thinking critical care: Recent Episodes
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a blog for thinking docs: blending good evidence, physiology, common sense, and applying it at the bedside!
Here’s a throwback to #HR23 when Andre Denault first introduced the PAC with an RV port to analyze the RV waveform, which we usually only have during initial advancement of the PAC (I confess I have sometimes pulled back just to get it and look at that slope!). But these are now available! As always, invaluable hemodynamics by the grandmaster Andre!
Thanks to BD for being an #HR25 sponsor!
So when we saw this study come out last week, we thought it was worth having a little chat about it, so let’s see what my usual suspects (when it comes to TCAV and, well a lot of other things…) had to say about it, and of course about TCAV in general!
So for anyone who hasn’t yet heard, #HR25 is coming up in a couple of months, and while this year, we are not specifically talking about TCAV, it will be absolutely fantastic, and there is an awesome ventilation pre-congree course, Eduardo Mireles Cabodevila’s SEVA Course, and of course Rory, Korbin and I will be more than happy to hallway talk your ear off about TCAV, so come and hang out!
H&R2025 – The Hospitalist & The Resuscitationist, Montreal, Main conference May 22-23, pre-post courses 21 and 24, 2025. #HR25 – REGISTRATION is OPEN !!!
Of course, for those who really want to deep-dive APRV-TCAV, our Flipping the Vent course is available online, and if you have a group/team, we can organize an online workshop as well.
Cheers!
Philippe
It was so great to meet, hang out and talk ECPR with Paris’ SAMU ECPR leader Lionel Lamhaut last month in Montreal, a city we are actively trying to bring pre-hospital ECPR to, thanks to the relentless work of Lawrence Leroux.
For more about Lionel’s team: https://www.paris-ecmo.com/
In the meantime, we are super excited to host the North American Premiere of Lionel’s famous pre-hospital ECMO course and open the registration for a two day, small-group affair with hands on workshops, lectures and discussions with ECPR experts. There are only 20 spots, so don’t wait. Come learn from some of the world leaders including Lionel himself, of course! And we may even have a surprise lab in the works…
Register here: https://ccusinstitute.wixsite.com/ccus/events/hr2025-fluid-tolerance-all-things-vexus-shock-hemodynamics
This takes place at Santa Cabrini Hospital, May 24th and 25th, 2025. Registration is 1,699 USD +tx. Here is the schedule:
DAY 1
- 9 :00-9 :45 High quality CPR
- 9:45 – 10:45 : ECPR Session, what does the literature say?
- ECPR Indications ? When? Where?
- 10:45 – 11:00 : coffee break
- 11 :00 – 11:45 : ECPR, different cannulation techniques
- Percutaneous implementation w/ ultrasound
- Percutaneous implementation w/ fluoroscopy
- Hybrid implementation:
- 10:45 – 11:30 : ECPR Training on mannequin (Percutaneous implementation)
12:30 – 14:00 : LUNCH BREAK
- 14:00 – 15:00 : Training on mannequin (Hybrid implementation)
- 15:00 – 16:00:ECPR implementation in different settings
- PREHOSPITAL
- ANGIO
DAY 2
- 9:00 – 10:00: Dealing with the machine
- 10 :00 – 11 :00 : ECPR and more
- What about post ECPR Oxygen, MAP, … ?
- Patient management in the ICU
- ECMO-related complications
- 11:00 -11:15 : Coffe break
- 11:15-11:45 Organ donation in ECPR
11:45 – 13:00 : LUNCH BREAK
- 13 00 1320 REBOA and cardiac arrest
- 13 20 – 1400 How to set up your ECPR program, Panel discussion
- 14:30 -14:30 : Priming devices
- 14 30 – 1530 Simulation
- 15 30 1600 Final discussion
So I’m always glad to spend some time chatting with my buddy Korbin, I always learn something! Here we talk about some nonsensical things we’ve seen and heard related to clinicians’ understanding of the hemodynamic circuit. And Korbin begins to introduce the interface 2.5!!! Lets see what develops with that.
Of course, anyone wanting to deepen their understanding and clinical use of hemodynamics and applying interfaces, its what we are focused on for #HR25!!! Join us!
H&R2025 – The Hospitalist & The Resuscitationist, Montreal, Main conference May 22-23, pre-post courses 21 and 24, 2025. #HR25 – REGISTRATION is OPEN !!!
Every resus doc needs to have a holistic approach to shock – MAP and forward flow simply isn’t enough. Here, Matt and I chat a bit about recent things we’ve heard in the world around us, as well as how we use and see the use of the interface concept.
Don’t forget to come up your game at #HR25!!! https://thinkingcriticalcare.com/2024/06/05/hr2025-the-hospitalist-the-resuscitationist-montreal-may-21-24-2025-hr25/
So over the years I’ve learnt invaluable stuff from each and every one of the colleagues I’ve managed to build a network with, and certainly I have learnt – and unlearnt – a lot from this guy. Here, Rory and I discuss the concept of interfaces that a group of us painstakingly crafted over the last year.
So I hope this starts to spark some interest. Recently I’ve heard of a few discussions around sepsis and shock resuscitation that took place at pretty respectable and large conferences, and, to be frank, I was fairly aghast at what was being taught, especially to the young trainees. This type of pure forward-flow/fluid responsiveness obsession with no regard for tissue perfusion, congestion, etc is really distressing to hear… We have a lot of teaching to do.
If you want to master a global approach to hemodynamics, come learn how to understand, analyze interfaces and generate a coherent management plan for your shock patients. Oh yeah, and also learn a lot about congestion! https://thinkingcriticalcare.com/2024/06/05/hr2025-the-hospitalist-the-resuscitationist-montreal-may-21-24-2025-hr25/
cheers!
P
(version francaise ci-dessous)
At our hospital, typical of community hospital intensive care units that do not have an extensive structure of junior and senior trainees who generally staff the university hospitals after hours, medical coverage depends on collaboration between nurses and intensive care doctors as well as their emergency room colleagues. If there is an immediate requirement for a doctor to handle a situation, the emergency room doctor will come right away, and handle things until the ICU on call doctor – who takes call from home – can make it in to take over, which is within 30 minutes.
A typical day for our intensivists consists of rounding on the patients in the ICU as well as handing the consults and procedures that originate from the wards or the emergency department. There are usually two doctors who divide up this work. For the evenings and nights, these two alternate during the week as to who covers emergency situations. However there are many clinical issues which simply reflect ongoing care of acute issues, such that the intensivists generally do evening “rounds” with the charge nurse, going over these issues and resolving whatever can be resolved. According to a recent poll on X (formerly Twitter), among over 400 intensivists who do home call, around 60% had a similar practice of evening or “before bed” telephone rounds.
Our team would often ask the nurses or respiratory therapists to describe curves or features in the vital signs, or at times nurses would like the doctor’s opinion on something about the patient. They then verbally describe as well as possible these findings. While generally excellent, there are inherent limitations to verbal description.
The recent release of the Apple Vision Pro AR/VR headset gave the team an idea for a pilot project: could the use of these on both ends improve the quality of these night rounds? Following a discussion with Mr. Ronald Davidson of our hospital foundation, we decided it was worth giving it a try, given the particularly impressive resolution of these headsets.
How it works: the nurse in the ICU can put on the Vision Pro and proceed to facetime the on-call intensivist, who puts his or her device on at home. The nurse then shares her view, such that the intensivist is now seeing an immersive and ultra-hi resolution view of the ICU, wherever the nurse is looking.
ICU Nurse sharing her view of the monitors using Apple Vision Pro/Infirmiere des soins intensifs partageant sa vue des moniteurs avec le Apple Vision Pro:
ICU On-Call Physician Virtually doing evening rounds / Medecin de garde faisant sa tounee virtuelle de soiree:
Armed with a myriad of additional visual cues, as well as the ability to ask the nurse or respiratory therapist to perform a maneuver or modification to certain parameters, for example on a mechanical ventilator, this makes for, in certain cases, a significant increase in the quality of the discussion and medical decisions taken. This enables the nurse or other health care practitioner to make sure issues and concerns are transmitted in the most reliable way to the on-call intensivist.
What’s Next? Our ICU team at Santa Cabrini always strives to be innovative and at the cutting edge of the care that can be offered to our patients, and has pioneered several medical advances in the last decade. This high level VR open many possible developments for remote medical consultations and assistance, both intra- and inter-hospital, as well as several possible educational application. We are looking forward to seeing what else we will come up with in the next years with this technology!
PS – Because this is part of the public domain, and because doctor-bashing is a popular sport, we feel it is necessary to nip pundits’ enthusiasm in the bud for certain issues. Firstly, during Facetime, recording is disabled in the Apple Vision Pro, as there is no image stockage, so patient confidentiality is at no risk, or at least no more risk than during a phone conversation. Secondly, this in no way decreases the physician presence at the bedside. Our team has a low threshold to come to the hospital and assess patients or do necessary procedures, and this has in no way impacted this aspect. It has, so far, only enhanced the quality of the exchanges.
The biggest thanks for this project goes to the Santa Cabrini Hospital Foundation (www.fondationsantacabrini.org) who have the vision, the drive and the personality to help Santa Cabrini Hospital remain innovative for the benefit of its community!
Dans notre hôpital, typique des unités de soins intensifs des hôpitaux communautaires qui ne disposent pas d’une structure étendue de stagiaires juniors et seniors, généralement présents dans les hôpitaux universitaires après les heures de service, la couverture médicale dépend de la collaboration entre les infirmiers et les médecins des soins intensifs, ainsi que leurs collègues des urgences. S’il y a un besoin immédiat d’un médecin pour gérer une situation, le médecin des urgences interviendra immédiatement et prendra en charge les choses jusqu’à ce que le médecin des soins intensifs de garde – qui est d’astreinte à domicile – puisse arriver, ce qui se fait généralement dans un délai de 30 minutes.
Une journée typique pour nos intensivistes consiste à faire le tour des patients dans l’USI ainsi qu’à gérer les consultations et les procédures qui proviennent des services ou du service des urgences. Il y a généralement deux médecins qui se répartissent ce travail. Pour les soirées et les nuits, ces deux médecins alternent au cours de la semaine pour couvrir les situations d’urgence. Cependant, de nombreux problèmes cliniques reflètent simplement la prise en charge continue de problèmes aigus, de sorte que les intensivistes effectuent généralement des “tours” en soirée avec l’infirmière en chef, abordant ces problèmes et résolvant ce qui peut l’être. Selon un récent sondage sur X (anciennement Twitter), parmi plus de 400 intensivistes qui font des astreintes à domicile, environ 60 % avaient une pratique similaire des tours téléphoniques en soirée ou “avant le coucher”.
Notre équipe demande souvent aux infirmières ou aux thérapeutes respiratoires de décrire les courbes ou les caractéristiques des signes vitaux, ou parfois les infirmières souhaitent connaître l’avis du médecin sur quelque chose concernant le patient. Elles décrivent ensuite verbalement ces constatations du mieux qu’elles le peuvent. Bien que généralement excellentes, ces descriptions verbales présentent des limites inhérentes.
La récente sortie du casque AR/VR Apple Vision Pro a donné à l’équipe une idée pour un projet pilote : l’utilisation de ces dispositifs des deux côtés pourrait-elle améliorer la qualité de ces rondes nocturnes ? Suite à une discussion avec M. Ronald Davidson de notre fondation hospitalière, nous avons décidé qu’il valait la peine d’essayer, compte tenu de la résolution particulièrement impressionnante de ces casques.
Comment cela fonctionne : l’infirmière de l’USI peut enfiler le Vision Pro et procéder à un appel FaceTime avec l’intensiviste de garde, qui met son appareil en marche chez lui. L’infirmière partage alors sa vue, permettant à l’intensiviste de voir une vue immersive et ultra-haute résolution de l’USI, selon l’endroit où l’infirmière regarde.
Infirmière de l’USI partageant sa vue avec l’Apple Vision Pro :
Médecin de garde en soins intensifs effectuant virtuellement des rondes en soirée :
Équipé d’une multitude d’indices visuels supplémentaires, ainsi que de la possibilité de demander à l’infirmière ou au thérapeute respiratoire d’effectuer une manœuvre ou une modification de certains paramètres, par exemple sur un ventilateur mécanique, cela permet, dans certains cas, d’augmenter de manière significative la qualité des discussions et des décisions médicales prises. Cela permet à l’infirmière ou à un autre professionnel de santé de s’assurer que les problèmes et les préoccupations sont transmis de la manière la plus fiable possible à l’intensiviste de garde.
Quelles sont les prochaines étapes ? Notre équipe de l’USI de Santa Cabrini s’efforce toujours d’être innovante et à la pointe des soins offerts à nos patients, et a été pionnière de plusieurs avancées médicales au cours de la dernière décennie. Ce niveau élevé de réalité virtuelle ouvre de nombreuses possibilités de développement pour les consultations et l’assistance médicale à distance, tant intra- qu’inter-hospitalières, ainsi que plusieurs applications éducatives possibles. Nous sommes impatients de voir ce que nous allons encore inventer dans les prochaines années avec cette technologie !
PS – Étant donné que cela fait partie du domaine public, et parce que critiquer les médecins est un sport populaire, nous estimons qu’il est nécessaire de tempérer l’enthousiasme des commentateurs sur certains sujets. Tout d’abord, pendant FaceTime, l’enregistrement est désactivé sur l’Apple Vision Pro, car il n’y a pas de stockage d’image, donc la confidentialité du patient n’est pas en danger, ou en tout cas pas plus qu’au cours d’une conversation téléphonique. Deuxièmement, cela n’enlève en rien la présence du médecin au chevet du patient. Notre équipe a un faible seuil pour se rendre à l’hôpital et évaluer les patients ou réaliser les procédures nécessaires, et cela n’a en rien impacté cet aspect. Cela a, jusqu’à présent, uniquement amélioré la qualité des échanges.
Les plus grands remerciements pour ce projet reviennent à la Fondation de l’hôpital Santa Cabrini (http://www.fondationsantacabrini.org) qui a la vision, la motivation et la personnalité pour aider l’hôpital Santa Cabrini à rester innovant au bénéfice de sa communauté !
The Cabrini Critical Care Team
These are without a doubt some of the hidden gems of any boutique conference. At H&R we’ve always had a great time with these, time for instructors to pass on some really actionable, hands-on skills to a small group of really motivated clinicians.
BJJ or Self-Defense for Humans & Health Care Workers – we feel that BJJ is a natural companion to medicine. On all levels the mental and physical benefits far transcend its martial core, and we’re happy to see more and more practitioners in medicine. We always have a lot of fun with it and are fortunate to have some black belts to lead this activity along with a few other aficionados. Even if you have no experience, join us for some basics and learn a few tips to protect yourself and buy time in a few bad scenarios. (Max 30 participants, FREE) – Faculty – SPIEGEL/MILLER/ROLA/MELO
The VExUS Course & Doppler Masterclass – Unbelievable how much VExUS has exploded. This is the original course, given by some of the absolute very best instructors on the plant, including several of its creators. It’s a 3-4 hour hands on course after participants have gone thru the online material. Here we not only show you how to perform it, but more importantly the nuances. Participants will get plenty of Q&A time with the leaders of the field of venous congestion, and will also explore other Doppler techniques which complements the venous side such as VTI, carotid Doppler, splenic Doppler and more. There may be many VExUS courses and workshops going on but this is THE One. Faculty – ARGAIZ/HAYCOCK/SPIEGEL/ROLA/DENAULT/KENNY & more (Half-day, MAX 40 participants) Wednesday May 21st Morning.
ArrestTEE Sim Cases – You’ve done your ResusTEE Course, hopefully a few live cases in your practice. Come and warm up those skills with a series of SIM cases and sharpen up not only your image generation, but also your clinical interpretation skills. Gotta get that muscle memory! FACULTY TBA (Half-day, MAX 12 participants) Wednesday May 21st Afternoon.
Sauv Life (eCPR) by Paris’ Lionel Lamhaut! – The French experience in prehospital ECPR is unparalleled. Participants will get to tap into these pioneers’ extensive experience and learn the ins and outs of starting an ECPR programme and the required skills! Specific programme TBA! FACULTY: LAMHAUT, TBA, Saturday May 24th Full Day.
SEVA Ventilator Course by The Cleveland Clinic’s Eduardo Mireles-Cabodevila – His social media vent rounds have an immense following on X/MedTwitter, and for good reason! No one breaks it down like Eduardo does. And he’s distilled it into one of the top courses in the world on mechanical ventilation. No matter your level, take your vent curve analysis to a whole other level with this full-day course. FACULTY: MIRELES-CABODEVILA/CHATTERJEE Saturday May 24th Full Day.
Basic Bedside EEG for Intensivists – Technology is rapidly bringing the EEG to the point-of-care realm. With several devices having the ability to provide the raw EEG signal, it is time for the clinicians to have some understanding of brain waves! Half day, May 21. FACULTY: TBA
Resuscitative TEE course by Felipe Teran – May 24th full day, follow resuscitativetee.com/workshop for registration which should be up in the next weeks!
Bookmark this page for more info, programs and further additions to the courses!
Registration is open! https://ccusinstitute.wixsite.com/ccus/events/hr2025-fluid-tolerance-all-things-vexus-shock-hemodynamics
For link to registration and main conference day info: https://thinkingcriticalcare.com/2024/06/05/hr2025-the-hospitalist-the-resuscitationist-montreal-may-21-24-2025-hr25/
The HR25 Scientific Committee
Here, Sara Crager takes a few minutes to discuss the hemodynamic interfaces with me. Over the next months, I’ll be picking the brains of my co-authors for the fantastic angles they can all bring to our “Trilogy in 4 Parts” (creative title by of course @EMnerd) which we all feel can be a really useful mental model for both learners and veterans and even better for patients!
Note that we are planning #HR25 around congestion and the hemodynamic interface model – so if you want to master the interfaces, be sure to come join us! https://thinkingcriticalcare.com/2024/06/05/hr2025-the-hospitalist-the-resuscitationist-montreal-may-21-24-2025-hr25/
cheers
Philippe
| We are excited to announce this year’s evolution of our H&R conference, the Hospitalist & Resuscitationist VExUS and Doppler Masterclass! This exclusive event, produced in collaboration with Flosonics Medical, will take place on September 28th, 2024, in Toronto, Ontario, CanadaThis masterclass is designed for those who seek a deep dive into the cutting-edge techniques of venous congestion, Doppler ultrasound, and fluid resuscitation. Our curated one-day workshop offers a unique opportunity to learn from world experts in an intimate, hands-on environment with a fantastic faculty-to-participant ratio. What to Expect:Pre-course Content: Over 5 hours of lectures covering the theory, evidence, and practical tips for venous congestion.Live Content: Hands-on VEXUS course taught by the creators of the VEXUS score, small group discussions on integrating perfusion, fluid responsiveness, and fluid tolerance, and hands-on fluid responsiveness practice using carotid Doppler and cardiac echo-VTI.Bonus Content: Faculty and participant dinner/social event on the evening of September 28th and hotel discounts.Certificate of Attendance: Attendees will receive a certificate of attendance (non-CME) and an optional certificate of VEXUS proficiency for those who complete the online content, in-person workshop, and pass a post-workshop quiz.Limited-Time Offer: Register before August 15th and receive $200 off the registration fee using promo code HR200! Don’t miss this opportunity to secure your spot and benefit from this exclusive discount. As always, we aim to create an incredibly high-quality and tailored learning experience for all participants, which is why we are capping registrations. Spots are filling up fast, so act now to secure your place at this unique event. Register Now For any questions or further information, please feel free to reach out. Looking forward to seeing you there! Philippe & The HR Family & The Flosonics Gang! |
A few words about it…
HR2025 is about putting it all together. We’ve been talking about the venous side for a long time and it has been fantastic seeing how much it has taken off – at least in the #medtwitter #foamed community. There’s enough data out there to show a real clinical utility of consciously examining the venous compartment. This applies to any hospitalized patients, whether in the ED, the wards or the ICU, so that’s why this year, the H and the R will spend the first day together doing all things VExUS and venous congestion, along with the corresponding workshops, again so that participants can leave with some actionable knowledge and skills. Whether you’re a beginner at this or a seasoned veteran, there should be something to learn. On day two, we’ll divide, and the one and only Katie Wiskar will be putting something amazing for the H side (preliminary details soon!!!) while the R side will deep-dive bedside hemodynamics and our 4-interface model of shock management. Of course there will also be some pearls and late-breakers as this is still a year away and there will undoubtedly be some really interesting things cooked up by the crew by then!
And as always, the ethos of H&R is about putting together physiological clinicians who love to both push the envelope and share their knowledge and experience. The energy that comes out of this is really quite unique, and the sheer number of successful collaborations that have stemmed from it since 2018 is really impressive. The unplanned, unscheduled small group discussions are the true gems of this conference… Many of the usual suspects will be there, and as always some new additions to the H&R family!
So the most important thing for you to do is to mark your calendars and make sure you don’t miss being a part of it! Bookmark this page as the registration link (november 1) will appear as well as developing programme information!
Montreal, May 21-24. Core conference May 22-23, Pre and Post-courses May 21 and 24.
Pre/Post congress preliminary courses
- BJJ or Self-Defense for Humans & Health Care Workers
- The VExUS Course
- ArrestTEE Sim Cases
- Sauv Life (eCPR)
- Bedside EEG for EDCritters?
- SEVA Course?
if there’s a course you want, go ahead and get in touch with us! hospresusconference@gmail.com or via twitter with #HR25 tag.
(very) Preliminary Schedule:
Day 1 H&R “Fluid Tolerance & All Things VExUS”
- 0800-0820 – The Concept of Fluid Tolerance – SPIEGEL
- 0820-0900 – The Femoral Vein – BHARDWAJ & DENAULT
- 0900-0930 – An Update on The Hepatic Vein – KATTAN
- 0930-1000 – Renal Venous Doppler – RVSI and VExUS – ARGAIZ
- Coffee break 30 min
- 1030-1100 – The Return of the Jugular – TBA
- 1100-1130 – VExUS Lit Review 2020-2025 – PRAGER
- 1130-1200 – TBA
- Lunch 60 min
- 1300-1330 – TBA
- 1330-1400 – TBA
- 1400-1430 – TBA
- 1430-1500 – TBA
- Workshops 1500-1700
Workshops
- Diastology, E/e’
- RV: TAPSE, PASP, S’
- RVOT Doppler (try to find models with pathology)
- CVP using jug POCUS
- VExUS stations (IVC/HV/PV/IRVD)
- Advanced Workshop – Intrarenal Hemodynamics (RRI, RVSI)
- Femoral vein (try to find model)
Day 2 – The H – Coming Soon!!!
Day 2 – The R “Fluids and Shock Hemodynamics”
- 0800-0830 – Intro to the circuit & interfaces – CRAGER
- 0830-0900 – What is Coupling? – KENNY
- 0900-0930 – Understanding MSFP – MILLER & HAYCOCK
- 0930-1000 – Interface 1: LV-VA coupling & How I Measure it – HOCKSTEIN
- Coffee break 30 min
- 1030-1100 – Interface 2: Macro-Micro – HERNANDEZ
- 1100-1130 – Interface 3: Capillary-Venular – KATTAN
- 1130-1200 – Interface 4: RV to PA – SIUBA
- 1200-1230 – Putting it All Together – SPIEGEL
- Lunch 1h
- 1330-1400 – TBA
- 1430-1500 – TBA
- Workshops 1500-1700
- Estimating E/A at the bedside
- Capillary Refill Time
- VExUS Stations
- Emergency Surgical Airway
- PA Catheter
- Carotid/Jugular Doppler Analysis
An awesome track by my intensivist friend and co-educator, Segun Olusanya, where he probes the mind of a seriously next-level physiologist, particularly about the formula he devised to estimate Pmsf. Not to be missed by bedside physiologists of all levels!
https://player.vimeo.com/video/948962900?badge=0&autopause=0&player_id=0&app_id=58479The Interview (Audio)cheers!
Philippe
Had the honour of being invited to give grand rounds by Dr. Paul Mayo and share some thoughts on fluid tolerance and venous congestion. Starts around the 17min mark – sorry I have no editing capabilities!
https://northwell.zoom.us/rec/play/Mn7Nt2zGzjzlnKw2Qr1UecKP-WpdGi8Mi0-uE2hn_pN97p0cOtxfrHZDGob65d3aA8yGRREm3pJmjsA6.fHrWBqxvMT7hfj23?autoplay=true&startTime=1714146104000cheers
Philippe
June 15, 2024, 10-4 EST – Online Webinar Only
Due to the tremendous amount of work required to put together a large live event, we’ve decided to skip 2024 in terms of a full-fledged H&R, but HR23’s Inpatient Medicine section, put together by none else than Katie Wiskar, was a real firecracker, and we felt that the spark to bring high level bedside physiology to the clinician on the wards should not be allowed to fizzle. So, while waiting for HR25 (May 2025), Katie once again worked her magic to put together a one-day webinar that packs a academic and clinical punch. Preliminary Schedule:
H&R 2024 Outline: Acute Inpatient Medicine – Next Level!
Date: June 15 10am-4:30pm EST (7am-1:30pm PST)
Format:
- one-day, 6.5 hours, online only
- Pre-recorded lectures
- Live Q&A
The Day
- 10am-10:15am: Intro and welcome (15min)
- Track 1 (90min) – POCUS et al
- 10:15am-10:35am: POCUS for shock – Ross Prager
- 10:35am-10:55am: VEXUS tips and tricks – Abhilash Koratala
- 10:55am-11:15am: Ventilators 101 – Segun Olusanya
- 11:15am-11:35am: Q&A
- Track 2 (90 min) – Fluids and physiology
- 11:35am-11:55am: Dysnatremias in cirrhosis – Eduardo Argaiz
- 11:55am-12:15pm: Top 10 diuretic mistakes – Frederik Verbrugge
- 12:15pm-12:35pm: Physiology of the shock patient – Ashley Miller
- 12:35-12:55pm: Q&A
- 12:55pm-1:30pm: Break (35min)
- Track 3 – The decompensating ward patient
- 1:30pm-1:50pm: The sick aortic stenosis patient – Trina Augustin
- 1:50pm-2:10pm: The sick pulmonary HTN patient – Matt Siuba
- 2:10pm-2:30pm: The seizing ward patient – Casey Albin
- 2:30pm-2:50pm: Q&A
- Track 4 – Practical pearls
- 2:50pm-3:10pm: Palliative Medicine pointers – Brittany Rance
- 3:10pm-3:30pm: Top 5 Geriatric Pearls on the ward – Gurmeet Sohi
- 3:30pm-3:50pm: Sepsis: what we should be doing – Sara Crager
- 3:50pm-4:10pm: Q&A
- 4:10-4:30pm: Concluding remarks (20min)
Also some online-only BONUS lectures – How-To VExUS by Dr. Taweevat Assavapokee!
Registration is OPEN! https://ccusinstitute.wixsite.com/ccus/events/hr2024-acute-inpatient-medicine-next-level-online-webinar
Cheers!
In the last couple of years VExUS has seemingly sparked a number of clinicians to focus on right-sided or venous congestion and its deleterious consequences. Many of us feel there is sufficient associative evidence and physiological basis to use VExUS to manage patients on a daily basis and do so routinely. Currently, several studies we know of (and probably many we don’t!) are on track to show that a VExUS-based approach is likely to be superior to a highly variable traditional approach. In teaching it at the bedside, however, we emphasize the fact that this tool should not be used in a brain-bypass, monosynaptic fashion – all elevated VExUS scores should NOT blindly be diuresed… These ways on how to integrate VExUS in clinical decision-making is what we will emphasize in this part of the Mini-Fellowship.
So due to demand, we have added this specific skill to our Mini-Fellowships which have been going strong for over a decade. The idea (just like in resuscitation!) is to tailor these days to what you need the most. Whether you want to focus on advanced POCUS, looking at coupling parameters and TDI or whether you want to learn to integrate these findings into a resuscitation approach, we will do our best to fill the gaps you may have.
We’ve been organizing mini-fellowships now for over a decade (obviously slowed by the whole pandemic business), because while learning the technical aspect of scanning is one thing, the translation into clinical application and decision-making is altogether another step that, for many, is achieved more readily by witnessing live clinical management.
This year, for the first time, we are adding a specific VExUS element. Participants will be able to pre-emptively watch the online VExUS Course, and then follow a senior instructor for 2-5 days of clinical practice (avg 4-6h/day) where they will be able to observe live scanning and management of real patients both in outpatient, inpatient, ED and ICU settings.
Tuition – Montreal Mini-Fellowships: 600$ CAN / 500$ USD per day for 1 physician, 400$ CAN / 350$ USD per person per day for additional days, and 400$ CAN / 350$ USD per person per day for a 2 to maximum 3 physician group. For physicians who are not from high income countries, do let us know, we will try to help get some industry sponsorship to make it possible.
CME : For Canadians, from the Royal College of Physicians standpoint, the Mini-Fellowships qualify for 25 Section 2 credits (regardless of the length) and 3 hours of Section 3 credits (per day of fellowship). For you Americans:
Through an agreement between the Royal College of Physicians and Surgeons of Canada and the American Medical Association, physicians may convert Royal College MOC credits to AMA PRA Category 1 Credits.
Please see the prior posts for participant feedback (https://thinkingcriticalcare.com/2018/05/09/ccus-institute-pocus-resuscitationist-mini-fellowship-evolution/), and if interested, please email hospresusconference@gmail.com and we will put you in touch with one of the senior instructors whose time matches your availability.
cheers!
The H&R Team
The H&R Advanced Airway Workshop
Santa Cabrini Hospital, Feb 9th, 2024, 1200pm-4pm
Airway/Intubation
Advanced airway skills are a key element of the resuscitationist’s arsenal. In this workshop, participants will be able to tailor their experience and spend as much or as little time as they want in each station to maximize their learning. We will cover basic direct and video laryngoscopy and intubation with and without the use of the bougie as well as bronchoscopic assistance. Emergency surgical airways – both percutaneous and scalper-finger-bougie techniques – will be reviewed and practiced until participants can perform both rapidly and adequately.
Basic Upper Airway Endoscopy
Endoscopy for basic diagnostic and procedural purposes will be reviewed for obstructive and airway toilet. This will include rhino-pharyngo-laryngoscopy for foreign body/lesion assessment and stridor management in the ER.
Critical Care Endoscopy
Basic bronchoscopy for rapid diagnosis and airway toilet will be covered. This will pertain to most critical care cases where removal of mucus plugs and broncho-alveolar lavage is the bread and butter. Following instruction, each participant will be asked to demonstrate the ability to identify basic anatomy and be able to orient themselves successfully.
Bedside Percutaneous Tracheostomy Course
Participants will spend the last 90 minutes in a separate track focused on the technique and will be asked to perform 5 unassisted techniques to obtain a certificate of adequate completion. {Note that, since this is not an emergency life-saving procedure, this does not qualify the participant to perform the technique independently in clinical practice and will require supervision by an experienced colleague until sufficient experience is attained.}
Participants & Registration
There will be 15 complimentary trainee registration slots and 20 spots for practicing physicians (249$/199$ for CEMTL MDs) and 5 spots including the percutaneous tracheostomy course (349$). Participants will receive a link to pre-course material to watch prior to the workshops. Lunch will be included. There is no formal CME accreditation for this event.
Registration link: https://ccusinstitute.wixsite.com/ccus/events/hsco-hr-airway-course-2024
The Faculty: Dr. Joe Nemeth (ER), Dr. Philippe St-Arnaud – (ER/Critical Care) Dr. Lawrence Leroux (ER/Anaesthesia), Dr. Andy Nguyen (Respirology), Dr. Olivier Abboud (Otolaryngology), Dr. Ian Ajmo (Critical Care), Dr. Philippe Rola (Critical Care).
Programme
Welcome and Lunch – 1230-1300
Stations A: 1300-1400
– Basic DL/VL station (St-Arnaud, Ajmo)
– The Art of the Bougie (Rola)
– Bronchoscopy-guided intubation (Leroux, Nemeth)
– Rhino/pharyngo/laryngoscopy – (Abboud)
Stations B: 1400-1500
– Emergency percutaneous cricothyrotomy (St-Arnaud/Rola)
– Emergency Surgical Airway (Scalpel-Finger-Bougie) (St-Arnaud/Rola)
– Emergency Tracheostomy (Nemeth)
– Bronchoscopy for toilet/foreign body extraction (Nguyen)
Percutaneous Tracheostomy w/ Bronchoscopy Assistance (Ajmo/Rola) 1430-1600
Open Practice and Q&A: 1500-1600
So HR2023 was awesome. So many good talks and workshops, as well as some fantastic hallway discussions with both faculty and participants!
I will be sharing several of the talks on #FOAMed and wanted to start with what I think is hands-down the best practical clinical talk on VA coupling. Matt, as a true clinician and bedside physiologist, finds a way to take a complex topic and make it understandable and usable. Kudos!
For those interested in the rest of the #HR23 lectures, they can be found here, with CME to come in the next weeks.
Super excited for this. No issues with travel this year, the H&R family all keen on getting together again, the lineup is awesome, most of the OGs able to make it, lots of new additions, and the programme is looking really sweet. Am totally amped to have Katie Wiskar as the Chair of The Hospitalist as she’s putting together a great group with sharp lectures and super interesting workshops. With help from the usual suspects (Rory Spiegel, Andre Denault, Korbin Haycock) we are focusing on some core areas in acute and critical care – sepsis, arrest and respiratory failure are perennials, but this year we are also adding neurocrit as a core component, which I think is a bit underserved and certainly deserving of more.
A message from Katie Wiskar: I cannot express how excited I am to be a part of H&R 2023, and to finally get to experience the magic in person. Building on the energy and ethos that Philippe has curated in the Resuscitation side, I’m thrilled to bring a killer set of on-demand lectures and in-person content delivered by a top-notch, multi-disciplinary faculty. The program is full of hot topics, evidence-based medicine updates, and practical ward pearls. I can’t wait to learn from this group of incredible educators; and I hope to see you all there!
When? September 27-30 with the core being 28-29 and the pre/post stuff on either side.
Where? Montreal – both at the Heart Institute (core days) and my shop, Santa Cabrini Hospital (pre/post courses).
CME? Of course, should be over 40 credits, watch this space in the next weeks.
What? So you get a bunch (about 50) lectures to watch prior to the conference, then during the in-person part, you get some live lectures followed by group discussions around those topics, as well as hands-on workshops. You can hop between the Hospitalist and the Resuscitationist tracks depending on your interest or mood. Most importantly, there’s plenty of hallway time where you get to hunt down the universally open minded and available faculty members to pick their brains, share ideas, start collaborations and who knows what else you might come up with. This is gold. There’s going to be a buffet of workshops to pick and choose from that we are still putting together, from airway management to bedside procedures, ekg workshops, neuro exam workshop, wound dressing, and of course all kinds of POCUS.
Oh yeah, and the pre/post stuff is pretty fantastic. If you’ve been following acute care and POCUS, you’ve noticed the beginning of an ear where we will focus on fluid tolerance rather than responsiveness, and VExUS is a pretty important part of it. Learn from the originators and other pioneers of the score in this VExUS course with real patients and pathology. If you struggle with refractory hypoxia in acute lung injury, add APRV-TCAV to your armamentarium. Understand the mode, shake off the myths and learn knobology on a couple of ventilators with simulated lungs. You do trauma or medical resus? REBOA is growing in use. Familiarize yourself with the technique using the different available aortic occlusion catheters with the REBOA course. The Resuscitative TEE Course, run by none other than Felipe Teran is back again! If you’re not personalizing your CPR, here’s the place to learn!
The Hospitalist POCUS Course will be split in Basic (AM) and Advanced (PM) and the focus will be on all core skills required at the inpatient level. The faculty is absolutely top notch.
A newcomer this year is the Jr. Doc Procedure Course, aimed at trainees but truly good for anyone entering the hospital arena, regardless of age or training status. Go over and practice intubation and basic airway management, central and arterial line placement, thoracic and abdominal pigtail insertion and more!
And of course, the Introduction to Brazilian Jiu Jitsu workshop is always a blast. Last year, participants were treated to a short philosophical discussion on breathing with guru coach Firas Zahabi followed by a hands-on training session. In previous years we had reviewed basic concepts to stay safe in volatile situations. Always a lot of fun! We are fortunate to have some pretty seriously BJJ-skilled faculty members such as Ashley Miller and Rory Spiegel! Can’t wait!
Who? So the H&R family keeps growing!
On the H side, Katie has assembled an impressive lot that I am really looking forward to meeting and exchanging with, such as Gigi Liu, Michael Fralick, Elaine Kilabuk, Ria Dancel and more to be confirmed!
On the R side, we have many of the usual (awesome) suspects, Korbin Haycock, Rory Spiegel, Matt Siuba, Segun Olusanya, Felipe Teran, Jeff Scott.
Some young guns like Ben Daxon, Trina Augustin, Max Hockstein, Eduardo Argaiz, Vimal Bhardwaj, Frederick Verbrugge and Jay Chatterjee.
Some who joined us virtually last year but whom I am totally psyched about meeting some in person such as Katie Wiskar, Abhilash Koratala, Casey Albin, Neha Dangayach, Ashley Miller, Hatem Soliman, Mourad Senussi and Sara Crager.
Not to mention some icons of emergency and critical care like Scott Weingart, Ognen Gajic, Sheldon Magder, Andre Denault, Ashish Khanna, Jan Bakker and Glenn Hernandez who have contributed so much to the literature.
…and we keep adding talks and faculty! Bookmark this to keep up!
For the preliminary programme and more information, https://hr2023.sched.com/
Registration is open! https://ccusinstitute.wixsite.com/ccus/events/the-hospitalist-the-resuscitationist-2023
See you there!!!
Philippe
Personally, I’ve never used it, so not really an issue to me. But it seems to generate a fair bit of emotion and debate, and having the pleasure of knowing some really smart and, in this case, highly experienced people, I think we have something good to share here, a story from Thomas Woodcock! This insight may help clinicians currently debating the issue…
Edomidate – A Brief Personal History.
By Thomas Woodcock, MD.
We all want Evidence, good solid peer reviewed communications with verifiable data, ideally randomised and controlled. But we are human, and our practices are also informed by unpublished experience, what used to be cited as “Personal communications”. I acknowledge the dangers of placing too much confidence in such evidence. Our recollections of events may become clouded or unreliable as the years pass. With that caution in mind, I am going to take the final opportunity to offer my unpublished recollections of events surrounding Iain Watt’s fortuitous discovery of the lethality of the intravenous anaesthetic agent etomidate back in 1983; forty years ago, though it only seems like yesterday.
This year our friends at San Raffaele Scientific Institute, Milan, Italy published a meta-analysis of studies reporting the use of etomidate to cover tracheal intubation in critically ill patients and concluded as follows;
We included 11 randomized trials comprising 2704 patients. We found that etomidate increased mortality (319/1359 [23%] vs. 267/1345 [20%]; risk ratio (RR) = 1.16; 95% confidence interval (CI), 1.01–1.33; P = 0.03; I2 = 0%; number needed to harm = 31). The probabilities of any increase and a 1% increase (NNH ≤100) in mortality were 98.1% and 92.1%, respectively.[1]**
This came as no surprise to me, and was predictably followed by etomidate anaesthetists explaining that the harm (euphemism for lethal effect) could only be proven by enrolling thousands of participants in a blinded RCT. Imagine the Consent form.
We have a broad selection of intravenous anaesthetic agents to offer for your general anaesthetic, but one of them has had serious concerns raised about a lethal effect. With your permission we would like to randomise you to receive a safe drug or etomidate so that we can learn more about the lethal effect.
In 1983 I was an Englishman abroad, the London anaesthetist who was appointed to be the English anaesthetist on the Shock Team only because the outstanding candidate from Oxford had preferred to take up a job doing muscle relaxant research with Kitz and Katz in the USA. The Western Infirmary Glasgow (WIG) was a Victorian red brick building on the Byres Road. The Boss was Professor Iain McAllister Ledingham, Editor of the book series Recent Advances in Critical Care Medicine, a founder of The European Society of Intensive Care Medicine and one of its first Presidents. With many original publications on shock and interhospital transfer, in the clinic and in the laboratory, Iain Ledingham was as reverered as Pope John Paul II who had been granted an audience with the Prof during the first Papal visit to Glasgow in 1982. A photograph recording the event was prominent on Iain’s desk. As an American visitor to the Unit observed, this was surely the best Intensive Care service in England (sic)[2]. Up to 1982, intensive care patients at WIG were being sedated with propofol infusions, opioids and benzodiazepines, but by the time I arrived the preferred hypnotic was etomidate with morphine analgesia. It may be that the change was prompted by a 1982 report from Sheffield entitled “Safer sedation for ventilated patients. A new application for etomidate.”[3] The ICU looked to me like something out of the 1978 movie Coma, based on the novel by Michael Crichton. Most patients were sedated to immobility with the new wonder drug that had no histamine release and a stable haemodynamic profile – except, of course, for the patients who were also receiving dopamine. Nursing tasks were thus greatly simplified, and the staff were able to enjoy a post round morning tea break at which everybody was offered an egg “piece”.[4]
The research agenda at the time was broad. Complement activation and histamine release were blamed for capillary permeability changes in shock, and imbalance between the arachnadonic acid metabolites was blamed for arteriolar dysfunction and microvascular coagulation. Adam Fleck had his own team investigating the transcapillary escape rate of albumin in severe disease and injury. To everybody outside Glasgow glucocorticoids seemed to be the answer and Chicago surgeon William Schumer was their chief flag waver, claiming in 1976 that steroid therapy reduced the mortality of saline-treated sepsis in his service from 33% to around 10%.[5] We had all witnessed the almost miraculous Shock Reversal that often followed the infusion of 30 mg/kg methylprednisolone (Solumedrone in the UK). Upjohn Pharmaceuticals sent their representatives around the country to ensure that every intensive care physician was aware of this. When I told a London Upjohn Representative that I was heading to Glasgow, he warned me that WIG may be the only UK service refusing to treat sepsis with high dose steroids. He predicted that by the time I returned from Glasgow any lingering doubts about the life-saving power of Solumedrone would have been cast off.
When I arrived in Scotland I was tasked with investigating the effects of the thromboxane synthase inhibitor dazoxiben on prostaglandin production in sepsis patients.[6] Once a week, on Dr Winifred Finlay’s ICU ward round, we would be joined by biochemist Dr McKee and patient adrenal function test results were reviewed. These ladies had published their findings on serum cortisol levels in severely stressed patients the year before.[7] Now, hydrocortisone was being prescribed for patients deemed to need it, targetting a “normal” stressed serum cortisol and this seemed to be reducing mortality.[8] I was bold enough to ask Prof Ledingham why he was opposed to “pharmacological dose” steroid therapy, and he merely pointed out that the research evidence was very poor. More studies were needed. Finlay and McKee’s surprising data had been shared with Joe Stoddart, a respected Intensivist in Newcastle, England. Joe replied that he had looked at twenty consecutive “severely stressed” Geordie ICU patients, and without exception they had appropriately high serum cortisol levels. You are giving them something harmful, he concluded.
The surgical Shock Team Registrar was Ian Watt, a rather reserved chap with an Aberdonian sense of humour[9]. The Shock Team day started with an early morning debrief in the Laboratory. The Team was Ledingham, two anaesthetic Registrars, one Surgical Registrar, Technicians Ian and Morag, Secretary Dianne and, quite often, a greyhound. Our clinical responsibilities included the advanced management of shock patients. Only the Shock Team were allowed to do right heart catheter haemodynamic studies, and I was entrusted with Ed Sivak’s double indicator dilution machine that measured the extravascular thermal volume of the lungs. We Registrars were each On Call for two weeks, with one week off. This meant that we could dispatch two Shock Team members to any hospital in Scotland, to stabilise and if necessary bring shocked patients into WIG, any time of any day or night. One of us would be the designated Ambulance driver. But I digress, let’s talk more about Iain and the greyhound. At the end of the debrief the Registrars would head off to the ICU to join their rounds, but on days when Ian was experimenting on a dog one of us might stay behind to help him anaesthetise, intubate, ventilate and catheterise the animal.[10] He was using the Gurll model to investigate hypovolaemic shock. The stabilised animal was allowed to bleed until the mean arterial pressure was around 45mmHg. This hypovolaemic shock state was to be maintained for one or two hours before the shed blood was retransfused and the effect of experimental drugs on resuscitation could be tested.[11] The problem was that Iain’s greyhounds died during the hypotensive phase. I do not recall one experiment getting as far as the resuscitation stage. We pooled our intellects on the challenge, and decided that maybe the choice of pedigree greyhounds was an issue. Glaswegians, after all, are not easily compared to thoroughbreds and so Iain acquired some mongrel dogs. Unsurprisingly they died during hypotension too. Ian was getting desperate. In need of data for a Master of Surgery degree, he decided to change tack and get stuck into some clinical research. An anaesthetic Senior Registrar called Richard Marsh was our computer geek – he kindly took me to an international Computing In Anaesthesia and Intensive Care meeting in Rotterdam, where I think he presented a paper. Richard was constructing a relational database of severity of illness scores and intensive care outcome at WIG. He was alarmed to observe a big step-wise increase in ICU mortality occurring in 1982, and Watt’s new research brief was to investigate. The Shock Team had an office with three desks, one for each of us. My own desk was untidy, but Ian’s desk grew an ever increasing tower of patient records with his own notes and annotations. Then came his Eureka moment. Focusing on the cohort of major trauma patients, for whom one could calculate an expected mortality, he confirmed a very sharp rise in the observed mortality at the time there was a switch to etomidate sedation. Moreover, he found that almost all of the adrenal insufficient patients in the Finlay & MacKee series were sedated with etomidate. I obtained plates with cultures of human adrenocortical cells from Glasgow Medical researchers and added various anaesthetic agents in concentrations approximating therapetic plasma levels, before adding ACTH to stimulate cortisol release. I was sure I would find all sedative or analgesic medicines could inhibit cortisol release, but I was very wrong. Etomidate was a very powerful adrenocortical inhibitor. Perhaps the mystery was solved. Then one morning an investigation team representing Janssen arrived. They took over the shock team office, poring over the patient records and Ian’s research notes. For several days I could not get to my own desk. We reassessed Ian’s abysmal animal research history, and realised he had decided to anaesthetise the dogs with etomidate, in line with local clinical practice. He rushed back to the Laboratory to anaesthetise dogs with other anaesthetics and was relieved to find he could successfully run a Gurll model experiment. He used etomidate again, and found that a shot of hydrocortisone enabled dogs to survive long enough to reach the resuscitation stage. How could the Sheffield team have claimed that etomidate provided safer sedation for ventilated patients back in 1982? The reason became clear. Their case series was just 6 healthy patients ventilated for 24 hours after major maxillofacial surgery, and each had received dexamethasone to prevent surgical swelling.
Iain knew he had a responsibility to communicate his discovery as rapidly and widely as possible. This is why he chose a Letter to the Lancet. Unfortunately this prior publication caused some Editors of scholarly journals to turn down his more thoroughly considered and detailed manuscripts that should have followed. The Scottish national press reported that deaths had been caused by etomidate at WIG, but the anticipated public outcry did not materialise. We were spared the ignominy of an Inquiry. The number of Glaswegians whose lives were lost to etomidate was never ascertained. Experts came forward to claim that etomidate was still a preferred hypnotic induction agent for patients who would benefit from its haemodynamic stability, even though this claimed superiority was never demonstrated in sick patients. In the UK the Committee for Safety of Medicines merely drew attention to potential hazards of etomidate administration. In Denmark, the license to infuse etomidate was limited to 12 hours,
Silly comments from Experts included “it only happened in trauma patients who stayed ventilated for 5 days or more” and “a shot of hydrocortisone will block the lethal effect”. Should regulatory authorities have done more to prevent the continued use of this poison?
There are post scriptums to this story. In November 1984 Charles Sprung and colleagues published a landmark trial showing that impressive early shock reversal with high dose corticosteroids was NOT associated with increased survival of patients with severe, late septic shock.[12] I had been offered a critical care research post for 1985-6 at The Victoria Hospital, London, Ontario but Upjohn withdrew their research funding and so I had to seek alternative employment. I went instead to a Fellowship at The University of Western Ontario (UWO) in London.[13]
When Charles Sprung later devised and led an international multicentric study on Hydrocortisone Therapy for Patients with Septic Shock (CORTICUS) I was pleased to be a contributing investigator.[14]
A final PS that I forgot to add is that my notoriety in the adrenal insufficiency arena got me tasked with a Working Party on the topic back in 2012. We did not achieve a publishable consensus until 2020.15 I thought it might be impossible. Anaesthetists in the UK severely underestimate the dangers of poor & inconsistent management in critical care. Many accused us of overstating the danger, while the endocrinologists were dismayed at the lack of commitment to do better.
______________________
Co-Published on Osler https://osler.app.link/1uB7SSRwUzb on May 18th, 2023
[1] J Crit Care 2023 Apr 29. 77:154317. 10.1016/j.jcrc.2023.154317
[2] I asked the distinguished visitor where the best intensive care unit in the world was; The Vic, in London Ontario was his confident answer. Iain agreed. And so I later went on to spend a year in that welcoming town, and met William (Bill) Sibbald).
[3] PMID: 7048991
[4] In Glaswegian, a piece is a toasted slice of bread split into two thin slices. The usual filling was a tiny spread of scrambled egg.
[5] https://doi.org/10.1016/j.jcrc.2023.154317
[6] Dazoxiben almost completely blocked the synthesis of thromboxane A2, but there was no discernable change in the patients shock state.
[7] Lancet 1982 Jun 19. 1:1414-5. 10.1016/s0140-6736(82)92531-4
[8] Lancet 1983 Feb 26. 1:484. 10.1016/s0140-6736(83)91489-7
[9] Humour was important in Glasgow at that time, as a young Billy Connolly was making national headlines as an outstanding comedian. I was told that Winifred was the daughter of Scotland’s most famous comedian Alec Finlay.
[10] We each had a Home Office License to conduct terminal animal experiments under anaesthesia. An Inspector called from time to time to ensure our work was humane.
[11] It is an under appreciated fact that much of the post haemorrhagic shock fatality occurs during resuscitation.
[12] N Engl J Med 1984 Nov 01. 311:1137-43. 10.1056/NEJM198411013111801
[13] I became the first researcher to report measurements of cerebral blood flow and cerebral metabolic rate for oxygen during cardiac surgery with induced hypothermia on cardiopulmonary bypass. I was allowed to spend occasional days at the Vic when my contractual commitments at UWO allowed.
[14] N Engl J Med 2008; 358:111-124 DOI: 10.1056/NEJMoa071366
15Anaesthesia 2020 May. 75:654-663. 10.1111/anae.14963
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