signs of structural damage or cell damage that would indicate these organs might be under stress. Stress might cause functional damage rather than structural damage. Stress is a normal coping mechanism which helps to deal with the various stressors we encounter. These mechanisms include changes in behaviour, as well as autonomic and hormonal modulation of various systems. These include inflammatory, immune, cardiovascular, respiratory and metabolic systems. Human bodies are not designed to cope with the stresses of prolonged life. These stresses include old age, co-morbidities, prolonged critical illness, modern lifesaving drugs, and organ support. Mervyn discusses the evolution of various theories associated with stress. Walter Cannon discovered acute stress response in 1915 when he noticed the manifestation of nervous exhaustion as physical illness in soldiers of World War I. Furthermore, Hans Seyle described the general adaptation syndrome in 1936, stating that when in distress, the physiological systems are functionally compromised. Moreover, Takotsubo identified cardiomyopathy in the early 90s in Japan – in this condition heart failure occurs due to emotional stress. Ultimately, Sterling and Eyer defined Allostasis in 1988 as "staying the same by being different." The body goes into allostatic overload when exposed to extreme stress conditions. Type 1 allostatic overload of stress causes the organism to switch off in order to regain energy balance. Hibernation, estivation, anoxia, and dormancy are all example of allostatic response to stress. Myocardial hibernation is an example of an allostatic response in humans. Multiple markers identify poor prognosis in stressed patients. Energy and metabolism are directly proportional to each other and a reduced level of either or both can be seen in critically stressed patients. An ICU patient is under multiple stressors. These include physiological, pharmacological, environmental, and psychological stress, all of which lead to chronic critical illnesses. Thus, multiple organ failure may be an allostatic response to the prolonged stress faced by an ICU patient. Mervyn ends the podcast by suggesting multiple pharmacological and non-pharmacological methods to de-stress the patients.
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Jon McCormack gives you what you need to know in the case of paediatric blunt traumatic cardiac arrest. This is a rare but deadly occurrence. Data shows that the population incidence for paediatric blunt traumatic arrest is 1 in 100 000. Of these, most are male, and most are involved in vehicle traffic accidents, along with falls and non-accidental injuries. The median age is 7 years old. The injuries are severe, and the survival numbers make for grim reading… around 1%. So, the numbers are low in both incidence and survival. However, the cases can be deeply personal and effect the clinician and bystanders for a long time. With that being the case, coupled with the enormous upside both socially and economically, surely emergency care should “go all in”. Jon explains why this is the wrong approach. He discusses the reality of the presentation of a paediatric blunt traumatic cardiac arrest. He advises to limit unnecessary treatments and risks to yourself and team. There are potential survivors. Children who maintain a detectable cardiac rhythm and show signs of life have better survival prognostics. Children in asystole or without signs of life will not survive. Objectively assessing signs of life may be important so Jon recommends being well versed in roadside echocardiograms. However, given the fact that the vast majority of children will be in excellent health at the time of injury, if they are showing no signs of life or cardiac activity, they have likely exhausted their enormous physiologic reserve. In this instance, they are in a decompensated which will lead to death. Finally, Jon concludes with some advice. In a paediatric blunt trauma cardiac arrest, initiate CPR and basic life support early, do not resort to a thoracotomy, and organise rapid triage and transport to a trauma centre if there are signs of life. If not, be prepared to stop futile treatments.
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Stephen Bernard shares his thoughts and the current evidence for using oxygen for cardiac arrest patients. Oxygen is ubiquitous in society! You can buy it in bottles and there are even oxygen cafes. This is especially true in hospitals where oxygen is used frequently and often without much thought. Oxygen is a natural substance. So surely, a short time on 100% oxygen can’t be harmful, right? Stephen wants to challenge that idea. In this talk he presents the data on why oxygen might be harmful to your patients, particularly following a cardiac arrest. Out-of-hospital cardiac arrest (OHCA) is common and carries a high mortality rate. In Victoria, Australia, approximately 50% of patients with an initial cardiac rhythm of VF achieve a return of spontaneous circulation (ROSC) and 30% overall survive to hospital discharge. The outcome for patients is improving. This is due mainly to faster ambulance response times and increased rates of bystander CPR. What is done in the hospital has altered the patient’s outcomes in the same way. Currently, OHCA patients who have achieved ROSC but who remain unconscious routinely receive 100% oxygen for several hours in the ambulance, ED, cardiac catheterisation laboratory until admission to ICU. However, there is now evidence from laboratory studies and preliminary observational clinical studies that the administration of 100% oxygen during the first few hours following resuscitation may increase both cardiac and neurological injury. Clinical trials are underway to test whether titrated oxygen to a target oxygen saturation of 90-94% in the immediate hours after ROSC results in improved outcomes compared with 100% oxygen. Join Stephen as he makes you think twice about blindly using oxygen for patients following a cardiac arrest.
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John Myburgh speaks passionately about the use of oxygen in resuscitation, and clinical outcomes in critical care. For the 30 years, clinical understanding of haemodynamic resuscitation has been based on physiological paradigms that focus on convective oxygen delivery. Most of these emphasise the role of cardiac output, haemoglobin and recommend interventions using synthetic agents such as dobutamine, synthetic colloids and blood transfusions. However, markedly influenced by industry, these interventions and strategies hijacked critical thinking creating a belief in the utility of attaining short-term physiological surrogates for resuscitation that have little relevance in improving patient-centred outcomes. This ‘physiological fallacy’ has been demonstrated in high-quality RCTs of fluids, goal-directed therapy and catecholamines, that paradoxically inform the interpretation of new insights in the physiological basis of health and disease. In this talk John presents two halves. In the first half, he discusses oxygen delivery. He begins with the oxygen cascade and applies this to the current thinking by some on oxygen delivery in critical care. He believes the two are incongruous. Measuring and altering oxygen is achieved using expensive toys and is likely not having a great impact on patient outcomes. John questions the whole concept of driving P02 to influence patient outcomes and mortality. In the second half John talks about the ‘physiological fallacy’ – the clinical practice of relying on variables we cannot accurately measure and do not understand. He presents a different approach. Physiology and haemodynamics encompass complex processes under intense neurohormonal vasoregulation. There is no one simple metric to rely on, such as V02 or D02. When considering a patient, the clinician must use their brain. John stresses the importance of focusing on understanding the disease process in its entirety rather than chasing instant gratification by altering a number. Work out where your patient exists on a spectrum. Consider acute versus chronic presentation, as well as compensated versus decompensated patients. This will dictate treatment. The situation usually complex and dynamic… Treat it as such.
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Scott Weingart discusses the scientific aspects of meditation. He believes meditation is to the mind what exercise is to the body. There are two types of meditation: focussed attention meditation or vipassana, and contemplative meditation. Generally, people exist in a default mode network. This happens when we are not focussed on anything in particular and thoughts occur in our brain without us being aware of it. Spending a few minutes every day aware of what thoughts are occurring in our brain is highly beneficial. This helps with stress control, relaxation response control, slowing of telomere degradation, control over emotions and increased concentration. Scott, however, wants us to focus on a single objective benefit of meditation - controlling the stimulus-response gap. Viktor E. Frankl explains - “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” Meditation helps to choose our responses to stimuli, both good and bad. Scott explains how to do mindfulness meditation or vipassana.
First, pay attention to your present circumstance by linking it to your breath.
Second, be non-judgemental and forgive yourself for the random thoughts that come up while meditating.
Finally, watch moment by moment as experiences unfold. A book written by William B. Irvine on Stoics, introduced Scott to contemplative mediation. Stoicism is based on a philosophy of happiness which tries to eliminate negative emotions like hate, envy, anxiety, and fear. Scott dedicates this podcast to John Hinds by explaining how he appreciated the moments he spent with John due to his practising of mindfulness. Meditation is a way to appreciate every moment that we have in our short life. Exercise is work to live longer, while meditation is work to live better.
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Paul Young discusses remote ischaemic preconditioning and along he delves into the pitfalls of clinical research. 2016 was the 30th anniversary of ischaemic preconditioning. Remote ischaemic preconditioning is the magical offspring of ischaemic preconditioning and refers to the phenomenon whereby brief periods of ischaemia in one organ can protect other organs from subsequent prolonged ischaemic insults. Ischaemic preconditioning rose to prominence after a seminal paper in 1986 that demonstrated the protective effects of ischaemic preconditioning in dogs who had coronary ischaemia. This effect had been appreciated in humans. For instance, pre-infarct angina leads to smaller infarcts that in heart attacks without preceding angina. Remote preconditioning is for more magical. Paul takes you through the basics. The idea is simple enough. Blockage to one site leading to ischaemia preconditions another site to subsequent ischaemia. This was first demonstrated by blocking the circumflex artery in the first instance with a series of temporary occlusions. The left anterior descending was then blocked for a prolonged period. This preconditioned the heart to the prolonged ischaemia and decreased deleterious effects. This effect was then repeated with transient renal ischaemia protecting the heart from prolonged cardiac ischaemia. This effect was demonstrated with different organs – with almost any organ being able to protect another organ. The clinical application? Inflate a blood pressure cuff on an arm (to above systolic blood pressure) for five minutes and you will protect the opposite limb… or the heart. Remote ischaemic preconditioning is a reproducible phenomenon. However, as Paul explains, no one knows how it works. In this talk Paul describes his research – a double blind trial on remote ischaemic preconditioning; the first of its kind. He also describes a systematic review and meta-analysis he conducted. He found conflicting results in his trial and heterogeneity across other studies. When considering further research Paul concluded that it nothing was convincing and there were many pitfalls in the papers. What matters? What the patient can do, how they feel, whether they live and to a lesser extent does the intervention save money. In the end it seems that it is the relationship between ischaemia and reperfusion that makes a difference. That is, apply the remote ischaemic preconditioning after the primary ischaemia but before the reperfusion.
This has potential clinical implications for the following:
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Heart surgery with cardiopulmonary bypass
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Planned percutaneous coronary interventions
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Acute myocardial infarction
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CBA being treated with lysis or clot retrieval
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Carotid endarterectomy surgery
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Hypoxic ischaemic encephalopathy
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Organ transplantation
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abdominal aortic aneurysm surgery While this technique is not yet ready for clinical application, it remains an exciting potential therapeutic modality for the future. Finally, Paul finished with his top tips. Don’t believe single centre studies, consider biological plausibility, be sceptical about secondary endpoints and don’t be misled by surrogate endpoints.
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Marius Rehn examines the difficulties and importance of evidence based medicine in prehospital resuscitation. Notably, combining academic activity with pre- and in-hospital clinical practice is hard work. Being an academic in a flight suit can be quite lonely. Marius wants this to change and is passionate about increasing the quantity and quality of prehospital research. Prehospital research that examines patient pathophysiology should dictate care – as it does in the hospital environment. However, Evidence based practice pertaining to the prehospital environment is minimal. This needs to change. Evidence based medicine in the prehospital setting can dictate care, critically appraise practice and enable improvements in process and cost effectiveness whilst decreasing harms. Evidently, in-hospital evidence is different to the field application. Ultimately, prehospital research is critical, 5.8 million people die from injury every year – around 10% of the world’s deaths. Unfortunately, pre-hospital research is underfunded. So, how can we take interventions from the hospital to the streets? Marius shares three important steps: The research that is needed How to interpret the evidence Why all research is important to consider (from case studies to randomised controlled trials) Moreover, Marius highlights the need to lean on other members of the scientific community when conducting your own research. For example, a statistician is worth their weight in gold in observational studies when fleshing out regression analysis. Finally, Marius discusses the importance of information dissemination across all platforms, including peer reviewed journals and informal FOAMed platforms such as Twitter. They all have their place.
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Anand Swaminathan brings precision emergency medicine and outcomes in critical care into the light.
He will convince you to start calling diseases for what they are and as a result start offering the proper treatments and care. All disease exists on a spectrum. You can’t treat one end of the spectrum the same way you treat the other end.
This talk is inspired by a case of Anand’s. An older man presented to the ED with acute onset shortness of breath and crackles. He was treated with Lasix. More and more Lasix – even though he wasn’t improving.
Anand knew this presentation was more than just an exacerbation of heart failure. This was acute pulmonary oedema and this man needed a different treatment. Disease is on a spectrum with ‘urgent’ on one end and ‘critical’ on the other.
The umbrella term that identifies the disease needs to be spread out so that it can be placed on this spectrum by you and others around you. Calling a presentation an exacerbation of CHF when it is in fact acute pulmonary oedema is wrong and leads to harm for the patient. We have the medications and treatments for both end of the spectrum. However, they aren’t always used.
Too often disease gets miscategorised on the wrong, milder end of the spectrum. Why? First, more patients exist at this end, and we therefore default back to this presentation of the illness. Secondly, there is an inverse relationship between the severity of disease and the research guiding treatment. Therefore, the temptation is to use this research to guide management all along the spectrum. Finally, time and resources are precious. The sicker a patient is, the more of these commodities they use up so err towards an approach for milder disease.
To counteract these points Anand wants you to understand the diseases better. How? First, educate yourself and those around you to assess and treat disease properly. Call the disease the right thing and ensure proper allocation of proper and adequate treatment and resources. Secondly, spend more time at the bedside – especially early in your training. This is how you rapidly identify sick patient, and rapidly determine what needs to be done. After this talk Anand hopes you are inspired and can walk into work tomorrow and make a change. Empower each other to act by calling things what they are!
For more like this, head to https://codachange.org/podcasts/
Sue Mason gives you her take on Geriatric Emergency Medicine. Sue’s bread and butter is managing the elderly in the Emergency Department. It is not a sexy topic and there are few gizmos and gadgets. Nevertheless, it is very important. How big is the problem? Patients over 65 years represent about a quarter of the patients that attend Sue’s Emergency Department. However, most of these patients arrive by ambulance and the vast majority of visits in this age group are deemed necessary. This culminates with 50% of these patients being admitted. Attendance and admissions in the elderly age group are both going up. What are we doing about it? Advances have been made in prehospital care. In Sue’s region, paramedics have been trained in assessing and managing elderly falls. This found a reduction in ED attendance by 25% and decreased admissions by 6%. Approaching the management of the elderly with a multidisciplinary team has proved to be effective in a ward setting. This has not been replicated in the Emergency Department. Within the ED there is potential for the inclusion of a pharmacist to improve admission rates. However there has not been any other “in department” interventions involving a broader team. The initiation of interventions from the ED to continue in the community has been looked at, although the evidence is mixed. How can we do it better? Sue explores the question of whether all Emergency physicians should be trained in Geriatric Medicine. Or whether there should be sub-specialists in Geriatric Emergency Medicine. She also explores other strategies. Simple things such as not putting elderly patients on beds/trolleys unless clinically indicated and ensuring they have fluids on board. Overriding all decisions should be the question – does this patient need this investigation, treatment, and admission.
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Dr Michelle Johnston talks about dystopian futures and the relevance of emergency medicine in forming such futures. Literature can provide insights into the two types of future we can expect: an optimistic, technologically advanced future as showcased in the movie “Blade Runner” or a dystopian future as envisioned by George Orwell in the novel “1984”.
She discusses how different authors have written along similar dystopian themes with government controlling all aspects of human life. Some examples are novels like “Brave New World” by Aldous Huxley and “The Handmaid’s Tale” by Margaret Atwood. Or, “The Hunger Games”, “The Maze Runner”, and movies like “Brazil”. The common theme of these stories is oppression of the individual, non-existence or illusion of freedom, poverty, and police societies.
Michelle believes that dystopian literature is based on the tiny fears of individuals and how they react to it, shaping the future.
Therefore, she asks the question: what are the things that we do today that might lead to a dystopian future?
She begins with discussing technology in emergency medicine that already exists and points towards a bright utopia. This includes augmented reality, smart glasses, shmeat, 3-D printed replacement parts, robots, nano-robots and genome mapping. Michelle next discusses factors in emergency medicine that might lead us to a dystopian future. Over use of broad-spectrum antibiotics combined with uncontrolled use of antibiotics in agriculture, and international travel has led to increased microbial resistance. Unnecessary tests and treatments are another factor contributing to a dystopian future.
Economic inequity in emergency medicine. One side of society spend huge amounts on sustaining the last years of a patient’s life. Meanwhile, on the other side, huge populations are deprived of basic needs. Increased waste production by hospitals due to increased usage of disposable tools is contributing to climate change.
Administrative bureaucracy is another factor which though necessary, might be restricting creativity and individuality. Michelle concludes by quoting Immanuel Kant: “Even small decisions ought to be made as if we were choosing for all of humanity, not just our paltry self.”
Finally, for more like this, head to https://codachange.org/podcasts/
Mike Abernethy runs you through the pitfalls and challenges of rural trauma resuscitation and prevention. The farm is a dangerous workplace. Accidents have an unusually high morbidity and mortality not only for the worker, but also his/her family members. The reasons are multi-factorial but are the result of a complex interaction of environment, equipment and human factors. The vast majority of agricultural deaths involve tractors. No other industry uses 70-year-old machinery operated by workers whose age ranges from 10 to 90. How can we prevent such incidents? Mike is a prehospital physician (who is a wannabe farmer & tractor mechanic) and long-time resident of an agricultural community. In this talk, he will examine the details of a life-threatening accident involving one of his neighbours which perfectly illustrates the multifaceted nature of agricultural trauma. He will then discuss agricultural trauma more broadly. The statistics are similar across the globe, from the United States to Australia, Cambodia to Ireland. Fatalities involve heavy machinery (usually tractors) and the farmer or their family. Furthermore, deaths occur between 18-60 years of age in most industries. In farming however, fatalities can occur across the whole life span. Whilst there are equipment changes that have made things safer, they have a poor uptake amongst farmers. This is due in a large part to interference with productivity and functionality. Mike believes change can only come about through community engagement and education at a meaningful, personal level. Rural and farming communities are faced with inherent risk of injury and death on a daily basis. It is pertinent to be aware of this and to educate these communities when the opportunity presents itself. After all, if it is made of steel, sharp and moving… It will %^&* you up!
For more like this, head to https://codachange.org/podcasts/
Dr Simon Carley discusses the future of emergency medicine. Simon begins by talking about how things have changed in emergency medicine since he started his career in the 1990s. He wants to shed some light on where we are going with emergency medicine, what is happening to us and what is shaping us. He believes that predictions about the future, as shown in movies like Back to the Future, might not always come true but they certainly provide clues as to what is possible. According to Simon, three major factors influence the future of emergency medicine. The first factor is the people. Population predictions show that life expectancy has gone up, leading to an increase in the number of elderly people. As the age of the population increases, the age of the people dying due to trauma becomes older. This changes the approach of emergency medicine. Moreover, the age of the workforce in medicine is also increasing. Simon believes that the rigid systems must change to encourage the next generation of healthcare workers to enter medicine. Patients, pathologies, and the workforce are changing. The second factor influencing emergency medicine is politics. There is an increased financial constraint on health services which is in part due to increases in technology. Horizontal equity, where everyone gets equal treatment, and vertical equity, where some people get more, must be balanced. This can be achieved by involving emergency physicians in the political decision making. The future points in a direction where emergency medicine divides into different specialties which according to Simon might not be the right path. Furthermore, the third factor affecting emergency medicine is technology. Technology is essentially revision and refinement making things cheaper, easier, and portable. Revolution in technology is what matters. It changes the way we approach emergency medicine in fields like decision support, disease probability models and personal diagnostics turning doctors into probabilistic clinicians. Simon believes that though we cannot actually predict the future, we can definitely get involved in shaping it, making the future of emergency medicine as exciting as the past.
Tune in as Dr Simon Carley discusses the future of emergency medicine.
Finally, for more like this, head to https://codachange.org/podcasts/
A Tribute to Dr John Hinds, Dr Janet Acheson speaks about her life with Dr John Hinds and how unexpected his death was.
John Hinds was known as the pioneer of pre-hospital trauma, a master educator and powerful orator. He was “son” to his mother Josephine, “John boy” to his father Dermot and “John” to his friends and family.
John Hinds inherited his meticulousness from his mother and sense of adventure from his father. Janet speaks about different lectures given by John Hinds during which he coined the term #ResusWankers and spoke about cricoid pressure and Cricolol.
She speaks about “Johnisms”, thoughts that she and John shared; find your people and acquire memories of life; do not let wankers bring you down, learn from your mistakes and finally, make your intentions honourable - the patient is the centre of everything. She requests the audience to help trend #WhatWouldJohnDo.
Dr Fred MacSorley, a good friend of John Hinds, talks about how promising and talented John Hinds was when he entered the field of anaesthesia in 2004. His passion for motorcycling and fierce determination to help those injured, though it helped him in his career, also led to confrontations with peers who had more rigid minds.
John, however, overcame these obstacles with passion, humour and risk-taking ability. Fred reminisces about how training sessions with John would stretch on as John was a passionate teacher. He speaks about the call sign Delta 7 assigned to John while being part of the Northern Ireland Ambulance Service. Fred remembers that John always arrived first at an accident scene and worked away quietly. He was polite and had excellent people management skills. He established a relationship with his critically ill patients by talking to them and reassuring them. Fred shares stories of John’s growth to become a flying doctor. He claims that John revolutionised the management of traumatic cardiac arrest.
A tribute to a legend, Dr John Hinds.
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Dr Victoria Brazil discusses the Dunning-Kruger Effect, Imposter Syndrome and quality improvement. Vic starts the podcast reminiscing about her initial days as a resuscitationist.
She talks about the two psychological phenomena noticed in people working in pre-hospital care. The Dunning-Kruger effect, where people tend to think they are better at a job than they are, and imposter syndrome, where people tend to think they are worse than they are at doing a particular job.
People's perception of their performance can impact their chances of improvement. She suggests scientific methods to reduce this gap in perception. Resuscitation quality improvement (RQI) is a machine-based assessment method to improve the quality of chest compressions that helps doctors and nurses assess and improve their chest compression skills.
An example is a person trying to intubate a patient while wearing a camera. This highlights how different his perception is of what he is doing. According to Vic, an important tool to improvement and reduce the gap in perception is feedback between the person in the field and the consultant. This is because according to Dunning, though we do not assess ourselves correctly, we are good at assessing others.
For the feedback loop to be effective it is essential to follow three basic rules. Firstly, be honest. Secondly, do it often and thirdly be good at extracting feedback. Vic suggests that everyone should start practising giving feedback by assessing speakers. She suggests that rather than giving vague comments like “Good talk mate”, people should make an effort to give speaker specific comments about the talk. This could include what they liked and what could be improved.
Vic demonstrates live feedback of her 47-year-old self giving her younger self, Registrar Vic, some feedback with help from the audience. Through this act she shows how to give effective feedback and how to extract good feedback.
For more like this, head to https://codachange.org/podcasts/
Dr Ashley Shreves discuses palliative care and critical illness. She begins by talking about a case she feels she mishandled during the initial days of her career. How she was unprepared to handle an end-of-life case efficiently. She goes on to enumerate the multiple specific challenges, a knowledge of which would have helped her handle the case more competently.
First - One must identify the dying trajectory i.e., use the background information to check the viability of the patient.
Second - Undertake a capacity assessment of the patient to ensure how much of the current situation they understand.
Third - Check for advance directives where a patient has already given instructions regarding their end-of-life care. Communicating to the relatives and/or the patient regarding the imminent death is another challenge in end-of-life care. Proper communication regarding the withholding or withdrawal of life sustaining treatment (LST) to the patient is also very important. Another crucial aspect is knowing the right treatment regimens for end-of-life (EOL) symptom management. Spiritual competency of doctors is essential as it helps to provide necessary spiritual assistance to people in their last moments. An ethical framework to guide the doctors through the management of EOL cases is crucial for a favourable outcome. Systems of care that help doctors to take care of EOL patients is necessary.
Ashley discusses various studies which show that many patients requiring end-of-life care end up dying in hospitals and the relatives and patients feel neglected most of the time. She feels that this is due to a shockingly low availability of palliative care department and workers. The solution, she feels, is to equip the Emergency Department doctors with the basic skill set to deal with the common end-of-life problems by doing Fellowship Training in palliative care. She suggests various courses like EPEC for Emergency Medicine, Palliative Care Education and Practice (PCEP) by Harvard University, online courses by University of Colorado, VitalTalk courses and information available on the Palliative Care Network of Wisconsin website.
She believes that a basic palliative care knowledge is essential for all Emergency Department doctors as all end-of-life patients should be given the best possible care in the short amount of time they have left.
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Rueben Strayer provides a masterclass in droperidol for emergency management of agitation. He discusses sedation in three patient groups. Agitated but cooperative If the patient is agitated but cooperative there is no concern for a dangerous condition. They respond well to some company and a sandwich. Drug therapy in this group is relatively straightforward. Disruptive without danger You can converse and engage with this group; however, they are not responsive to suggestion. They are loud and disruptive and need to be sedated. You can do a history and exam and be fairly confident that there is no dangerous underlying condition. There is no threat to themselves or others. They can be managed by observation in an unmonitored bed. So, you can sacrifice speed of sedation to ensure safety. Simple and well worn, tried and tested methods of mixed medical sedation are fine in this situation. And Reuben stresses this… it is fine. To be better than fine, consider a single agent - droperidol. Droperidol is the most effective and safest agent for undifferentiated agitation. If droperidol is unavailable the next best choice is midazolam intramuscularly. Be careful. Dosage is trickier in this situation. You need to monitor for respiratory depression and ne prepared to manage it. It works quickly but has a narrow therapeutic window. As such, for unmonitored patients, Reuben combines drugs to get away with smaller doses. Listen in to learn how! Excited delirium This patient is rare. But this is a dangerous situation. A few clues are the patients who are thrashing, angry, incoherent, un-engageable. They may have a fluctuating level of consciousness. Have a low threshold if you are not sure – err on the side of caution and treat as excited delirium. How do you treat this person? Five strong people are needed (not including those administering care), one for each limb plus one at the head. Administer high flow oxygen via a mask immediately. Do not wait for sats or vitals. This stops spit and provides oxygen! Get the patient out of dangerous positions such as the “hogtie” position and ensure no one is applying pressure to the chest or neck. Next chemical restraint – IM shot as soon as possible. This is as opposed to any mechanical restraints. The priority is immediate control. This allows you time to properly assess and treat the patient whilst ensuring their safety and the safety of the treating team. Join Reuben for a no nonsense run through of managing the agitated patient.
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This is a fresh ICH discussion covering controversies in 2015: blood pressure control, reversal of anticoagulation, and prognosis.
Tom Bleck has been in the top echelons of neurocritical care for decades. As a highly active member of the CCM-L internet group, he was pioneering internet based crit care discussions before Twitter was ever conceived. Considered by many to be the leading world expert on status epilepticus, he brings insights from research and extensive experience you will hear from no one else. A rare treat.
A panel of neurocritical care fanatics discuss the nuances of managing aneurysmal subarachnoid haemorrhage (SAH) from pre-hospital through ED to ICU. This is a fascinating insight into international practice variations and the justification for these. It's very unusual to have such a panel of experts all in the same room speaking so frankly. This was recorded live at the SMACCBRAIN workshop in Chicago 2015.
SMACC Chicago Beat the Bug Q&A session with Kath Maitland, Mark Crislip, Flavia Machado and Chris Nickson.
SMACC Chicago Q & A session on Funky Physiology with Mybourgh, Saxona, Hensley and Perner.
Heart, Brazil and Gatward discuss The Future of Continued Medical Education in this SMACC Chicago Q&A Panel Review.
Warwick Teague and Andy Sloas argue similar cases in their #SMACCChicago Cage match 'All Paeds Trauma Should be Managed in a Paediatric Trauma Centre’. An interesting insight into Paeds trauma centres in Australia and America. Teague and Sloas offer valuable idea’s on timely and affective treatment of paediatric trauma patients.
Howie shows us the tools in his toolkit:
- Tourniquets save lives and do not cause limb ischaemia. The aorta is clamped for many hours in cardiac surgery. Data from the battlefield showed that in >800 cases where tourniquets were applied, there were 3 adverse outcomes (loss of sensation in the distal fingertips).
- Haemorrhage control (Israeli) bandages are tourniquets with a haemostatic agent that can be applied to a bleeding wound
- QuickClot (haemostatic powder) can be used for abdominal wounds but may draw the ire of surgeons because they cause an exothermic reaction that burns surrounding tissue.
Howie emphasises that not all bleeding have to be stopped - if it’s not pouring out, it can wait. He teaches us to quantify blood loss in the field - three 335 mL cans of soda worth is when to start worrying.
The talk ends with an interesting mini Q&A session as trauma surgeons and paediatricians also weigh into the debate.
Airway management induces stress and fear in the heart of many Critical Care practitioners. In a high pressure situation, it’s easy to falter on the see-saw of demand vs. ability. Rich argues that in difficult airway management, we are hindered by: complex algorithms, anecdotal expertise and the negative perception of the task as ‘undoable’ and the downplaying of our abilities. In crisis, we need simple!
Rich discusses the need to redefine the priorities of the airway (away from ‘find the vocal cords/cricothyroid membrane’), incrementalisation and consensus of method. Rich also briefly discusses the future of airway management - nasal oxygenation and the need to move past the surgical airway as a failed airway.
Andy Naidech gives a fascinating and powerful short talk on controversies in management of aneurysmal subarachnoid haemorrhage, followed by discussion from the panel of experts and questions from the crowd. This was recorded at the neuro workshop for SMACC Chicago and was a very popular session.
In this hypothetical panel discussion, our protagonists have just started work at the Utopia Trauma Centre – a state of the art facility that is world renowned for its excellence in trauma care, research and teaching …
Our panel includes a social worker in intensive care, a senior intensivist and director of training for ICU, an emergency physician and director of ‘physician leadership development’, a trauma surgeon, an ICU and flight nurse, a consultant high performance coach for the institution, and the director of research and global health programs As we work though a series of clinical cases and events at the hospital we consider performance – highs and lows, including the dark side of high performance/ ambition.
We teeter over boundaries and ethics in pursuit of high performance. We consider the impact of diversity in our staff profile. When it all goes wrong we discuss resilience, and dealing with human fallibility - mental health, substance abuse, physical illness, and aging. What does it all mean for our own practice and our critical care communities. Food for thought.
Simon Carley has us asking ourselves some confronting questions about our abilities in his SMACC Chicago talk ‘Are You as Good as You Think?’. Carley has us delve into our confidence, competencies and whats makes for a good self learning environment.
Initially Carley asks how good we think we are at driving? He then sites studies of Australian and European driver responses stating that 93% of Aussies and 69% europeans rate themselves as above average drivers. In using the example Carley suggests as individuals we are not particularly good at rating ourselves, while inexperienced people tend to rate themselves more highly then experienced people, calling this illusory superiority cognitive bias.
Carley asked the question since you can’t have awesome without average, how do we measure ourselves?. He then talks us through the following tools and processes to establish better self learning and teaching processes;
Reflection Diaries - revisit it (clinically and physically), follow up.
Peer reviews: 1:1 feedback doesn’t work. It needs to planned with clear goals and objectives such as;
Clarify expectations
review logistics
focus lens
plan feedback
observe event (i.e teaching)
debrief and action
Clinical Feedback
Follow up - not just the exceptionally sick patients, but follow up with the routine ones.
Build Peer Reviews into your practice.
Carley finishes by asking us to choose on of the following items and commit to ourselves to making it happen within the month.
I am going to …
Organise Trainee Feedback
Focused 360 Assessment
Keep a Patient/Teaching Diary
Be Peer Reviewed
Reflect
Develop Team Feedback
Follow up with Patients
Something Else
Nothing I am already Awesome!
What have you committed too?
Cliff Reid unites our passion of Critical Care in his SMACC Chicago talk Advice to Young Resuscitationist - It’s up to us to Save the World. Talking us through his advice to his former younger self, Reid sights mistakes, case examples, and essentially provides us with invaluable tips to nudge us along to Resus Mastery.
Reid offers the following advice to his former, younger self;
- Your career and speciality is a journey and you chose your destination: Don’t be defied by the expectations of one chosen path. Have an appreciation of what other specialities can add and what you can learn from them. Leave your ego at the door.
- Have a balance of confidence and competence. When something goes wrong you have to change something: Be it either yourself, your colleagues or the system.
- Follow up on your hypothesis: You won’t know if you got it right or wrong and will not gain or learn from the experience.
- Preserve comfort and dignity for your patients: 'No one knows how much you know, until they know how much you care' - Greg Henrey.
- Protect yourselves: Think about the people around you and share your experience with them, chose your colleagues and where you work wisely.
- Increase team cohesion - it is protective against burnout and compassion fatigue.
- Be Aware: look after the tools of your trade, your body and mind. Try and maintain good physical health, and train your mind to be more effective under stress.
- Remember society puts their trust in you - you only fail them when you fail to learn in them.
- Every patient is a gift/lesson accept it with grace and gratitude.
- Behave in the way you want to be remembered.
- Keep perspective and enjoy the ride!
Simon Finfer has spent his career managing patients with traumatic brain injury nad has watched treatment fads come and go. He's also taken part in some of the best and biggest clinical trials in this area which give him a unique perspective on why we do what we do in managing this devastating but common condition. In the contraints of 15 minutes, he'll make you think and hopefully question your own practice!
Imogen Mitchell’s SMACC Chicago talk 'Morphing the Recalcitrant Clinician’ talks us through the steps to engage the reluctant physician when implementing change.
Imogen initally touches on the stages of physician engagement from aversion, to apathy, to engaged and then outlines the steps to morphing the reluctant physician.
- Seek out a clinical champion
- Establish a common purpose/vision
- Standardise what is standardisable
- Communication, communication, communication
- Work out barriers and overcome them
- Deal with the ‘Whats in it for me?’WIFM
David Juurlink SMACC Chicago talk 'Drug Interactions That Can Kill (and How to Avoid Them)’ takes us on a journey of drug interactions, case studies, and avoidance strategies.
Juurlink starts by educating us on the two different drug-drug interactions (DDI) - effects of one drug altered by the use of another . First of which is Pharmacokinetic where by one drug alters the level of another, the second Pharmacodynamic being no change in drug levels, and uses this as a basis for his following case studies.
Juurlink speaks of the dreadful literature that is available on the thousands of drug interaction per year, stating that most information comes from case reports and volunteer studies, and suggests that majority of these interaction are avoidable.
Juurlink then goes on to discuss the findings of 4 case studies involving the following Drug-Drug Interactions and their effects on the patients.
SMX/TMP + sulfonylureas
Macrolides + digoxin
APAP + warfarin
SMX/TMP + ACEI/ARB
Juurlink provides us with a short list of trigger drugs that we should be aware of, a list of meds that warrant extra caution and list of possible safer alternatives. He also suggests that it is of the up most importance to have a good pharmacist to turn to as they are given more information on drugs interactions then physicians. And, to utilise resources such as pharmacy times - where you can get information on drug interactions at a push of the button.
Juurlink also suggests that an Informed patient is a very useful safety mechanism.
Rick Body’s SMACC Chicago talk 'Is compassion a Patients Right?' takes us on a journey of emotions in critical care.
Starting with his rendition of john Lennons ‘Love’. Body, explains the origin of the word compassion - a move to act based on someone else suffering, a sharing of suffering with.
Body, initially focuses on a study conducted within his hospital of 125 patients, who were interviewed when admitted to their emergency department and when they where discharged. From the study it was depicted that, what patients truely wanted was simple human intervention; reassurance, friendliness, explanation, basic care. These responses were then coded into 5 different themes to depict how patients believe their suffering should be addressed;
- Emotional distress
- Physical symptoms - including pain (but not restricted to)
- Information - Included reassurance and explanation
- Care - Basic care
- Closure - patients want to put this horrible episode behind them
Body notes that patients are telling us that they want something positive from us. They don’t want us to focus on what we shouldn’t do. They want us to be thinking about what we can do to help… suggesting that if we follow the above ‘EPPIC' we could provide more compassionate care. The problem is this is not compassion as compassion is an emotion and needs to be felt.
Body then explores whats stopping us (care providers) from showing compassion? Sighting the The Good Smaritian Study: that depicts the more in a rush one is the less likely they are to show compassion. The By Standers Affect: if a large crowd is doing nothing, you are more likely to do nothing. Unclear of Who is Responsible: less likely for anyone to respond and Personal Reasons: the responsibility for other peoples lives, fatigue, tough, resilient to showing emotion, emotion been seen as a weakness and a feeling as doctors we are not meant to show emotions.
Body, then shows a picture of a doctor crouched slumped over and inconsolable, shortly after the image was taken the doctor loses a 19 year old patient he was treating and minutes later the he walks back into the emergency room and continues working. This picture went viral on social media and the doctor pictured was seen as admorable. Body sites this example to state that clearing having compassion and showing compassion is right, but is it a right?. And, asks the question 'Would you prefer the surgeon who shaking with emotion as you go into surgery or the surgeon who is composed, objective, calm, tough, resilient, unmovable and efficiently get on with the task in hand?'.
Body believes that patients don’t have a right to compassion as it is an emotion and means to suffer with but asks for health providers to be emotionally intelligent. Explaining that emotional Intelligence recognises that there is a difference between traditional intelligence, IQ and our ability to form effective forms of interpersonal relationships. Siting the 5 domains of emotions intelligence as;
1. Know your emotions - know what we are feeling
2. Manage your emotions - cool rational and object in the rests room, show emotion with patients and family
3. Motivating ones self
4. Recognising emotions in others - empathy
5. Handling Relationships - interpersonal Skills - relate to other people
Body suggest that these are skills that can be developed as ones life goes on and by building skills in emotional intelligence that maybe one can be both a compassionate and effective doctor.
Body concludes by asking the question 'How are you going to care more for your patients?'
Andrew Healey takes us on an exploration of the early phases of donor management in ICU and Emergency Medicine in his heart felt SMACC Chicago talk Optimizing the Care of the Organ Donation Patient. Which focuses on the processes of managing donor patients and their families, while they ride their ICU/ ED journey through to organ donor.
Healey summarises his talk into four main points: 1. Set families up to make the right decisions - be it with end of life care or organ donation. 2. Preserve the opportunity for donation - understand that this is often the last decisions a family will have to make about a loved one and they may need time. 3. Never Say No - never say no to an organ donation, ask the specialist. The only people who can decide if a person is not ideal for organ donation are those people who intimately know the recipient. Healey sights some interesting stats that are worth thinking about such as; 1 out of every 4 people who are on the heart transplant list in Canada die. While, the risk of contracting HIV or Hepatitis from a transplant heart is 1 in 4000 (HIV) and 1 in 245 (hepatitis). With these in mind the elevated risk donor can look less risky. 4. Remember Organ Donation is never merely a mention - It's up to physicians and critical care providers to guide families to make the right decisions.
Jeremy Cohen took us on an Adrenal Function journey at SMACC Chicago with his talk Raging Hormones in Critical Care.
Cohen explores the natural roll of cortisol in the human body, various schools of thought and recent research in the areas of sepsis and cortisol resistance.
Trauma is Risky Business Deborah Stein SMACC Chicago talk Trauma is Risky Business - delves into the risk patients and physicians undergo when treating or being treated for Trauma.
Stein’s speaks of the Risk Benefit Determination that physicians make daily and how this is used to best answer on going questions such as; can a patient have?, how do we care for this patient? and how do we best make all the these decisions?.
Stein’s suggests a thorough Risk Benefit Determination will include:
# Analysis of best available data
# Use of best available judgement
# Gathering of different opinions
# An understanding that you won’t always make the right decision
# To document the 'crap' out of it!
# And, to remember you’ll never know what you prevented from not occurring.
Stein’s also focuses on the risk to patients due to missed injuries, stating that 1.3-39% of injuries in trauma are missed (a majority of which present as orthopaedic cases). And, touching on the processes designed to prevent missed injuries such as; Territory Trauma Survey, Roles of Clinical Decision Rules, to scan the living ‘crap’ out of them - whole body CT scans (can decrease mortality but comes attached with its own risks).
Stein’s then delves into the risks trauma providers (physicians) face on a daily bases. Stating that in the USA trauma providers are one of the highest categories of physicians to be sued, have higher indemnity payment awarded against them and achieve a higher risk score in studies for being sued. While, lawsuits are more likely to increase the chance of physician burnout, career burnout, depression and are emotionally and physically exhausting. Steins sights recent studies that suggest the more open, honest and forthright a physician is with their error with their peers and their hospital, the likelihood of being sued reduces.
Stein’s also notes that needle stick injuries in most departments have decreased in recent years due to universal precautions, yet have increased in trauma care due to the nature of the ER environment and proper precautions not being taken. Violence is of risk to attending ER nurses, physicians and paramedics, sighting an Australian study that 79% of triage nurses have experienced physical violence from patients. And, the emotional harm the trauma environment can have on trauma providers.
Steins suggests that trauma providers must be aware and learn how to manage risk better to ensure patient and provider safety.
Walter Eppich engages us on the topic of Interprofessional Communication: Challenges and Opportunities.
Eppich describes communication as the engine of learning - providing it is coming from a psychologically 'safe' environment free from humiliation and punishment. Eppich characterises a psychologically safe environment being; an environment where people can speak up with idea, questions and mistakes without being fearful of being wrong and stresses when communication breaks down, patient safety breaks down and learning breakdown. It takes a team to do patient care.
Summary by: Rosy Wang
Lactate has been viewed as a byproduct of anaerobic metabolism and an indicator of tissue hypoperfusion since the 1900s. This theory is still widely believed. Paul busts the myths surrounding lactic acidosis, anaerobic metabolism, tissue hypoxia and the role of lactate in sepsis.
Key take-away facts include:
- The production of lactate actually consumes hydrogen ions. Lactic acidosis is really lactic alkalosis.
- Lactate is produced physiologically and is a precursor for gluconeogenesis.
- During exercise, skeletal muscle exports lactate as the primary fuel for the heart and brain.
- At VO2max, intracellular oxygen stays the same. Anaerobic metabolism in cells only occur as a pre-terminal event. The exception is in complete arterial occlusion.
- Adrenaline promotes lactate production
- Lactate infusion has been shown to increase cardiac output in septic and cardiogenic shock
- Lactate is a survival advantage!
Summary By: Rosy wang
You don’t have to be Bear Grylls to stay alive in the wild. Remember the rule of three - you can live 3 minutes without air, 3 hours without shelter, 3 days without water and 3 weeks without food.
The two biggest killers in the wild are cold and heat. Justin discusses the physiology of our body’s responses to cold and heat and the pathophysiology of hypo- and hyperthermia. He also talks about the simple of ways of preventing cold and heat injury, including staying dry, adding layers, drink any water you can get your hands on - just not sea water.
Lastly - don’t panic.
Kath Maitland takes the perspective that we should be cautious with how we give IV fluids. She argues that the underlying physiological evidence supporting the benefits of giving fluids is not there. The findings of the FEAST study are clear. Kath describes how during FEAST, the administration of fluids made the children look better, and improved the recorded physiological parameters. However these surrogate outcomes did not translate to a mortality benefit - fluid boluses were associated with increased mortality.
Nick, a paeds intensivist, retaliates with how it's really about understanding physiology. He defends the position we take at the moment and discusses the issues with the parameters used to assess fluid responsiveness, but urges that we shouldn't change everything we do at the moment until we understand the physiology better. He also has nice description of the glycocalyx - "the pubic hair of the blood vessels, only more useful".
The Mystery of MODS Summary By: Oli Flowers
Mervyn Singer entertains the SMACC crowd with tales of MODS (Multi Organ Dysfunction Syndrome). With videos of Raquel Welch, stories from the Battle of Trafalgar and lessons from evolution, he makes us think about the important physiology underlying critical illness. This lecture precedes the latest SIRS definition and really puts them into context and leads on to the promise of precision medicine.
Scott Weingart's lecture at SMACC-Chicago was on OODA loops and the supremacy of System I for resuscitation. Check more here
How to Diagnose Dying A patient's death maybe certain but the timing isn’t.
Ashley Shreves talk is on the difficult subject of dying, and how best to understand and help diagnose when the battle is lost.
Shreves discusses the correlating patterns present in the functional decline in end of life patients, with particular reference to the type of disease a patient is suffering from. Shreves suggests, that understanding these patterns is paramount to understanding the care and medical intervention require, at certain points of a patients disease lifecycle.
Selective Aortic Arch Perfusion - Summary by: Jim Manning
Selective Aortic Arch Perfusion (SAAP) is an endovascular-extracorporeal perfusion resuscitation technique designed specifically to treat cardiac arrest. SAAP involves the blind insertion of a large-lumen balloon occlusion catheter into the descending thoracic aortic arch via a femoral artery. With the SAAP catheter balloon inflated in the thoracic aorta, the heart and brain are relatively isolated for resuscitative perfusion through the SAAP catheter lumen with an oxygen-carrying fluid (such as blood, hemoglobin-based oxygen carrier or fluorocarbon emulsion). SAAP promotes restoration of spontaneous circulation (ROSC) by the heart while protecting the brain from further ischemic insult. SAAP can be used to treat both hemorrhage-induced traumatic cardiac arrest and medical, non-traumatic cardiac arrest.
In traumatic cardiac arrest, SAAP provides the combination of (1) thoracic aortic balloon occlusion for control of hemorrhage below the diaphragm, (2) rapid volume replacement in hemorrhage-induced hypovolemia to restore normovolemia and (3) perfusion of the heart and brain in an effort to achieve ROSC. SAAP also allows titration of small doses of intra-aortic adrenaline or other medications to achieve ROSC.
In medical cardiac arrest, SAAP catheter balloon occlusion of the thoracic aorta limits the distribution of oxygenated perfusate toward the heart and brain. Since medical cardiac arrest patients are not typically hypovolemic, SAAP with an exogenous oxygen-carrier is a volume loading intervention that can only be used for a short time period (5-10 min). If ROSC is not achieved with the limited volume of exogenous oxygen-carrier, femoral venous access during initial SAAP infusion allows venous blood withdrawal for continued SAAP support to promote ROSC without further volume loading (autologous blood SAAP or, essentially, aortic arch ECMO). Intra-aortic adrenaline and anti-reperfusion agents can also be used. Even if ROSC is not rapidly achieved, SAAP serves as a bridge that limits hypoperfusion until cannulation for full body ECMO can be achieved.
Historical prospective provides a great appreciation and understanding of Prehospital Medicine. Stefan cleverly highlights the journey of a specialty from its roots on the battlefield to the present day, where prehospital medicine has not only begun to influence, but also dictate, in hospital medicine. A brief and fascinating look at "How far we've come”.
PHARM Physician, Per Bredmose, provides an in-depth look at Ketamine in the prehospital setting. Per discusses the uses, benefits and potential complications of Ketamine, providing tips and tricks from his wealth of experience.
Dr. Karel Habig of Sydney HEMS, leads a global panel in the discussion of the retrieval of patient with a difficult airway in a rural ED. Additional discussion surrounds the capabilities of HEMS services around the world. Participants include: Dr. Geoff Healy, Dr. Stephen Hearns, Dr. Craig Bates, Dr. Mike Abernethy, Dr. Minh Le Cong, Crystal Upshaw.
Justin Bowra - The elephant in the living room
Justin Bowra takes a break from ultrasound to broach the uncool but crucial subject of health care economics. Health care spending make up a large proportion of the budgets of OECD nations, and it is increasing in relation to GDP. This is an unsustainable situation and something has got to give.
In part 1 of Justin’s talk, he asks the question, where is the money going? The commonly asserted points of the aging population, better medical treatments, litigation and corporatisation of health care contribute. Justin argues, however, that the biggest problem is the system itself. To acknowledge the elephant in the living room is to acknowledge that we as doctors contribute to the problem, but we also have the greatest responsibility to be part of the solution.
In part 2, Justin briefly discusses ways in which the system can be fixed. He touches on taming special interests, shared decision making, surrendering autonomy and to look at the big picture - remembering that what we do for each individual patient has consequences for everyone else.
Tom Bleck - Subarachnoid haemorrhage: what matters?
Tom Bleck gives an overview of the pertinent facts regarding the complications and management of aneurysmal subarachnoid haemorrhage (SAH).
The complications of aneurysmal SAH can be divided into immediate, early and late. The risk of re-bleeding is maximal on the first day, it is fatal in 75% of patients and the best management is to secure the aneurysm by coiling or clipping. Blood pressure control is utilised widely but parameters are arbitrary and the data is scarce.
Early complications (days 1 - 3) include early brain injury in its various forms, stress cardiomyopathy, neurogenic pulmonary oedema and cerebral salt wasting. The most important late complication (day 4 onwards) is vasospasm.
Tom briefly discusses the mechanisms and manifestations of SAH-associated brain injury including ischaemia, blood brain barrier breakdown, sustained depolarisation, hydrocephalus, vasospasm, seizures, hyperglycaemia and fever. He goes on to discuss in more detail the management of vasospasm, the associated evidence and the importance of distinguishing between clinically detectable and subclinical vasospasm.
Dr. Brian Burns of Sydney HEMS, facilitates a global discussion on blunt abdomino-pelvic trauma 30 minutes away from ED, leading this incredible panel of experts on a hypothetical trauma case. Participants include: Dr Gareth Grier, Dr Howie Mell, Dr Thomas Dolven, Derek Sifford, NREMT-P, Dr Clare Richmond.
Veteran Airforce Pararescueman turned critical care paramedic, Mike Lauria discusses the
Rob MacSweeney and Paul Marik debate whether the assessment of fluid responsiveness in the resuscitation of patients with shock a waste of time? Both Marik and MacSweeney agree that many of the traditional methods of assessing patients volume status are flawed and of no value. Marik goes on to argue that the only clinically meaningful outcome that we should measure in response to a fluid challenge is Stoke Volume. In at least 50% of patients there is no improvement in stroke volume and further treatment with fluid boluses will only likely cause harm. Marik goes on to argue that we must know where our patients are position on their Frank-Starling curve to predict whether they are fluid responsive and we can assess this with passive led raise.
Pretty much everything I learned as a resident in terms of the sequencing of airway management in ED has changed over the past 15 years. No longer is there simply RSI or stick a laryngoscope in with nothing and use pure brute force to intubate a patient; we have a host of different options and pathways when approaching airway management in the emergency department.
This lecture discusses some of these updated ways of getting from a sick patient requiring airway management to a tube between the cords…with only minor technical mishaps.
Daniel Kornhall's is an introduction to snow avalanche physiology and the realities of mountain rescue.
Dying in an avalanche is an extremely rare cause of death but for us who live in mountain regions and who enjoy winter mountain sports it is a thing that needs to be dealt with. The overall mortality in avalanche incidents is roughly 20% but this increases to 50% in the buried victims, which is why my talk, and most avalanche medicine, focuses on the buried victims. Asphyxia causes the vast majority of deaths, accounting for roughly 80% with trauma in second place at 20%. Hypothermia as the primary cause of death in avalanche victims is extremely uncommon. Asphyxiation causes a dramatic plunge in survival from 80% down to 30% within the first half our of avalanche burial. This is why timely location and extrication of the victim is of vital importance.
Kornhall explains why organised rescue service rarely, if ever, manage to get to the victim within this critical asphyxia phase. Survival rather depends on immediate bystander or companion rescue. Extrication times can be reduced by being properly equipped with avalanche transceivers, quality snow shovels and avalanche probes.
Kornhall briefly discusses the avalanche airbag, a fairly recent innovation that may reduce the likelihood of being buried if you get avalanched. In the last part of my talk i describe modern extrication techniques and how implementing these into rescue training dramatically improves extrication times.
Two legends of medical education, doctors Johnathan Sherbino and Robert Cooney go head to head debating whether assessment is a barrier to learning. Sherbino argues that assessment is in fact a first essential step in the learning process.
Making Teams Work - Chris Hicks In Chris Hicks talk Making Teams work, Hicks discusses the systematic failures in training ourselves and our trainees for chaotic situations. He challenges the assumptions that people learn over time by osmosis (by just watching) and debunks the idea that by watching physicians will become skilled at soft non-technical skills. Hicks goes on to discuss what makes a high performing team - touching on;
- Shared mental model of team and task.
- Implicit co-ordination/communication
- And, how to create this in an ad hoc team.
Hicks then discusses emergency specific team training and the results they are seeing by implementing programs such as; CREW Training - Crisis Resources Emergency Workers, Stress Inoculation Training and Mental Simulation Training. Hicks finished by explaining how best physicians and medical staff can implement these trainings and skills into the real world practice.
Rapid response systems (RRSs) have become a routine part of the way patients are managed in general wards of acute care hospitals. They have been adopted by national health and safety organisations in North America, Canada, the United Kingdom and Australia and are increasingly being used in other parts of the world.
Studies have almost universally shown significant reductions in outcome indicators such as mortality (up to one third) and cardiac arrest rates (up to 50%). However the validity of these outcomes is questionable as most of these studies are single-centre, before-and-after studies conducted by one or two clinical champions in Rapid Response.
This presentation reveals that the implementation of an Intensivist led Rapid Response Team in an Australian quaternary hospital did not demonstrate such dramatic results. In fact, after one year of service the standardised mortality ratio and the in-hospital cardiac arrest rate remained similar.
The presentation explores some of the operational impacts of a RRS including the replacement of critical thinking with reliance on protocols and the progressive super-specialisation of medical teams. Despite these impacts and relatively static patient outcome data, the service has rapidly become an integral part of the hospital.
Barriers between Intensive Care and ward staff have broken down and quality outcome results have consistently shown ward nurses and doctors feel better prepared, educated and supported in managing clinical deterioration. These surprising results raise the question; should we place more value in quality outcomes?
Poisons and novel agents are a moving target in the clinical arena. This talk begins with a historical look at decontamination and pitfalls that have been discovered along the way. The advent of intubation and critical care was a major boon in the improvement in mortality from poisoning. The Scandinavian Method is described and is an important lesion to this day. The rise of antidotes is mentioned.
Emerging drugs are highlighted in the context of where we have come from. The phenylethylamine compound structure and corresponding variants are described. The importance of the principles of supportive care as learned in the Scandinavian method is emphasized. Other emerging topics including synthetic cannabinoids, and anti-NMDA receptor antagonists are discussed. Emerging interventions of prescription naloxone, and ED ECMO are outlined. High vigilance for new agents, and innovative treatments will enable clinicians deal with these evolving trends.
Is There a Doctor on the Plane? Summary by: Joe Lex
How Common Are In-Flight Emergencies?
• Occur on one in every 600 flights
• 44,000 of 2.75B airline passengers / year
What Are Most Common Emergencies
• Lightheadedness or fainting ~37%
• Respiratory problems ~12%
• Nausea or vomiting ~10%
• Cardiac symptoms ~8%
• Seizures ~6%
• Other Emergencies
• Laceration ~0.3%
• Cardiac arrest ~0.3%
• Ear pain ~0.4%
• Obstetrical or gynecological symptoms ~0.5%
• Headache ~1%
Who Responds to the Call?
• Physician passenger responds in ~48%
• Nurse passenger responds in ~20%
• EMT passenger responds in ~5%
Minimum first aid kits on commercial airliners
16 Adhesive bandage compressors, 1 in
20 Antiseptic Swabs
10 Ammonia Inhalants
8 Bandage compressors, 4 in
5 Triangular bandage compressors, 40 in
1 Arm splint, non inflatable
1 Leg splint, non inflatable
4 Roller bandage, 4 in
2 Adhesive tape, 1 in standard roll
1 Bandage Scissors
2 Protective latex gloves pair
2 Insect sting relief pad
2 Triple antibiotic ointment
2 First Aid/burn cream, 9 gm.
2 Povidone iodine infection control wipes
2 Alcohol cleansing pads
2 Gauze dressing pad 2" x 2" in
2 Motion Sickness Tab
4 Ibuprofen tablets
4 Non Aspirin Tablets
2 Sunscreen lotion towelette
2 Trauma pads 5 x 9 in (12,7 x 22,8 cm)
1 Survival rescue blanket
1 Pelican case 1170 waterproof
1 Emergency first aid guide (American Red Cross)
Required medications on flights
• Antihistamine – tablets and injectable
• Atropine 0.5 mg injectable
• Aspirin tablets 325mg
• Bronchodilator MDI
• Dextrose 50% injectable
• Epinephrine 1:1000 and 1:10,000
• Nitroglycerin tablets
• Lidocaine injectable
• IV needle
• 500ml Saline injectable
All crewmembers are trained for common emergencies. For each flight attendant
¥ Instruction to include performance drills in the proper use of automated external defibrillators
¥ Instruction to include performance drills in cardiopulmonary resuscitation
¥ Recurrent training … at least once eve
Don't Forget A & B!
Over 500,000 patients per year suffer sudden cardiac arrest. Despite advances in our understanding and management of cardiac arrest, less than 15% of patients survive to hospital discharge with meaningful neurologic survival. In recent years, the focus of cardiac arrest resuscitation has been the delivery of high-quality chest compressions and early defibrillation for those with a shockable rhythm. As a result, airway interventions and ventilation now follow attempts to optimize circulation in cardiac arrest patients. Though high-quality CPR and early defibrillation are essential in the initial stages of resuscitation, advanced airway placement and appropriate ventilation are critical to overall patient survival.
Dr. Winters' discusses the current literature on the timing of advanced airway placement, oxygenation, and ventilation for the cardiac arrest patient. In addition, he discusses optimal targets for oxygenation and ventilation in the patient with return of spontaneous circulation from sudden cardiac arrest.
Lisa McQueen - Pearl or Fecalith? Summary by: Lisa McQueen
I’ve long been a fan of David Newman’s “Pseudoaxioms,” those medical proclamations handed down from generation to generation despite growing evidence that they are false. In this talk, I turn a critical eye toward common pseudoaxioms in pediatrics. Does aspirin really cause Reye syndrome? Should you routinely use atropine in preparation for neonatal intubation? Join me in an exploration of these and other pseudoaxioms. I may even debunk the notion that “children are not just little adults.”
ECMO or extracorporeal membrane oxygenation has shown promise in the use of cardiac arrest patients. Zack Shinar and his crew from San Diego have lead the way in emergency physician initiated ECMO for patients in cardiac arrest.
In this lecture he explains briefly how ECMO works, what their outcomes have been and where ECMO is moving. Initially 5 of their first 8 patients were neurologically intact survivors. Their first patient had over an hour of downtime when cardiac bypass was initiated. He walked out of the hospital completely neurologically intact nine days later and now has been featured on the film “Code Black”. Physicians from their hospital, Sharp Memorial, were also recently featured on the television show “Untold Stories in the ER” for a save of a 21 year old female arresting from hyperkalemia. Dr. Shinar also discusses some of the latest physiologic questions as the Australians have pushed for smaller diameter catheters that allow for smaller flow volumes.
He also discusses how in Paris pre-hospital ECMO is being done by physicians in various places like the subway, apartment buildings and even the Louvre.
In the end, Dr. Shinar discusses the biggest question in any novel resuscitation technique: cost. Prolongation of life and particularly after a cardiac arrest is expensive and many people do not survive.
Dr. Shinar uses various pioneers in the world of technology to tell how true genius is not in technologic advancements but in making those advancements available to the masses. He ends with a story about Linus Torvalds. Dr. Shinar shows how this man through the use of the collective minds of computer programmers worldwide created one of the best operating systems ever created: Linux. He asks the medical community to endorse this idea and introduces the concept of “free open access medical innovation”.
Goodbye GCS! Summary by: Mark Wilson
Consciousness comprises “wakefulness” (that’s the brain stem, opening your eyes component) and “content” (that’s the supratentorial, thinking, “someone’s home” component). You can have wakefulness without content (e.g. persistent vegetative state) but not content without wakefulness.
Describing a “level” of consciousness, converting this multifaceted human brain ability into a linear scale was possibly the biggest neuroscience break through of the 20th Century. The 1974 Lancet paper in which Brian Jennet and Sir Graham Teasdale proposed the Glasgow Coma Scale (GCS) is certainly the most cited neuroscience paper. We had even put a man on the moon before this had been created. It’s relative simplicity and repeatability meant GCS was rapidly taken up across the world. Now 40 years on, is it out of date?
There are problems with the GCS – it doesn’t include pupil response, it doesn’t look at ventilation or other autonomic functions hence other systems such as the 4 score system have been proposed. But these take longer, and are poorly known so cannot be used like GCS to rapidly convey in a meaningful way the level of consciousness of a patient between clinicians.
In this talk Mark Wilson goes through the history of the GCS and other conscious measures… is it time to say Goodbye to GCS?
One of the many things that we, as intensivists or emergency physicians, do better than anyone in the business is obtain the emergent airway. We are usually introduced to our patients on the worst days of their lives and even though we may sometimes wish for it, we do not have the option to reschedule our intubations. Smashed, bloody, distorted, edematous airways secondary to trauma, anaphylaxis, and GI bleeds are the commonality not the exception. We manage those airways routinely with nary a complaint or even a hither for a better look at the glottis than what we can obtain. We often feel lucky to even get a glimpse of the arytenoids much less something that actually resembles normal laryngeal anatomy.
Personally, if I knew that I would need to be intubated today, that my airway would be a bloody, edematous, traumatic mess and there was only chance for one person to take a shot at placing the tube, then I would pray to God that the last face I saw before the Roc and Ketamine pushed me asunder was the familiar grill of one of my EM/critical care colleagues. Who better to bet all my chips on then someone who deals with the most difficult airways on the face of the planet as part of their daily routine?
The EM doc or critical care provider can not only get that airway, but is so relaxed about it that they will often casually check on the patient in the next bed before and after the intubation. That’s the confidence I’m looking for when it comes to the fast-paced life and death world of emergency airway. Now put a child’s life on the line. Are you ready to intubate what was a perfectly healthy three year old two hours before trauma threatened their life and placed their airway in your hands? You will be...
Andrew Sloas DO, RDMS, FACEP, FAAEM, FAAP Editor-in-Chief: The PEM ED Podcast www.pemed.org
This talk will cover what we should do for patients who are considered too sick to have emergency surgery. These patients provide major management challenges in Critical Care. Do we admit them to intensive care to optimise them prior to emergency surgery or should we get on with surgery and resuscitate them intraoperatively? Should the surgery, if undertaken, be limited to damgae control surgery or operative resuscitation, or should more definitive surgical procedures be undertaken.
There often isn't good evidence to mandate a course of action either way so the decision will mostly be based on the treating clinicians opinions. In these complex cases, who should decide? These factors and others will be examined
Error is almost inevitable in our clinical practice so we should be prepared to help and prepare those individuals involved for the benefit of them, our systems and our patients. Do you remember that patient you saw last night?': A phrase the strikes terror into the hearts of all physicians. The prospect of a patient coming to harm as a result of a mistake is terrifying but it can and does happen. The consequences for the patient and their family are often tragic but what of the clinicians who made the error? For many the result of making a terrible error is life changing. Those permanently harmed by error are often referred to as second victims with the consequences of terrible events being life-long.
This talk explores the predictable course for clinicians who are involved in error and asks whether we can prepare and support such individuals through a difficult time.
In 2013, ~500,000 children in sub-Saharan Africa died as a direct result of Plasmodium falciparum malaria, accounting for 90% of global malaria mortality. The scale-up of control efforts has led to some reductions in malaria incidence in parts of Africa, but countries where transmission is high malaria continues to be a major public health problem. Early optimism that the most promising malaria vaccine candidate (RTS,S) would reduce the burden of malaria proved premature since following (3-dose) vaccination since immunity rapidly wanes >20 months post-vaccination. Severe malaria remains a major cause of hospital admission and paediatric death across sSA. Nevertheless, clinical research has been fragmented, resulting in only two large Phase III clinical trials - both with landmark results. The AQUAMAT trial, enrolling 5425 children demonstrated significantly lower in-hospital mortality in those receiving artesunate (8.5%) versus quinine (10.9%) (relative risk reduction 22.5%). Second, FEAST a pragmatic trial of fluid resuscitation as a supportive treatment in 3141 African children with shock, of whom 57% had severe malaria; this trial was stopped early due to higher 48-hour mortality in bolus arms (RR increase 45%) than no bolus (control) across all sub-groups.
Even with artesunate as standard antimalarial treatment, overall mortality remains ~10%, but includes large sub-groups with substantially higher case fatalities (15-20%) with 3 key prognostic markers (coma, metabolic acidosis or a high blood urea nitrogen) and/or bacterial co-infection (CF ~24%). There seems little prospect for further reducing the substantial mortality of severe malaria within the foreseeable future without a concerted and strategic effort from funders and researchers. SMAART (a nascent consortium for research and trials) aims to catalyse and accelerate the severe malaria research agenda. SMAART will formulate and coordinate seamless Phase I/II to large multi-centre Phase III trials using efficient trial designs to inform treatment guidelines and ultimately the outcome amongst African children
Resuscitation- what's the point.
Cardiopulmonary resuscitation (CPR) is unique as the only medical intervention performed on anyone without explicit contrary documentation. Therefore, CPR need to be understood in terms of societal expectations, legal mandates and professional duties. We also need to understand not just the the likelihood of survival, but also the likelihood of disability and the cost (both literally and figuratively) to patients, healthcare workers, and to an already stretched healthcare system.
Even the term 'resuscitation' means different things to different people...and that's before we even wade into such terms as 'autonomy', 'paternalism' and 'patient-focused care'. In short, doctors, nurses patients and families can no longer shy away from discussing CPR: it's time to talk.
It can be a remarkable way to prevent premature death, it can also squander finite resources and be the beginning of a terrible ordeal for frail patients and frazzled families.
The management of the septic patient in ICU is a recurrent topic for debate amongst intensivists. The decision of if and/or when to give blood transfusions is one of the key sources of contention. Dr Anders Perner is one of the most qualified people to weigh in on this debate. In this talk from SMACC Chicago, he delivers his stance on when to pull the transfusion trigger.
Dr Anders Perner is an Intensive Care Specialist at Rigshospitalet and a professor in intensive care at Copenhagen University. He is the chairman of the Scandinavian Critical Care Trials Group and the strategic research program “New resuscitation strategies in patients with severe sepsis’. The contents of this talk are based on the findings of the TRISS trial - Transfusion Requirements in Septic Shock. This trial, Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock was published in the NEJM in October 2014. The aim was to evaluate the recommendations from the Surviving Sepsis Campaign regarding transfusion in septic shock. The recommendation is that after the first 6 hours, transfusion threshold should be a Hb <7g/dL aiming for a Hb between 7-9g/dL in patients who do not have MI, severe hypoxia, acute haemorrhage or ischaemic coronary artery disease. Unfortunately, these recommendations were made with limited supporting data, hence the TRISS trial was born.
The TRISS trial was conducted as a multicentre, parallel-group trial run across 32 ICUs in Denmark, Norway, Sweden and Finland. Patients with septic shock who had a Hb
What’s your transfusion trigger? Is it time to rethink it?
Simulation is one of the most important advances in healthcare education and skills training of our generation. We now have simulation mannequins that can blink, breath, or even give birth thus allowing us to practice scenarios and skills before we encounter them in real patients. However, these sim dummies are not real people and so it is all too easy to dehumanize the scenario. According to Dr Phil Hyde, Director of Children’s Major Trauma and Southampton Children’s Hospital, it is this lack of emotional attachment that makes pure sim inadequate for training health care professionals in the management of trauma – especially trauma in children.
In his talk from SMACC Chicago, Dr Phil Hyde illustrates why he and his colleagues have developed an educational program that takes sim to the next level. The key difference in this sim program is the incorporation of volunteer children to play the roles of injured paediatric patients. Another key aspect of this program are the incorporation of multidisciplinary teams including undergraduate students for all scenarios.
The benefits of such a program have been far reaching. For the health professionals involved, it humanizes the scenario and induces an emotional attachment to the training exercise which adds an essential component to the training. Furthermore, it teaches professionals from different fields (nursing, medicine, allied health etc) to work together in these scenarios as would normally occur in real life. For the children involved, it is a safe controlled environment where they can learn about the health professionals and the health system, they learn about primary prevention and they can provide feedback to staff from a different vantage point. The community benefits through the improved primary prevention which is the most important aspect of treating trauma, a “man made disease”.
This is a simple, yet powerful program that has so many benefits beyond the training of doctors and nurses to manage children involved in trauma. This is an intriguing, innovative talk that everyone can take something away from.
Southampton Children’s Hospital is part of the University Hospital Southampton NHS Foundation trust. It is one of the largest teaching trusts in the UK. All of the simulation programs developed by Dr Phil Hyde and his colleagues at Southampton are open access and available for all health professionals to incorporate into their practice.
Are you ready for this rumble in the urban jungle?? Chris Ho vs Joe Bellezzo in the no holds barred debate about whether ECMO CPR is a step too far? The next cage match from SMACC Chicago.
Chris and Joe are the director and vice-director respectively, of Emergency Medicine at Sharp Memorial Hospital in San Diego, California. They are two of the leading experts in ECPR, with Joe being one of the key players behind EDECMO. On a day-to-day basis, they are friends and colleagues, working together in one of the very few centers around the world to deliver ECPR. However in this Cage Match, friends become foe and there are no limitations to how far each will go to prove their side of the debate.
On the AFFIRMATIVE side, Chris Ho delivers a convincing argument for why ECPR IS a step too far. From lack of evidence to the cost of “re-animating the dead” and everything in between, Chris Ho delivers a practical approach to the argument and demonstrates without a doubt why we are not ready for this to be the next step in resuscitation.
On the NEGATIVE side, Joe Bellezzo delivers an outstanding rebuttal to “Dr Ho’s Nutty Brown Bullshit”. In an inspiring argument filled with anecdotes and occasional facts, Joe Bellezzo makes it impossible to think the ECPR shouldn’t be the next step in our ALS algorithm.
Despite strong arguments from either side, as in all debates, there must be a winner. Do you agree with the outcome?
If you want to find out whether Chris and Joe were able to kiss and make up, check out the exclusive ICN interview with the two, where they discuss more on ECPR.
Working night shifts is a part of medicine that we have come to accept. We work these shift because generations of people before us had done it. But could working night shifts have negative consequences? Night shifts have been shown to be detrimental to patient safety by increasing errors in medication administration and direct patient care. Working night shifts may negatively affect our health by increasing the risks of substance abuse, obesity, social relationships, and certain malignancies. Finally, working night shifts may lead to career burnout leading to dissatisfaction and early retirement from the profession.
Several strategies can be used to combat the negative effects of working night shifts and these include a better awareness of the problem, improved sleep hygiene, strategies for better rest, and alternative staffing techniques. The Casino shift is an alternative approach to scheduling, which has been found to combat several of the problems associated with night shifts.
Night shifts will never disappear because hospitals must operate 24 hours a day. We must be aware, however, that there are many potentially negative consequences to this practice as a better understanding of this problem will allow us to develop and research new solutions.
Patients are at risk – from the moment they begin their healthcare journey. They are at risk of bad outcomes (as defined by us) and of bad experience (as can only be defined by them) Patient safety experts like James Reason, and groups like the Institute for Healthcare Improvement (IHI) have prompted us to think about systems and complexity as sources of error – and supported strategies to remove predictable human fallibility as far as possible. This is important to make healthcare safer.
Vic Brazil’s talk suggests there is also a human face to patient safety - in the behaviour and attitude of healthcare practitioners and patients themselves......
We think too little of patients. We feel affronted if patient takes a different view of ‘evidence’ or of ‘risk’. …and they think too much of us....! Every day patients allow nurses (and doctors) to inject drugs into their IV line without asking “whats in that syringe”....
This combination of our subconscious paternalism and patients’ blind faith is a heady mix……but ripe for us to make a difference. Vic suggests there are are small, human ways we can involve patients in safer healthcare, of better quality and with an improved patient experience.
We can ask them.
We often do involve patient advocates at the ‘strategic end’, but when was the last time you invited a real patient to your departmental teaching or consultant meeting (or smacc conference...!)
We can connect with advocates for patient experience and ‘personalised medicine’, especially if we are interested in social media. Follow people like @JenWords and @EricTopol Involve patients as another layer of Swiss cheese. Ask them to be on the lookout for mistakes. And maybe Stop ‘looking after’ patients and start ‘partnering with’.
In this talk from SMACC Chicago 2015, Larry Chu takes a step back from the clinical side of things to discuss Innovating Medical Education.
Dr Larry Chu is an Associate Professor of Anaesthesiology and the Executive Director of Stanford Medicine X. Medicine X is an initiative from the Stanford AIM lab. It is a project aimed at promoting new ideas for the future of medicine, healthcare and education using emerging technologies. It focuses on empowering patients to participated in their own healthcare and improving medical education and training to focus more on patient-centered medicine.
Each year, Medicine X holds a conference in which they explore theses themes. In 2015 the team from Stanford held a spin-off conference called Medicine X Ed. This conference focused on the future of medical education and the role of technology in educational innovation as well as continuing the theme of the changes that are fundamental for establishing more patient-focused health care. This conference was held in September 2015. At SMACC Chicago, Larry Chu shared a sneak-peak into some of the exciting medical education innovations that were going to be explored at Medicine X Edu.
During his talk, Larry Chu shared insights into why traditional teaching methods don’t work for millennials aka gen Y, the successful educational programs being used in the US for their anaesthetics trainees and new ideas for structuring the delivery of effective medical education.
For all trainees, in particular those with impending exams, and for all teachers/lecturers/educators this is an interesting and thought provoking lecture to listen to! Yet again proving why SMACC is the most dynamic, well rounded, original conference around!
What is the problem?
Delivering bad news and having an end of life conversation are core skills for any practitioner who deals with critically ill patients. Current data show that while 22% of deaths in the USA now occur in ICU, 54% of families surveyed have a poor understanding of patient’s diagnosis, treatment plan and prognosis. Dr. Kate Granger found this out first hand while admitted to hospital in the UK and started the #hellomynameis campaign.
What is the evidence?
While families feel more validated if given longer to speak, doctors speak for 71% of the time in family meetings. -Longer meetings are also associated with greater patient and family member satisfaction. -Patients perceive that doctors spend longer with them if the doctor is sitting down. -Use of a simple mnemonic increases satisfaction and reduced the incidence of PTSD in family members.
What do experts do?
1. Prepare for the meeting. Decide who will attend, what you will talk about and what your goals are.
2. Introduce everyone and explain the agenda.
3. Gather everyone’s understanding
4. Listen and don’t interrupt
5. Empathise (physicians express no empathy in 1/3 of family meetings)
6. Make the patient’s voice heard
7. Make your recommendation to go forward
8. Reflect on the meeting after it concludes
What about the difficult situations?
Hope is an issue that comes up often. Many other specialties emphasise the importance of hope, while intensivists are often seen as being nihilistic. But we can still foster a degree of hope in patients and families without being unrealistic. -Techniques for managing conflict are discussed such as identifying discord in the family and avoiding mixed messages from staff. -The importance of spirituality is discussed.
Pain in children is often under treated due to practitioners lacking the knowledge or confidence to be aggressive enough. This is partly due to the lack of structure presented in pain managment and it is frequently made to seem more complex than it is.
Almost all acute pain in children can be dealt with by a simple stepwise regime using a small number of common, established and easy to use drugs.
Likewise, procedural sedation can be safely and simply performed with simple regimes.
Advances in understanding the cardiopulmonary physiology during CPR, perfusion and reperfusion of the brain, and advancing technologies have made possible directed and customised resuscitation of cardiac arrest. We will present where current CPR fails, and what it may look like in the future.
Phil Hyde vs Greg Kelly - We Should Perform Therapeutic Hypothermia (T32– 34C) for Children After Cardiac Arrest
The recent publication of THAPCA-OH filled an important gap in our knowledge. THAPCA does not support cooling children after cardiac arrest which was a common practice until recently in many units. It is illustrative to look at how a practice became routine with no supporting evidence at it raises questions about what questions we ask and how we operate in the absence of good evidence.
Working in a remote hospital often means working without the aid of formal medical imaging or Labs. So does this mean that we must compromise on our patient’s care? No.
Bedside Ultrasound has changed the way I diagnose, treat and care for patients in this paradigm.This talk will explore the utility and a practical approach to bedside sonography for range of clinical situations: trauma, fracture management, sepsis diagnosis and resuscitation, Paediatric fever and bowel obstruction – all without X-rays.
Ultrasound can allow us to provide faster, more accurate and compassionate care – regardless of where you work.
Preparing your hospital for a disaster
Sara Gray Synopsis: This talk will highlight essential components of hospital-based disaster planning.
We will discuss tips for planning training exercises, getting funding, and effective debriefing. Preparedness really matters, find out why!
Objectives:1.
Discuss essential components of a disaster plana.All hazardsb.IMS structures. Should your plan be long or short?
2.Talk about training exercisesa.Low fidelity versus high fidelity exercises.Getting funding
3.Review why debriefing mattersReferences and Links1.Canada’s national preparedness site, pitched mostly to individuals http://www.getprepared.gc.ca/index-eng.aspx
2.Ontario’s Emergency Management Office site includes some training tools and resources for organizationshttp://www.emergencymanagementontario.ca/english/home.html
3. The CDC Emergency Preparedness Site http://emergency.cdc.gov/hazards-all.asp
4. FEMA’s site has some good resources for organizations.
Also has an interesting text message program about hurricanes and other natural disasters, where people can sign up for text updates about local disasters. https://www.fema.gov/
5. A good site for improving debriefing skills: http://thoughtleaderzone.com/2013/03/11-questions-and-prompts-for-insightful-debriefing-sessions/
Improved patient outcomes as the goal of training. With this philosophy in mind, Bill Hinkley shares his three pillars of training; train yourself, train as a team, train others.
Advice from an inspiring educator on how to build a personal learning network, tips on training as a team and how influential passionate educators are to teaching others.
Sonowars continues to find new ways to make Ultrasound teaching exciting, inspirational and most importantly informative. The team of James Rippey, Matt Dawson, Mike Mallin and Andrian Goudie are back with an all-star supporting cast. Keep an eye out for the light sabre, simulating ultrasound guided venous canulation as well as the mechanical bull ultrasound challenge. Things are bound to get a little crazy when these guys get fired up.
The host response to injury is inflammation.
The inflammatory response may have been naturally selected over millions of years of evolution to give the injured tissue the best chance of healing and recovering. On the other hand, over the last 50 years animal models of traumatic brain injury (TBI) suggest that fever, occurring as part of the inflammatory response, may be harmful to neuronal recovery. Some observational clinical studies support this. However we lack high quality clinical trials.At present clinicians commonly use drugs and physical cooling techniques to suppress fever after TBI and stroke.
These approaches have costs and can be resource intensive, as well as be associated with side-effects. We will share with you some of the results from our program in this area. We will discuss ...
What is normothermia?
How effective are the interventions we use?
What temperature do/should we target? What do we achieve?
Surely we need a reliable answer to the question of whether the strict maintenance of normothermia (36-37°C) reduces disability and death after TBI?
References1.Saxena M, Andrews PJ, Cheng A, Deol K, Hammond N. Modest cooling therapies (35ºC to 37.5ºC) for traumatic brain injury. Cochrane Database of Systematic Reviews 2014.2.Saxena M, Young P, Pilcher D, et al. Early temperature and mortality in critically ill patients with acute neurological diseases: trauma and stroke differ from infection. Intensive Care Med 2015:1-10.3.Young P, Saxena MK, Beasley CRW, et al. Early peak temperature and mortality in critically ill patients with or without infection. Intensive Care Med 2011;38:437-44.4.Saxena MK, Taylor CB, Hammond NE, et al. Temperature management in patients with acute neurological lesions: an Australian and New Zealand point prevalence study. Crit Care Reusc 2013;15:110-8.5.Saxena MK, Taylor C, Hammond N, et al. A Multi-Centre Audit of Temperature Patterns After Traumatic Brain Injury. . Crit Care Reusc 2015 (June);17:129-34.
Making Transitions of Care Safe - Pat Croskerry Summary by: Pat Croskerry
It is now well recognized that transferring the care of a patient from one caregiver to another is a vulnerable point in a patient’s care and a potential threat to patient safety. There may be many intra-disciplinary and inter-disciplinary transition points in the ED during an individual patient’s care. The process requires that each participant communicates well with others to establish an accurate shared mental representation of the important issues.
To minimize transition failures, the process should be trained and standardized, recognized as a multi-professional activity, defined by who should be present, where and when it should occur, and have an end-point that is a clear plan for the ongoing care of the patient. The reliability, consistency, and efficacy of the transition should be a hallmark of departmental culture.
Training should be provided in how the process works and how it fails. The broad distinction between the transfer of poor information (unwarranted opinions, stereotyping, stigmatization, gratuitous comments, overconfidence, and other cognitive biases) and poor transfer of information (unstructured, casual setting, rushed/fatigued, interruptions/distractions, limited input from others, verbal only, degraded narrative skills) should be recognized. It is important to reliably express the amount of certainty attached to what is actually known at transfer so that recipients clearly understand what is expected of them.
The vulnerability of human memory should be recognized and strategies used to deal with it (SBAR, I-PASS and others). There should be awareness of particular biases in communication at transition time. Serial position effects describe how primacy (information presented at the beginning) and recency (the last information to be presented) may influence what is perceived and retained. It is important to be aware of specific biases that operate at transition time: framing, fundamental attribution error, search satisficing and others) and consider strategies to mitigate them.
The master of Dogmalysis himself, Cliff Reid, challenges current practices in prehospital and emergency medicine. Warning listeners to be skeptical, Cliff dissects the dogma of acute crush injuries and spinal immobilization. He also explores the false dichotomy of “scoop and run vs. stay and play”. Cliff reminds us that “not to challenge current practice is intellectually lazy”.
Kevin Fong is an astrophysicist, astronaut and anaesthetist who gives an incredibly entertaining talk about human space exploration and our dreams of a manned mission to MARS. This is a mission that stands on the boundary between science fiction and science fact. A mission that would be a minimum of 1000 days in length and which would be twice as long as any previous manned space mission.
Fong focuses on the the incredibly destructive effects of such prolonged weightlessness on the human body. He outlines the somewhat predictable effects of this on the muscles and bones, but surprises us with the changes in vestibular balance, linear acceleronomy, baroreceptor calibration and probably most frighteningly the psychological effects of prolonged isolation in space. Despite considerable work in the area of human adaptation for space and the ongoing development of counter-measures these physiological challenges remain largely unsolved.
In essence Fong explains, to overcome the detrimental physiological effects of prolonged weightlessness engineers need to design a craft capeable of generating 1G of gravitational force to mimick earth's gravity. This could require a craft the size of the London EYE rotating four times per minute. Perhaps if this can be achieved, astronauts might arrive at MARS after 30 months in space in a physcial state capeable of allowing them to stand upright and walk from the landing craft.
A pair of outrageously high heels next to a pair of tattered combat boots, set the stage for Ashley’s talk on the stress of PHARM.
Ashley draws on lessons learned in combat to support her theory of mental health survival. She emphasizes the importance of critical incident recognition, response and elimination of stigma associated with seeking help.
Bouncing Back from the Beach – Cutting to Air to secure an Emergency Surgical Airway Summary by: Thomas Dolven
To handle airways means being prepared to handle them all the way. You need to be prepared for a cannot intubate cannot oxygenate CICO scenario. The common, final end point of airway management in a is the emergency surgical airway, the cricothyroidotomy.
So how to prepare?
Often, it is not being taught right. This is a rare procedure under high stress and time sensitive. And most importantly, it is a bloody procedure that will be blind. You cannot use your eyes. So it needs a simple technique without fine motor skills, and it must be tactile. Your finger is the perfect tool for this task, and will guide you through it. The video of my personal real world experience is backed by available empirical evidence and lab training. There will never be an RCT, this is the best evidence we will have. So read NAPP4 and the case series article on the scalpel-finger-tube technique.
Read these available articles, train, and remember these two key points:
1) There will be blood. But that’s OK, because.
2) Your finger can see.
Tox-Dogmalysis is a talk about evidence in Toxicology. It’s been said that 50% of what we learn is incorrect; we just don’t know which 50%. As the complexity of medicine increases, it is of the utmost importance for clinicians to be skeptical of old data and new data alike.
Many in the FOAM community have made huge strides in busting myths that have persisted over time.
However, sometimes we may declare myths busted too prematurely based on incomplete or misunderstood data. This talk will explore three topics in toxicology for which the perceived myths may actually be true, or at least not completely busted.
Fluids in Critical Care: Time to SPLIT With Normal Saline? Summary by: Paul Young
Intravenous fluid therapy is a ubiquitous treatment for critically ill patients and has been used in clinical practice for over 175 years. Despite this long history, the majority of intravenous fluids have not been subjected to the same level of scrutiny as other drugs. That said, large-scale fluid trials evaluating albumin and starch solutions compared to 0.9% saline have been conducted and their results have changed clinical practice around the world so that crystalloid fluid therapy is now predominant in many parts of the world.
While 0.9% saline is the world’s most commonly prescribed crystalloid fluid, increasingly clinicians are turning to buffered or balanced crystalloid solutions as an alternative to 0.9% saline. This practice change from 0.9% saline towards balanced crystalloids is not based on high quality evidence but is supported by observational data suggesting that saline may be associated with an increased risk of renal toxicity and mortality compared to buffered crystalloids.
This talk gives an overview of the data comparing the comparative effectiveness of 0.9% saline and buffered crystalloids, provides an overview of the historical context of intravenous fluid therapy (and proctoclysis), and describes the design of the Saline vs. Plasma-Lyte 148® for Intravenous fluid Therapy (SPLIT) trial which has now been completed and was recently published in the Journal of the American Medical Association.
External Links
• [The Bottom line] SPLIT trial reviewed
• [article] Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit The SPLIT Randomized Clinical Trial
• [editorial] Editorial accompanying paper
• [videocast] Presentation of SPLIT trial at ESICM by Dr Paul Young
• [Further reading] Association Between a Chloride-Liberal vs Chloride-Restrictive Intravenous Fluid Administration Strategy and Kidney Injury in Critically Ill Adults
• [St Emlyn's] SPLIT trial published. Saline or Plasmalyte on the ICU?
Mark Wilson hosts an all-star cast!
Summary By: Mark Wilson
Traumatic brain injury (TBI) is a hugely important topic in critical care. It is a major cause of morbidity and mortality throughout the world with hospital presentations totaling over 2million in the US, 1 million in the UK and 700,000 in Australia each year. Not only do they represent a huge proportion of injuries, but they are a unique in their potential to fundamentally change “who a person is”. As critical care and trauma practitioners there are many aspects of management that can change outcomes for patients in the short and long term.
Dr Mark Wilson (@MarkHWilson) is a neurosurgeon and doctor for the Air Ambulance in the UK. In this session from SMACC Chicago entitled “It’s a Knockout”, he expertly leads a discussion which holds a magnifying glass to the current practice guidelines for managing TBI as taught in ATLS. On the discussion panel is a star-studded international cast including: Pierre Janin, Andrew Dixon (@DrAndrewDixon), Karim Brohi (@karimbrohi), Karel Harbig (@karelharbig), Deb Stein, Michael McGonigal, Bill Knight, John Hinds and Ralph the Janitor (who looks remarkably like Cliff Reid @cliffreid).
In this discussion forum, international specialists from the fields of neurosurgery, intensive care, trauma surgery, emergency medicine and radiology engage in a discussion of the step-by-step management of a real case of a patient with a head injury. This discussion highlights the many management controversies including how to manage the c-spine, whether or not to oxygenate, whether or not to intubate, when to extubate, if and how to sedate the patient, when to CT and how to monitor the head injured patient. In typical SMACC style this discussion demonstrates the approach to the management of a patient from different vantage points and demonstrates why it is so difficult to come to a consensus of the approach to this type of injury.
Panelists delve into the features of TBI that you won’t find in textbooks including impact brain apnoea, multi-compartment syndrome and more. Watch out for the a segue into the Good Sam App, a smartphone app which alerts registered medically trained personnel to nearby emergencies to minimize downtime when medical emergencies occur.
This forum has everything you have come to love and expect from SMACC including international experts, heated debates, controversial #hashtags, guest speakers and more!
Summary by: Paul Young
The febrile response to infection occurs in most animals and is regulated by a common biochemical mechanism involving prostaglandin E2. This common mechanism suggests that the response may have evolved in a common ancestor more than 350 million years ago. As the febrile response comes at a significant metabolic cost, its persistence across a broad range of species provides circumstantial evidence that the response has some evolutionary advantage. Furthermore, it logically follows that the components of the immune system would have evolved to function optimally in the physiological febrile range.
There are a number of historical examples of dramatic responses to treatment with therapeutic hyperthermia in some infectious diseases, including neurosyphilis and malaria. The relevance of these historical examples to the modern era is unclear. Furthermore, arguments based on the evolutionary importance of the febrile response do not necessarily apply to critically ill patients who are, by definition, supported beyond the limits of normal physiological homeostasis. Humans are not adapted to critical illness. In the absence of modern medicine and Intensive Care, most critically ill patients with fever and infection would presumably die. Among critically ill patients, it seems likely that there is a balance to be struck between the potential benefits of reducing metabolic rate that come with fever control and the potential risks of a deleterious effect on host defence mechanisms. Where this balance lies is very unclear as there are very few interventional studies of fever management in critically patients.
Remarkably, although paracetamol is very widely used in ICU patients with fever and infection, only one RCT, the HEAT trial, has investigated the safety and efficacy of administering paracetamol to critically ill patients with fever and infection. This talk gives the background to the HEAT trial which has now been published in the New England Journal of Medicine.
Links
• [The Bottom line] HEAT trial reviewed
• [NEJM article] Acetaminophen for Fever in Critically Ill Patients with Suspected Infection
• [NEJM supplement] Supplementary reading • [podcast] Paracetamol improves recovery in critically ill patients. Radio interview with Paul Young
• [other studies] Paracetamol therapy and outcome of critically ill patients: a multicenter retrospective observational study
What is it that enables some physicians to step into a high pressure situation with poise, presence, and consistently perform to their capabilities?
What else is there beyond technical knowledge and clinical skill that can be developed to help immunize the person that is a physician from some of the more human challenges that can present?
In a field so ripe with immense performance pressures, demands, and expectations what are those people doing who seem to thrive amidst it all?
In this session you will be introduced to a variety of strategies rooted in the principles of performance psychology, and their application in high-pressure performance environments such as medicine. Learn how the top performers I have observed through my extensive collaborations with physicians, and others in high-pressure fields (e.g. elite athletes, business leaders and military/tactical officers) have come to gain efficiencies in how they focus, stay perceptive, maintain equanimity, process their experiences, create and sustain an optimal “feel” in their work and ultimately, perform to their potential when it matters most.
Kevin Fong is an astrophysicist, astronaut and anaesthetist with an interest in medical error and safety. In this talk he focuses on lessons learnt from his time at NASA which can be applied to medical practice. Fong believes that key to safer practice is in the collection of accurate data. He outlines some aspects of the famous communications between Sully Sullenberger (pilot) and the Le Gardia air-traffic control tower as Sullenberger miraculously lands a commercial airline on New York's Hudson River - Fong's point is not in the words said or in the calmness of the communications, but that we can go back and analyse every word spoken because the data is collected so accurately.
He goes on to discuss some of the failures surrounding both the Space Shuttle Challenger and Columbia accident's. More importantly he stresses not so much the lessons learnt but the lessons forgotten and the need to ensure organisational memory. We only protect ourselves and our patients through technology and the systems of operation we create.
Is the care you deliver to critically ill patients in your ED the same as the care delivered in your ICU? And if not, why not?
Consider the challenges facing the delivery of excellent care in the ED, and be inspired to make changes at your hospital to improve your system. Learn ten strategies for optimizing the care of critically ill patients in your ED.
References:
1. Learn more about ED-ICU’s at Scott Weingart’s excellent site http://www.emcrit.org
2. Consider a resuscitation fellowship like this one: http://www.resuscitationinstitute.org/index.cfm/education/resuscitation-fellowship1/
3. There are zillions of articles about the benefits of simulation and training, here is a link to just one, if you only want to dip your toe in the water: http://qualitysafety.bmj.com/content/19/Suppl_2/i34.full
4. Audit and feedback around quality outcomes are a potential strategy. Read more about the pros and cons from the World Health Organization here: http://www.euro.who.int/en/data-and-evidence/evidence-informed-policy-making/publications/2010/using-audit-and-feedback-to-health-professionals-to-improve-the-quality-and-safety-of-health-care
When settings outside the hospital are taken into account (ED, primary care), the overall number must be considerably higher. While many factors contribute to diagnostic failure, a variety of sources suggest that physician’s thinking has a lot to do with it.
Dual Process Theory describes how the brain makes decisions in one of two modes: through fast, unconscious, intuitive processes (System 1) or through slower, conscious, analytical processes (System 2). Mental short-cuts (heuristics) and biases are predominantly located in the intuitive mode where we spend most of our conscious time, and this is where the majority of decision failures occur. Thinking straight essentially means achieving a good balance between System 1 and System 2 decision making, and much of our cognitive effort needs to go into monitoring what our unconscious brains are doing in System 1. This is referred to by a variety of terms: metacognition, reflection, mindfulness, and others. They all involve cognitive de-coupling from System 1 and characterize the process of cognitive de-biasing. This is not easily accomplished in the ED or any environment where decision density is often high, throughput pressure exists, resources may be limited, and where decision makers may be fatigued and/or sleep deprived.
While medicine has acquired a variety of strategies over the years for de-biasing clinicians, added benefits can be obtained by developing specific mindware to tackle particular biases. Clinicians need to be aware of the operating characteristics of the dual process model of decision making, of the prevalence and nature of biases, and of how to apply and sustain de-biasing mindware in their decision making.
The human circulation is a complex system that has evolved over millenia, primarily designed to promptly respond to conditions of stress - the fight and flight response. The traditional physiological approach focuses on the heart as a pump, adapting to changes in volume and metabolic states.
These principles are underpinned by the Starling equation and incorporated into an adaptation of Ohm\'s law. These principles have been maladapted, punctuated by an increasing reliance on surrogate and derived variables that have little to do with teleological haemodyanamic responses.Insights into the central role of the autonomic nervous system are provided by Guytonian theory that in part explain the physiological fallacy germane to many clinical protocols and practices.
These fallacies have been amplified by commercial studies directed at short-term physiological improvements that have little to do with patient-centred outcomes in the medium and longer term.Such effects have been demonstrated in recent high-quality RCTs that force a re-appraisal of seductive short-term physiologically-based gratification.
The Force is strong with this one… Despite years of research and new technology, the adjusted mortality rate for traumatic brain injury remains near 25%. Currently, primary injury occurs before we can intervene, and all our pre-hospital, ED and ICU care is directed towards preventing remarkably complicated and poorly understood secondary injuries.
TBI is a heterogenous group of diseases often treated homogenously. You too can master the ways of the Force, by reviewing the Top 10 items you need to know to care for your next patient with a severe traumatic brain injury. Topics covered will include the most up to date evidence, anticoagulation reversal, early aggressive care, and future directions. Become a master of this complicated disease process in your clinical practice.
Neurologically intact recovery after out-of-hospital cardiac arrest remains dismal. In the United States, an 8% meaningful recovery rate is hopeful at best. The introduction of extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR) is not new but has been shown to provide upwards of 27-30% meaningful recovery, when applied to the appropriate patient population. In 2011 we began extracorporeal CPR (ECPR) in our emergency department - a suburban non-academic center in San Diego, California, USA; the results have been very promising. As a result, we also began refining all aspects of resuscitation. What specific things did we change about the way we do resuscitation?
Proper preparation of the resuscitation suite: If we assume the patient will end up on ECMO, then early femoral vessel access is the priority. Traditional paramedic offloading was problematic for many reasons. To address that we:
attempt transfer of the patient from medic gurney to hospital gurney in the ambulance bay, where there is more room.
When ‘CPR ala fresca’ isn’t possible, we bring the patient into the resuscitation room on the right side of the room, which allows the doctor accessing femoral vessels to be sterile-prepped with ultrasound in-hand.
Early femoral arterial transduction to guide the resuscitation
Hemodynamic-Directed Dosing of Epinephrine intra-arrest
Nurse Code-Team Leader: assign the rote elements of the code, the ACLS protocols, to a trained nurse code team leader. This provides physician cognitive offload.
Use a mechanical chest compression device
Use an Impedence Threshold Device:
increases venous return
decreases intracranial pressure (ICP)
increases coronary perfusion pressure (CPP)
Does any of this make a difference? Well, review of CARES data (U.S.-based cardiac arrest registry) shows that the 2014 arrest recovery rate, with meaningful neurologic outcome, at our hospital was almost double that of the nationwide data. And of the 50 patients included in the CARES database for our hospital, only 4 of those were resuscitated with ECPR. Perhaps we are just paying better attention and providing better overall care throughout the resuscitation. Perhaps we can all improve our resuscitation outcomes.
Reuben Strayer takes us through the myriad uses of Ketamine, and dispells some myths in the process. A Special K classic.
Is Suspended Animation only in the realms of science fiction, or is this a realsitic treatment option? Mervyn Singer questions if we can prevent secondary reperfusion injury following cerbral ischaemia.
In Coping with Isolation - All alone on Kangaroo Island, Tim talks with brutal honsety about the reality of being a rural doctor.
Oli Flower brings lessons from cage fighting that are relevant to all health care professionals. Be open minded about this one!
Christine Bowles takes on the big issue of Sex in critical care. In 2015, why is sexual equality in the workplace even an issue and how can we address it?
Roger Harris shows us just how complex decisions about resuscitation can be and when stopping can be the right thing to do.
ENT surgeon Georgie Harris takes you through a logical approach to managing the horrific scenario of a transcected airway
Guess or Gestalt? by Simon Carley. The secret to being a great Emergency Physician lies in Skill, Knowledge and Clinical Acumen!
Failure is a fundamental part of learning, and growing. Michelle teaches us about failing better and the benefits and freedom this brings.
Rob Orman drills down on what suicidal ideation really means and how you can tell if your patient really has it.
An all-star panel of world sepsis experts discuss the controversial areas. Expertly hosted by Scott Weingart and lubricated with on-stage alcohol.
Hemorrhage is the leading cause of preventable death following trauma. Deborah Stein talks REBOA - who, what and why...
Beating sepsis in Latin America is a serious challenge. Flavia Machado descibes the 5 major issues & how they're being tackled.
Education Theory for the Clinician - Jonathan Sherbino will improve the quality and efficiency of how you teach.
Shreves shows palliative care providers how to re-align with their patients and provide the highest quality end-of-life experience.
Karim Brohi on tranexamic acid in trauma. With the "TXA denier's handbook" laminated with sarcasm, Karim's talk is a must-hear.
Roger & Oli go through the latest information about registration for smaccDUB, discussing the program, workshops, student rego, the ticket release, why Dublin, other pre-confernece events, the social program and accommodation. See you in Dublin!
The battle is on...who will win out? The heroic healthcare individual or the faceless safety checklist? Brindley takes saftey talks to a new level. A true SMACC highlight.
John Hinds shows us why he will be so dearly missed in this superb talk from SMACC Chicago. This is about resuscitative thoracotomy but really so much more.
Opioids are extraordinary agents that have been used for millennia for the relief of pain and suffering; however, the history of opioids is also one of abuse and addiction. In the US, we are in the midst of a devastating iatrogenic chapter in this history, a prescription opioid epidemic that kills 15,000 Americans per year by overdose and destroys hundreds of thousands of lives and families.
In this presentation we will consider the magnitude and consequences of the current epidemic; describe how clinical organizations and clinicians were appropriated by the pharmaceutical industry so that Americans–5% of the world’s population–consume more prescription opioids than the rest of the world combined; and discuss strategies for managing patients who present to emergency departments with acute or chronic pain complaints that account for our competing mandates to palliate and protect.
These strategies center on an assessment of the likelihood that using opioids will deliver benefit or cause harm. For patients at low risk to be harmed by opioids, utilize aggressive multimodal analgesia, including opioids as needed to control acute pain, and prescribe optimal outpatient non-opioid analgesia with a small number of breakthrough opioids if indicated. For patients at high risk to be harmed by opioids, including patients with chronic pain and patients with flags for opioid misuse, avoid using opioids in the ED and outpatient settings, utilize non-opioids to manage symptoms, and, when misuse is suspected, nudge the patient to addiction treatment. The goals of optimal opioid stewardship are to provide effective symptom relief while preventing de novo cases of addiction, to control the supply of opioids in the community, and to protect existing addicts from further harm while promoting recovery.
For slides, the HELPCard treatment referral business card, and phraseology to use when managing patients at risk for opioid misuse, go to http://emupdates.com/help
Kath Maitland, the author of the FEAST study, talks about where we go now with fluids in kids, following FEAST
Personal tragedy will touch all of us. Rob's talk is an incredibly personal story but offers much practical advice for dealing with the inevitable.
Liz Crowe delves into the deeper issues surrounding critical care and religion. She explores how religion influences patients and their families, why doctors can push against faith, and how the healthcare community can integrate an acceptance of faith into their care.
The ultimate goal in working with any patient and their family is connection. This guarantees respect, integrity and ensures all communication is understood and goals are worked on together to optimise health outcomes. Connection is also a protective factor for patients and staff as it builds resilience and wellbeing. Health professionals are often uncomfortable or annoyed if people of faith want to integrate their beliefs and hopes into medical conversations and outcomes.
Health professionals may perceive faith or religion as a threat or oppositional to science and the reality of the situation. Ideally faith may be an additional resource for health professionals to use with patients and their families in times of crisis, uncertainty, and end of life care. There is a strong connection between faith and hope. Prayer and crisis-orientated faith are commonplace in critical care medicine even for people who have been ambivalent or non-believers of faith in the past.
Challenging a person’s faith or belief in times of crisis may result in a severing of the therapeutic alliance or relationship which will have the opposite effect to what the health professional may desire. People who ‘refuse’ to believe a diagnosis or prognosis in the hope of a miracle or divine intervention are vulnerable. To enter a dispute with religion is disrespectful, futile, and unhelpful. To learn more about someone’s beliefs and join in a genuine hope for a ‘miracle’ shows compassion, understanding and respect.
Nobody wants to suffer. Most of us are frightened by loss and illness. Inviting and sitting comfortably with faith and prayer while also gently holding their fears and preparing for the worst is a more powerful and honest way to work. Regardless of personal values and beliefs, hoping that others can receive comfort and peace from a sense of spirituality and faith is to remain human.
We aim never to fight with a higher being, rather invite the presence into the family room and join with the family in the desire that the family never feel alone or abandoned by either their faith or us as health professionals. Long after we may have forgotten the specifics and details of families, they will remember us. The health professional who can sit with someone, who can build health goals and care based on the beliefs of others, will be those who are most respected and valued.
For more like this, head to our podcast page. #CodaPodcast
John Hinds gives his last talk - on the subject he was most passionate about. Back with popular demand, More Cases from the Races.
Chris Ross & Oli Flower discuss the latest update on SMACC Chicago - an incredible cadaver workshop with small group expert tuition on a huge range of critical care procedures. At a hugely discounted price. This will sell out so get in there fast.
A long time ago in a galaxy far, far away.... Watch our fearless masters of Sim battle for galactic supremacy on the SMACC main stage.
Own the ventilator! Irma Bilgrami lays down a framework for analysis of ventilator settings and waveforms to enhance your daily practise.
Integrity, Reflection and Professionalism. Stuart Lane examines how we respond to mistakes, errors and poor outcomes in clinical practise.
Treating the mind AND the body. Imogen Mitchell on putting the 'person' back in 'patient'.
Penny Stewart's enthralling tales of high acutity cases in rural and remote Australia. A unique take on consistently challenging case-mixes.
The quest for normality. Chris Nickson reflects on our perpetual number chasing. What constitutes 'normal' in critical care patients.
Cracking the chest. Michaela Cartner on the nuances of cardiac arrest post cardiac surgery.
Richard Levitan on 'conquering the fear'. Tips and tricks for emergent paediatric airways.
Setting up for Success. Anthony Lewis highlights the importance of preparation and planning to minimise emergent airway failure.
Tools for success. David Pilcher examines the plethora of available tools for outcome prediction in critical care.
Levitan, Weingart, Hind, May, Neil - The Airway Experts discuss all things cricoid, BURP and checklists. Airway Q&A
Bilgrami, Westafer, Gatward, Rogers, Brazil, Roland - FOAMed and the future of medical eduction. The education Q&A.
O's in the Nose. Richard Levitan's tips and tricks for optimising the nasopharynx as part of your airway management.
Lipman, Raper, Murphy, Philpot, Myburg, Mitchell - The ICU Q&A panel discuss clinical scenarios.
Yogesh Apte gets back to basics. How we should integrate physiology into our bedside clinical practise.
The Twitter debate comes to a dramatic conclusion. Should Airway doctors use checklists ?
The Emergency Medicine panel discuss high sensitivity troponins, stroke thrombolysis and problems facing emergency medicine
Sonophiliac, Justin Bowra highlights strategies for teaching our juniors to become adept at utilising bedside ultrasound in critical care settings
The single best test ? Pierre Janin examines the use of transthoracic echo in ICU. The best possible applications and how they will change patient outcomes.
The power of the probe. Matt Dawson delivers an emotive talk on minimising paediatric procedural risk with ultrasound.
Death of the stethoscope? Mike Malin demonstrates the power of bedside ultrasound, unique applications, and future directions.
The Future of Bleeding. Anthony Holley enthralls the crowd with exciting advances in blood product replacements.
The mental game. Richard Levitan on how our approach to the difficult airway benefits from planning and introspective affirmation.
Conquer the random number generator. Lawrence Weinberg's guide to modern haemodynamic monitoring devices.
Three Tiered Therapy. Ollie Flower gives an enthralling history of seizures throughout the ages and expertly outlines the management options for terminating status.
What's in the box ? Andy Neil expertly demonstrates simple approaches to neuroanatomy and the interpretation of imaging.
Resistance is futile?. Jeff Lipman examines our dwindling antimicrobial arsenal. How can we bolster our defenses?
The Sim revolution. John Gatward on the future of simulation in critical care. Strategies for pulling it off, no matter your resources.
Seeing the future with Pieter Peach. Technological developments that are sure to influence the way we learn and teach medicine.
Roger Harris & Oli Flower announce opening of registration for SMACC Chicago - 5th (US/UK) / 6th (AUS) November 2014. They explain why you need to get in quick:
- Save Cash
- Don't miss out on workshops
- Don't miss this unique event
And much more.
Go to smacc.net.au for more!
Mark Little builds a framework for the clinical approach to patients with suspected poisoning or envenomation. Particularly useful in a country where everything is trying to kill you.
A conniseur's guide to the different families of non-invasive cardiac output monitors. Haney mallemat expertly details the pros and cons of each.
Vampire Planet? Ed Litton on the worldwide dependance on blood products. Future strategies for reducing our requirements.
Anaphylaxis and Anaesthesia. Michael Rose examines changing paradigms in how we approach the 'allergic' patient. Risks, Reactions and Results.
Is base excess the new bicarb ? David Story's breakdown of an often complicated and confusing topic.
Imogen Mitchell critiques our relationship with MET. How current medical and nursing education is propagating junior staff reliance.
Steve Smith enthralls the crowd with an eye-opening exploration of subtle ECG changes with potentially catastrophic outcomes
Augmentation by Echo. Deidre Murphy examines advanced aspects of bedside echocardiography, and the immense amount of information it provides in a critical care setting.
Rob Rogers delivers an emotive and inspirational speech on the dying art of bedside teaching. How we can return to our roots
Celia Bradford dissects the fundamentals of renal replacement therapy and examines its niche in the ICU.
A golden mile too far? Lewis Macken dissects evidence suggesting that chasing urine output in burns patients leads to overzealous fluid resuscitation.
Crystal caves in Mexico. David Rosengren's enthralling tales of humidity, hyperthermia and human limits. How does the body cope?
It's not easy bringing a resus room to a cliff-face. Brian Burns illustrates some of the daunting challenges encountered in the pre-hospital environment
Disaster Medicine! Mark Little on strategies for the 'away team'. How the focus of medical teams needs to change when faced with large scale catastrophes.
Geoff Healy rises above traditional views on the use of anaesthesia, highlighting the unique challenges and key role it plays in the pre-hospital environment.
Is mum always right ? Roger Harris' evolutionary approach to feeding in the ICU. Are we fighting mother nature?
Evolution and inflammation. Karim Brohi critiques our approach to sepsis and how we should consider more judicious, multi-directional approach.
The 1%. Jeremy Cohen examines what makes us unique. Are there observable genetic traits that will determine how we respond to severe illness and can we measure them?
Exploration medicine. Glenn Singleman enthralls the crowd with tales of the deep, his experiences following James Cameron into the Mariana trench.
Rob mac Sweeney dissects the current evidence base that governs our diagnosis and management of ARDS. Distressing results.
Jeff Lipman explores how our conventional regimes for drug administration may be drastically underperforming when treating our critically ill patients
Karel Habig reveals exciting, emerging technologies that have the potential to revolutionise pre-hospital care.
Casey Parker examines what makes us human. The principles and practice of empathy in critical care, the importance of introspection. How to improve your practice.
Deidre Murphy on Murphy's Law. The importance of training, planning and preparing for the worst. ECMO emergencies
Sarah Webb highlights how the upskilling of critical care nursing staff can make for more efficient and effective high acuity care teams.
Little Adults? Fran Lockie examines our approach to critically ill children and the importance of sticking with our tried and tested formulae.
Resus room Feng shui. Tim Leeuwenburg on 'training hard to fight easy'. Challenges and strategies for the remote emergency department.
The best way to convey the worst. Steve Philpot highlights flaws in our approach to discussions surrounding terminal illness and palliative care.
In Troponin we trust? Rick Body examines the clinical approach to the diagnosis of ACS, how our judgement can be notoriously wrong.
From ECPR to ECMO. Steve Bernard examines evolving trends and technology for post-arrest care in Australia.
Scott Weingart unveils his mantra for the surgical airway, whilst exploring its vital role and the stigma surrounding it.
Commonly missed catastrophes. Rob Rogers expertly details strategies for improving our early identification of aortic dissection.
Tales from past lives. Deniz Tek regales the crowd with unlikely parallels between his other loves; music, aviation and emergency medicine.
Louise Cullen and Rick Body fuel a contentious debate on the clinical significance of the high sensitivity troponin assay. Will your patients benefit from that extra digit ?
Louise Cullen and Rick Body fuel a contentious debate on the clinical significance of the high sensitivity troponin assay. Will your patients benefit from that extra digit ?
Scott Weingart revisits his famous video, illustrating how awake intubation can be done efficiently and effectively, with the proper preparation.
Scott Weingart revisits his famous video, illustrating how awake intubation can be done efficiently and effectively, with the proper preparation.
John Hinds delivers on his promise of ‘in extremis’ whilst exploring the unique patterns of injury seen in high speed motorcycle trauma.
Westafer, Lauren — Adventures in FOAM: Gizmo Idolatry or effective learning? The allure of false idols? Lauren Westafer examines how FOAMed compares to traditional medical education. Are patient outcomes being affected?
Ray Raper examines the continued use of the pulmonary artery catheter in critical care. Are alternative monitors up to the task ?
John Myburgh on the misunderstood craniectomy. The management of raised ICP and what we do when our options run out.
Steve McGloughlin on tactics and treatment. Critical care specialties as the frontline for the assesment and management of exotic diseases.
Scott Weingart simplifies emergent data on our approaches to early, goal-directed therapy in sepsis. How a little goes a long way.
Education as an Intervention. Damian Roland highlights how patient outcomes should be a benchmark for the quality of our teaching.
John Myburgh on the emerging evidence for the use of beta-blockade in sepsis. Direction for future research.
Jeremy Cohen examines changing paradigms in fluid resuscitation. Is recent focus on the glycocalyx justified?
Michelle Johnston tackles a weighty problem. The challenges of morbid obesity in trauma.
How does our approach to the paediatric patient and their family help or hinder us in critical care? Natalie May reveals all.
Think about improving your thinking. Simon Carley examines the only constant in our ever-changing medical world.
Question everything! Louise cullen examines the minefield of published research and importance of reading around topics, not articles.
Tony Brown's emotive expose on the bias of medical research and publication. The flaws in our current paradigms.
The ABC's of practicing what we preach. Cliff Reid examines the over-complication of resuscitation and our need to return to the basics.
Cliff Reid delivers another moving talk on when we should, and especially when we shouldn't stop when resuscitating.
Simon Carley examines the value that diagnosticians place on risk factors. Are we under or over diagnosing ?
Roger Harris and Oli Flower talk about next year's SMACC conference - why the dates have been locked in for 23-26 June 2015 and what makes this conference different.
Iain takes on a topic that is traditionally uninspiring and delivers an incredible talk that left the crowd in tears.
Brohi dissects why trauma management has changed so dramatically in the last 20 years and how it may look in the future.
Liz gave a standout performance on coping strategies for stressful situations, firing a shot at political correctness gone mad.
Weingart tackles the dogma and evidence around resuscitation algorithms brings us the concept of truely advanced life support.
The debate that ignited a war that is still raging. Whatever your stance, you need to hear this!
Haney gives an erudite summary of the controversial topic of measuring and managing fluid responsiveness in shock.
Brazil leads an all-star cast through a thought provoking discussion on the prickly topic of end of life care in critical care.
Flipping the classroom. Victoria Brazil examines how different approaches to teaching can improve patient outcomes.
Vic Brazil opens smaccGOLD with a powerful insight into how conflict between "tribes" in our everyday working environment can adversely impact upon patient care.
The third of the three part literature review extravaganza with Chris Nickson and Rob Mac Sweeney. This time, it's the best of the rest...
Fennessy adds an unexpected high note to the topic of managing the anaphylactic patient.
Gatward details the application of mobile and in-situ simulation training for medical teams.
Vassiliadis inspires with his trajectory from novice to teacher of airway skills and checklist applications.
Webb delineates the case for experience over hierarchy in advanced resuscitation scenarios.
Brazil illustrates the depth of communication required in medical practice between people within health care delivery systems.
Little's erroneously named presentation underlines the importance of including complementary and alternative medicines in the clinical picture.
Dawson draws on his experience in areas of high prevalence organophosphate poisoning to optimise management of sick patients.
Buckley analyses the details and prescribes a more logical remedy for a toxic overdose.
Roger Pye offers up a graphic description of advances in ECMO and ECMO retrieval services.
Larkin pulls a few hairy ecg's out of the bag before offering the solace of a host of brilliant foamed ecg references.
Roger Harris exacts the forgotten part of the cardiac output equation and considers venous return in the management of the septic patient.
Brannigan busts the current recommendations on the use of stroke thrombolysis by showing no evidence of benefit.
Flower draws from experience to bring clarity to spinal cord management in the acute setting.
Carley chews through numbers and logic to arrive at some good reasons for diagnostic indeterminacy.
Nickson steps back to consider the metacognition of it all in the pursuit of minimising medical errors.
Reid's not to be missed talk takes medical care to a whole new level. Prepare to be moved.
Weingart does indeed take you on a journey into the mind of the resuscitationist, while simultaneously attempting to slow your heart rate down enough to manage a patient hell-bent on exsanguinating with the odds stacked against you. Join him for a shot of adrenaline drizzled with a dose of wisdom.
Two teams pit their wits in the finals armed with their ultrasonography experience and an ultrasound machine.
Holley analyses the cascade of events in bleeding trauma patients leading to Australia's latest evidenced-based guidelines on transfusion protocols in critical bleeding.
Macken looks with a cool and calculating eye at the application of therapeutic hypothermia following out of hospital cardiac arrest.
Cohen drills down on the thinking and value of using steroids in sepsis in the way that one of the creators of large international trials can.
Davis aims to spare you some of the pitfalls and arm you with some tips along the journey from non tech app idea to fully fledged release.
Habig draws from his experience in aeromedical retrieval to consider how we improve our medical practice.
Brazil gets you clued up in the art of presentations from newbie to tech savvy in 30 minutes.
Julian Walter clarifies what 21st century tech activities you ought to avoid to keep your medical career in optimum health.
Casey Parker offers up some juicy generalist knowledge from his experience in the far north west of Australia.
Johnston draws us away from the the dry aptness of medical texts to prise open our more expressive, sensitive selves with sage words.
Wahl brings her technological know-how to smacc to help you maximise your foamed presence.
Lex reflects upon the art of learning in the field of medicine as an indispensible practise for medical professionals.
Carley delineates the potential of an anarchistic mindset to bring developments in the field of medical care.
Join Weingart on the path to excellence strewn with medical books, and a list of journals which is truly insane. Once Weingart has your head in the right space, revel in the reading at EMCrit's Recommended Reading page.
Cadogan fronts up on the creation of #foamed and current developments in free open access medical education.
Victoria Brazil, Mike Cadogan, Simon Carley, Joe Lex, Chris Nickson, Ming Le Cong, and Anthony Holley consider the pitfalls and potential of free open access medical education and social media.
Brazil sizes up the limitations and possibilities of technology and social media applied to medical education.
Joe Lex, Osler, and Hippocrates on free open access medical education as a tenet of medical practice.
A meander through the grounding ideas and aspirations of social media and critical care with Joe Lex, Scott Weingart, Mike Cadogan, Simon Carley, Chris Nickson, Nadie Levick, and Oliver Flower.
Kane Guthrie packs all the Free Open Access Meducation highlights from the past year as he can into 30 minutes.
Alex Tzannes talks reviews areas of advancement and contention in pre-hospital and retrieval medicine for the past year.
Paolini considers key talking points in Emergency Medicine from the past year, including high sensitivity trop T, non invasive real time vital sign measurement, and new forms of anti coagulants.
Seppelt ranges over a year of fraudulent behaviour, reviews, and news in intensive care.
Paul Young's talk suggests how honey bees, senegalese grasshoppers, and desert iguanas might prompt a large RCT investigating paracetamol use in the context of fever.
Goudie expounds upon the virtues of being approximately right rather than precisely wrong when performing cardiac ultrasound.
Marek Nalos gives us the finer details of using ultrasound as a diagnostic tool for respiratory illness.
Bowra examines the possibility of 'turning off the machine' and behaving like a doctor versus a detailed examination of the IVC.
Michael Parr's 'how-to' for maximising hospital care: systematic, protocol driven, and technology intense.
Anthony Holley brings a military perspective to advances made in trauma management on and off the battlefield.
Cath Hurn chews through some data and gives us some of the finer points of fluid resuscitation.
Michelle Johnston gets past the numbers and puts gestalt back into managing a shocked patient.
Anthony Delaney examines the evidence for usefulness of goal directed therapy in the septic patient.
The lowdown on getting your priorities straight and your doses optimised when tubing a shocked patient.
Matt O'Meara reads the fine print on fluid management in paeds and straight talks on best practice.
Step into the shoes of Mary McCaskill as she walks us through some not to be missed neonatal presentations.
Andrew Numa on the art of defining futility in conditions of uncertainty and rationing healthcare to maximise benefits. Another paeds talk from SMACC 2013.
Simon Carley shines a light on the value of a resuscitationist in the realm of paediatric medicine, the first in our line up of paeds talks.
Cliff Reid makes things happen conveying the core concepts of an optimal resus as performative act. Our final talk from the resuscitation plenary.
John Myburgh brings his experience and analysis to bear upon the use of catecholamines in the crashing patient. The second talk in the Resuscitation plenary.
Scott Weingart's call to resuscitationists. The first of three Resuscitation plenary talks. Scott's amazing Podcast is found at emcrit.org.
The Director's cut features a low-key talk through the Opening Ceremony video with Oli Flower and Roger Harris.
Welcome to the beginning of a series of podcasts, released in video and audio formats, of the Social Media and Critical Care Conference 2013. This first podcast, in video format only, is the entire opening ceremony of SMACC 13 filmed 11th March, featuring the SMACC 13 opening video.
In the spirit of free, open access medical education, we appreciate all of the hands which have contributed to making these releases possible, not least the inspiring and thought provoking contributions of the SMACC 13 key speakers.
Warning: Video not suitable for viewing while operating heavy machinery.
Cliff Reid delivers another moving talk on when we should, and especially when we shouldn't stop when resuscitating.