SMACC

Is there a specific time during our shift when we are too fatigued to safety practice? That was the question that led to a 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. These 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 the opposite proved true. Blinded reviewers assigned the day shift providers lower performance scores and noticed some surprising medical errors committed during these simulated cases.
So are we “awake” when we come to work? Should some type of case-based warm up exercise be encouraged just prior to a shift? Also, upon reviewing the data, it was found that the majority of the providers studied had been off the day prior to their morning shift. Jan Paderewski, a famous pianist said, “If I miss one day of practice, I notice it. If I miss two days, the critics notice it. If I miss three days, the audience notices it.” 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 anything be done to improve our abilities in real time?
This lecture will review the available literature surrounding mental fatigue and critical care based shift work and focus on techniques both before and during shifts to recognize and potentially mitigate any clinical sluggishness and improve patient care.

Direct download: Jo_Anna_Leuck.mp3
Category:general -- posted at: 7:00am AEDT

Ah, but you don't look like a professor! A recent statement from a (female) patient says it all, doesn't it?

Since the first women were admitted to medical schools – quite a while ago in most countries, the participation of women in clinical and academic medicine has increased steadily. Overall, women represent the majority of health care workers and also medical students in most countries of the world today. SMACC audience is almost 50% female.
However, only few women make it to the top, and with each step up the career ladder, the proportion of women decreases substantially, a phenomenon called the “glass ceiling” or the „leaky pipeline“. This is particularly true for some medical specialties such as critical care or trauma surgery, as opposed to specialties like endocrinology, pediatrics or gynecology. Although often subtle, gender discrimination against women continues to be a problem – for instance, it has been shown that a ficticious student named “John” would receive a higher salary and find a mentor easier than “Jennifer”. A manuscript written by “John” is judged more favourably than one that is authored by “Joan”, and female grant applicants with the same scientific productivity are given substantially lower scores than male applicants by reviewers (men and women). Sheryl Sandberg’s statements are as true in clinical and academic medicine as in other areas.
This talk will definitely raise your awareness for the topic.

Direct download: Karin_Amrein_2.mp3
Category:general -- posted at: 7:00am AEDT

Motorcycle Trauma Simulation and discussion

Direct download: SMACC_Brent_May.mp3
Category:general -- posted at: 7:00am AEDT

Time tested rules and myths explored in a real life adventure, meant to honor and display the courage, commitment and sacrifice made by emergency medicine and critical care professionals around the globe. In a painfully honest reflection, Ashley crushes stigma and leaves us acutely aware of how our words and actions affect our colleagues and those that we love.

Direct download: Ashley_Liebig.mp3
Category:general -- posted at: 7:00am AEDT

What paradigms should take precedence during a humanitarian emergency when the needs may overwhelm the resources, particularly in the early phase ?
Is it possible to resolve the tension between quality and quantity in a resource constrained situation ?
How has a changing geopolitical climate affected humanitarian medical action ?
Is there a rôle for a critical care specialist at all, when medical resources are simple and finite ?
What are the particular challenges of living and working together with a group of colleagues in an unfamiliar and stressful remote environment ?
What can be learned for critical care practice in resource rich settings from our colleagues working in resource constrained emergency situations ?
These, amongst other complex questions will be explored.

Direct download: Nikki_Blackwell.mp3
Category:general -- posted at: 7:00am AEDT

In Africa up to a quarter of children will visit a health facility in their final illness; many dying on the day of admission. Targeted emergency care may be a very cost-effective means of reducing child mortality, but has not been afforded a high enough priority. Moreover, the most basic treatments provided in the emergency room have never been subjected to evaluation in clinical trials, including in resource-rich settings. The controlled FEAST trial of fluids resuscitation demonstrated that guidelines, developed for the rest of the world, cannot be safely translated to Africa.
Although oxygen is a basic element of hospital care, there are no relevant trials to guide which level of oxygen saturation or the best method of how to administer it (low flow or high flow) improves outcome. In practice many children in low-income countries do not receive oxygen, despite being recommended, owing to the lack of its availability due to the high cost, or supplies that are unpredictable (erratic delivery of cylinders and/or electricity) Outcomes of children in sub-Saharan Africa with pneumonia, remains poor with an in-hospital mortality 9-10% (for those with oxygen saturations between 80% and 92%) and 26-30% case fatality for those with oxygen saturations <80%. The Children’s Oxygenation Administration Strategies Trial (COAST) will start in 2017 in 3 countries and will enrol 4,200 children (aged 2m to 12y) with presumptive pneumonia and hypoxaemia (defined as SpO2<92%). The key questions COAST will establish are whether liberal oxygenation for SaO2≥80% will decrease mortality compared with a strategy that includes permissive hypoxia (usual care); and whether use of high flow oxygen delivery will decrease mortality (at 48 hours and up to 28 days) compared with low flow oxygen delivery (usual care).

Direct download: Kathryn_Maitland.mp3
Category:general -- posted at: 7:00am AEDT

Francesca Rubulotta and Karin Amrein both came out swinging in this debate that universally gets people going!

The crowd was 50:50 split to start with - where will you stand by the end of this podcast?

Direct download: Francesca_Rubulotta__Karin_Amrein.mp3
Category:general -- posted at: 7:00am AEDT

Darren Braude and Karim Brohi battle it out in the #SMACCDub Cage Match 'It is time to throw away the hard cervical collar'.

Direct download: Darren_Braude__Karim_Brohi.mp3
Category:general -- posted at: 7:00am AEDT

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!

Direct download: John_Myburgh__Peter_Brindley.mp3
Category:general -- posted at: 12:14am AEDT

Martin -PRO- :

The management of severe traumatic brain injury (TBI) has undergone extensive revision following evidence that longstanding and established practices are not as efficacious or innocuous as previously believed. Very few specific interventions have been shown to improve outcome in large randomized controlled trials and, with the possible exception of avoidance of hypotension and hypoxaemia, most are based on observational studies or 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.

Improved understanding of pathophysiology and advances in neuromonitoring and imaging techniques have led to the introduction of more effective and individualised treatment strategies that have translated into 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 using a systematic, stepwise approach to maintenance of adequate cerebral perfusion and oxygenation. As well as being used to guide treatment interventions, multimodal neuromonitoring also gives clinicians confidence to withhold potentially dangerous therapy in those with no evidence of brain ischemia/hypoxia or metabolic disturbance.

The days of blind adherence to generic physiological targets in the management of severe TBI have been replaced by an individualised approach to optimisation of physiology which has translated into improved outcomes for patients.

 

Mark -CON- :

The New England Journal of Medicine has published a number of articles recently that demonstrate no benefit from classic neurotrauma interventions (ICP monitoring, cooling, decompression). This is because factors such as ICP and CPP are associated with bad outcome by association rather than causation. This debate will demonstrate that critical care just complicates things and it is high time for the randomised trial between the very best Neurocritical care and NOB therapy (Naso-pharyngeal, Oxygen and a Blanket).

Direct download: Martin_Smith__Mark_Wilson.mp3
Category:general -- posted at: 7:00am AEDT