SMACC

Your most favorite resuscitation items such as oxygen, bolus epinephrine, intubation and cardioversion may in fact be harmful for the pediatric cardiac patient presenting to the emergency department in extremis. Due to the physiology of certain complex congenital heart diseases, the usual resuscitation maneuvers 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 epinephrine boluses in patients with single ventricle physiology who are dwindling (nearly arresting), can actually worsen their systemic output by increasing systemic vascular resistance and promoting pulmonary overcirculation.
Cardioversion of a previously healthy pediatric 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.

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

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 (see Murphy’s Law). This talk focuses on describing common complications encountered in the postoperative period, with a focus on anticipation, prevention and planning for rapid recognition and successful management of potentially life threatening complications.

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

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.

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

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.

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

You owe it to yourself (and to your patients) to learn about burnout and resilience in healthcare workers. This talk aims to be brutally honest, occasional humorous, and quite personal about the speaker's experience and what he learnt along the way. Burnout is shockingly common. Burnout is also bloody important when it comes to our productivity, empathy, culture, and even our outcomes. Fortunately there are internal and external strategies. This talk hopes to address them head-on, and without the usual BS. After all, you can't do well unless you are well.

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

The number of published studies related to burnout, moral distress, conflicts, stressful conditions in the Intensive Care unit (ICU), is dramatically increasing over the last few years. Clinicians perceive the care as "inappropriate" when it clashes with their personal beliefs and knowledge. Care is considered “Disproportionate’ when the intervention or the action is perceived as too much or too little in relation to the expected prognosis in terms of survival or patient’s quality of life. ICU workers, who provide inappropriate or, more broadly, disproportionate care, are at risk for “burnout” and “moral distress”. This phenomenon is poorly investigated even if it could jeopardize patients’ quality of care and outcome. Similarly, no intervention has ever been tested with the aim of avoiding the mentioned threats. APPROPRICUS and DISPROPRICUS are European Society of Intensive Care Medicine (ESICM) studies performed over one day and one-month period respectively, in the ICU. Healthcare providers’ perception of care was measured as well as patients’ outcome. Results show that all healthcare providers in the ICU perceive every day both not appropriate and/or "Disproportionate care". Moreover, people within the ICU are so much accustomed to a disproportionate behavior that they don't consider it as deviant, despite the fact that it far exceeds their own rules. This phenomena is called "Social normalization of deviance” and people in one ICU grow more accustom to such behavior the more it occurs. Stress, conflicts, moral distress and burnout are driven by deviant behaviors and are proven to impair communication among the ICU staff. There is evidence in the medical and non-medical literature suggesting that the burn out leads to low performance and concentration. Good teamwork and an emphasis on clarifying ethical issues are associated with lower perception of inappropriateness of care, fewer conflicts, and smaller staff turnover rate.

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

Show me an intensivist that cares about bone! I do.
Critical illness is detrimental to bone health for various reasons – profound vitamin D deficiency, extreme immobilisation, inflammation, excessive cytokine levels, malnutrition, endocrine dysfunction and medication all may lead to accelerated bone turnover and rapid bone loss.
Today, many ICU patients are elderly, and therefore at substantial fracture risk even before critical illness. As an example, one year after a hip fragility fracture, 50 % of patients are either dead or independent. Bone health is therefore very important for morbidity and mortality of ICU survivors, adding up to the long-term sequelae after severe illness. Generally, osteoporosis remains underdiagnosed and therefore undertreated.
On the other hand, recent evidence suggests that osteoporotic patients previously treated with a bisphosphonate may have a survival benefit compared to other patients.
Furthermore, several publications in the last years showed that FGF-23, a phosphaturic, bone-derived hormone predicts outcome in the acute setting very accurately.

Overall, the link between critical illness and bone is strong in both directions and will be discussed in this talk.

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

Paediatric major trauma is rare and terrifying. Seriously injured children need good care but a number of factors (the relatively unusual presentations, their size, the way they communicate, their parents..!) make looking after them feel a lot harder than it really is. So what do clinicians really need to know to look after paediatric major trauma? We need to understand differences in physiological responses to injury (and how these can fox our triage assessments), differences in patterns and mechanisms of injury (and how these correspond to the way we diagnose, image and manage injuries in children) and how we can best prepare ourselves to make sure we look after these children well.

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

Airway management in confined spaces conjures up images of intubating entrapped victims of motor vehicle crashes, but these challenges can be found from the bottom of caves and crevasses, inside road and air ambulances, during natural and man-made disasters and even in multiple areas of the hospital, such as cath labs and hybrid theatres. 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. Ice-pick, BIADs, transillumination, inverted, tomahawk, reversed, blind, digital…if these words excite you, you need to come learn how getting into tight places will teach you how to get out of tight spots.

Direct download: 03_Ross_Hofmeyr_FINAL.mp3
Category:general -- posted at: 7:00am AEDT

After a major formative experience at a life-threatening mass casualty incident (MCI), emergency physician Christina Hernon felt incredibly unprepared despite over 2 decades of training in emergency and first response.
Despite every first aid, first responder, and emergency course teaching students to ask, “Is the scene safe?” and instructing them not to enter an unsafe scene, all of this training is completely inadequate for those present the very moment an incident occurs, who are then amidst and surrounded by an unsecured and potentially unsafe scene.
Afterwards, she had an acute stress reaction exactly like after rough calls in prehospital Emergency Medical Services, yet was offered none of the typical supports offered to first responder agencies or hospital personnel.
Feeling somehow betrayed, but unsure what to be mad at, she 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, but as an on scene, immediately responding, victimized rescuer. Realizing that she didn’t fit into any already existing category, she uncovered a new group of rescuers and 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 first of the clearheaded First Responders arrives. In this definable time gap, the only available rescuers are people who are on scene when the event happens, who may be traumatized by their experience themselves, and who, regardless of tools or training, take immediate action to help another person or make the situation better. These Immediate Responders are present at virtually every scene and have been for all of time, yet 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.

Direct download: 02_Christina_Hernon.mp3
Category:general -- posted at: 7:00am AEDT

What can hospital specialties learn from teaching and training in prehospital and retrieval medicine? A medical education enthusiast's thoughts on the application of educational theory to the challenges of the prehospital environment, based around experiences at Sydney HEMS. Reflections on teaching and learning about patients, the environment, the team and the clinician herself - and how this educational experience will shape future challenges as an educator.

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

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. Come and learn what the literature suggests, and join the global debate about this controversial topic.

Prefer a paper to a podcast?

Find solid overviews here:

1. Devereaux A V. Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care. Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL. Chest. 2008;133(5 Suppl):51S - 66S.
2. Christian M et al. Chapter 7. Critical care triage. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster. Intensive Care Med. 2010;36 Suppl 1:S55-S64. doi:10.1007/s00134-010-1765-0.

And nice reviews of the ethics here:

1. Upshur R SP. Stand on guard for thee: ethical considerations in preparedness planning for pandemic influenza: a report of the University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group. Univ Toronto Jt Cent Bioeth. 2005;(November).
2. Gostin LO, Powers M. What does social justice require for the public’s health? Public health ethics and policy imperatives. Health Aff (Millwood). 2006;25:1053-1060. doi:10.1377/hlthaff.25.4.1053.

Direct download: 01_Sara_Gray.mp3
Category:general -- posted at: 7:00am AEDT

Does love have any place in critical care? If we love and care are we more vulnerable to burnout and compassion fatigue? Will we be identified as weak leaders, too ‘soft’ for the area? Are we supposed to love an environment full of carnage and suffering? Are we meant to ‘love’ our colleagues and see our team as an extended family? Should we ‘love’ our patients or is that a ‘boundary crosser’? Critical Care consistently looks internally to resolve the past and emerging problems when there is research across disciplines that will assist critical care environments to adapt to the changing landscape of ethics, new technologies, issues with teams and a need for leaders to be more than skilled clinicians. Love and humanism may hold the key? Drawing on theories and models that hold love and compassion at their core this talk will draw examples from couples counselling, family therapy, development of teams, acceptance and commitment therapy and some of the greatest leaders in history to provide an innovative framework that can create flourishing and wellbeing within critical care for both the patient and professional. Discover where love can take us in critical care. Exploring the developmental phases of love and critical care we can learn to use our passion and energy for the job as strength instead of as an allergen. We will be reminded from the greatest leaders of our time how to transform health care and working relationships into an environment of love, support and resilience. That if we can negotiate relationships with partners, in-laws, children and friends we have the skills and resources to manage, love and thrive at work. Love, connection and compassion have much to teach us, it is time we learned to listen

Direct download: 04_Liz_Crowe.mp3
Category:general -- posted at: 7:00am AEDT

A voyage through the darkest places, sharing doubts and fears.

Direct download: 02_Ross_Fisher.mp3
Category:general -- posted at: 7:00am AEDT

Agitation poses a direct threat to the safety of both patient and staff, as well as being an important manifestation of dangerous conditions that require rapid identification and treatment. Management of agitation consists primarily of physical and chemical restraint, and the details of how restraint is carried out–usually based more on tradition than considered plans or thoughtful protocols–directly determine case outcome. In this talk, we’ll discuss the initial approach to agitation, focusing on the appropriate role of physical restraint, as well as best practice technique for physical restraint. We will then deliberate the options for chemical sedation and propose a menu of the safest and most effective agents for a variety of common agitation scenarios. Some of the questions we will address include: What are the most important dangerous conditions that cause–or are caused by–agitation? What are dangerous restraint holds, and how can physical restraint be accomplished in the safest manner? In the initial management of an agitated patient, should chemical restraint be administered by the intravenous or intramuscular route? How do haloperidol and droperidol compare speed in efficacy when used for calming the agitated patient? How should providers manage concerns around prolonging the QT interval when using butyrophenones for sedation? Which benzodiazepine is preferred, as a treatment for agitation? How should neuroleptics and benzodiazepines be used as monotherapy or in combination? In which type of patient should ketamine be used as a sedation agent? How should ketamine be dosed for tranquilization, and what adverse effects should providers be mindful of when using ketamine for this indication? Can ketamine be used in patients with hyperdynamic vital signs? What is the role of crystalloids in managing the agitated patient? Once the agitated patient has been calmed, what are the primary, secondary and tertiary resuscitative maneuvers (diagnostics and therapeutic)?

Direct download: 03_Reuben_Strayer.mp3
Category:general -- posted at: 9:00pm AEDT

In this talk I will summarize the pearls, pitfalls, and lessons shared by leaders in my own life, both inside and outside of medicine. In my experience, leadership is not a particularly male or female quality. It is a trait of an individual. Individuals tend to dichotomize into leaders and into followers. And people know good leaders “You know the way you know about a good melon” When Harry Met Sally

I will share with the audience my lessons and personal examples on leadership. Some of these include 1. There is never a need to publicly embarrass someone. Always give the person an out and speak in private. 2. Make a decision. Being indecisive is perceived worse than making a wrong choice. 3. Know your strengths and build on those. Know your weaknesses and identify people for whom those are strengths and bring them onto 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 5. Leaders must be comfortable with solitude 6. Leaders are not afraid to ask for what they need.

Direct download: 01_Resa_Lewiss.mp3
Category:general -- posted at: 7:00am AEDT

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.

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

Sepsis is incredibly dangerous for our patients and very topical in ICU and Emergency. In intensive care and emergency medicine we rightly dissect and discuss extensively how best to resuscitate patients, Airway, Breathing, Circulation – the ABC! Our training focuses on the urgency and adequacy of resuscitation and the provision of excellent supportive care. However, for the critically ill, especially in sepsis, we have very few therapies available that actually change the natural history of illness and can cure our patients. Surely that is what being a doctor is all about – helping people and changing the course of their illness – giving the patient a chance to survive!

Over 75% of patients in ICU will receive antibiotics and the choice, timing and dose will directly influence your patients chance of surviving. Antibiotics are one of the few truly disease modifying therapies we have available and by far the one we utilize the most.

In addition, no other therapy is important to not only get right for the patient you are treating but, in the case of antibiotics, the therapy for one patient may influence other patients. Attention to correct antibiotic use might save the patient in front of you. However thoughtless antibiotic use might make it harder to save the next patient by increasing antibiotic resistance in your unit.

How and why must we get antibiotics right?

Direct download: 04_Steve_McGloughlin.mp3
Category:general -- posted at: 7:00am AEDT

Inhaled nitric oxide, iNO, is usefull for retrieval and transport of the critical respiratory failure patient. Also, there is a well documented role in the retrieval of the newborn with pulm HT, PPHN or resp failure. Its used in retrieval as well as ICU settings.

Direct download: 03_Per_Bredmose.mp3
Category:general -- posted at: 7:00am AEDT

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.

Direct download: 02_Patricia_Gerritsen.mp3
Category:general -- posted at: 7:00am AEDT

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.

Direct download: 02_Patricia_Gerritsen.mp3
Category:general -- posted at: 7:00am AEDT

Since it was first described in 1763 Bayes' theorem has been applied, rejected and rediscovered in many fields. It's use in medical diagnostics is a relatively recent phenomenon. This talk will review the history of Bayes in medicine. We will then explore how Emergency doctors can practically apply these ideas in daily practice. How can we estimate pretest probability? How does Gestalt work? How can we use likelihood ratios to understand our diagnostic testing and the results? We will explore the threshold model of diagnostic reasoning and its application to patient-centred, shared decision making. Bayesian reasoning will be illustrated with common diagnostic dilemmas: subarachnoid haemorrhage, chest pain, cervical trauma, appendicitis, pulmonary emboli and tonsillitis.

Direct download: 01_Casey_Parker.mp3
Category:general -- posted at: 7:00am AEDT

"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? This talk will cover rewriting the ABCDE of ATLS, the delivery of self and buddy first aid, the use of novel haemostatics and tourniquets, rapid delivery of specialist pre-hospital emergency care by physician-led teams, AKA the Medical Emergency Response Team or MERT, with high quality pre-hospital interventions such as io access, blood transfusion, RSI, analgesia and how these lessons learned from the battlefield can be translated in to civilian practice. However, sometimes the very best we can do isn’t enough, because of the catastrophic nature of the patient’s injuries and a vital lesson learned is to how to cope when your best just isn't good enough.

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

Peer review is central to science and yet was not scientifically examined until the 1980s. Studies of peer review show that it is slow, expensive, something of a lottery, anti-innovatory, ineffective at detecting errors or fraud, prone to bias, and easily abused. So we have lots of evidence of its failings but no convincing evidence of its effectiveness. "If it was a drug it would never get onto the market." Attempts have been made to improve peer review, but these have not proved successful. The time has come for journals to abandon prepublication peer review and "let the market if ideas decide," which is what happens anyway.

Direct download: 04_Richard_Smith.mp3
Category:general -- posted at: 7:00am AEDT

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.

Direct download: 03_John_Carlisle.mp3
Category:general -- posted at: 7:00am AEDT

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.

Direct download: 01_Jeff_Drazen.mp3.mobile_low.mp3
Category:general -- posted at: 7:00am AEDT

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.

Direct download: 01_Jeff_Drazen.mp3
Category:general -- posted at: 7:00am AEDT

Sepsis is a difficult diagnosis to make, even in the hospital, where a plethora of tests are available to assist the clinician. However, 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, eluding early diagnosis and treatment. 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 twofold: First, early diagnosis of cases ranging from early sepsis to septic shock. Point of care testing is essential. Lactate can assist in identifying occult sepsis and may also be used to prognosticate. Measurement of EtCO2 serves two purposes: first, in systems where point of care lactate is not available, there is evidence suggesting that EtCO2 is a reasonable surrogate for lactate. Secondly, for spontaneously breathing patients, EtCO2 provides 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 etiologies by identifying a source, such as pneumonia.

The second fundamental aim is treatment equivalent to that available in-hospital, with judicious administration of balanced IV fluids guided by POCUS and clinical assessment of fluid responsiveness, early pressors (including push-dose pressors during RSI), 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, in order 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.

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

Normally the endothelium plays a key role in maintaining homeostasis. Systemic and pulmonary endothelial dysfunction in the setting of critical illness results in multiple organ dysfunction. In this presentation, the following will be reviewed;

1) Evidence for the role of endothelial dysfunction in the pathogenesis of critical illness. Systemic endothelial dysfunction is implicated in the pathophysiology of sepsis and trauma, pulmonary endothelial dysfunction is involved in the development of ARDS.
2) Methods used to assess endothelial function in critical illness will be reviewed.
3) Mechanisms by which interventions may modify endothelial function will be discussed. The future potential role for treatments to modulate endothelial function in the management of the critically ill will be speculated.

In summary the aim of this review will be to highlight an important role for endothelial dysfunction in the critically ill.

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Direct download: Danny_McAuley.mp3
Category:general -- posted at: 12:00pm AEDT

Bill Knight gives a superb 20 minute talk with the North American perspective on Organ Donation, brain death and management of the brain dead donor prior to organ donation. Bill is an neuro intensivist, pre-hospital and emergency physician from Cincinnati so he has a great global perspective.

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

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.

Direct download: Greg_Kelly.mp3
Category:general -- posted at: 12:00pm AEDT

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.

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

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.

Direct download: Warwick_Teague.mp3
Category:general -- posted at: 5:30am AEDT

Neonates are a nightmare.. until you appreciate the physiological transitioning required in the journey from fetal to neonatal state in the big outside world. Learn to understand the challenges faced by not-quite-ready-yet premature babies to those with critical physiology gone wrong and unlock the key to providing quality neonatal intensive care. Take the fear out of caring for newborns and in performing emergency care procedures. Don’t fly blind, use your tuned in clinical awareness and tools such as point of care lung and cardiac ultrasound. Apply your revised empathy and understanding of a journey you once made and learn how to think again like a baby!

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

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 however there can be significant morbidity and mortality. This acronym-busting talk will focus on some acquired haematological disorders in critically ill patients.
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 hemolytic anemia (MAHA) will also be described including the role of ADAMST13.
HIT is an uncommon but important conditions which is difficult to diagnose in a critically ill patient. An approach to HIT is discussed.
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!

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

Multiple biomarkers - physiological, biochemical, biological - can prognosticate early in critical illness, even in the ED. This implies the die is already cast (literally as well as figuratively) so we are simply prolonging death is those predetermined to die. We thus need to adopt a completely different strategy for such patients. This also applies to trial design, especially where survival is the endpoint.

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

The use of adrenaline in cardiac arrest resuscitation has been advocated since the 1960s. Laboratory studies and anecdotal experience showed improved rates of return of spontaneous circulation (ROSC) with the use of adrenaline at a dosage of approximately 0.01 mg/kg. This led to the widespread adoption of adrenaline administration during cardiac arrest into every resuscitation guideline for decades to come. Extensive laboratory studies characterized 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 has been shown to correlate with ROSC in both 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, it was subsequently recognized that larger doses of adrenaline did not result in improved survival. Furthermore, questions have been raised as to whether or not “standard-dose” adrenaline improves survival from cardiac arrest. Recent meta-analyses have raised serious questions about the value of adrenaline, 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 effects while avoiding excessive adrenaline doses.

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

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.

Direct download: Nick_Pigott_.mp3
Category:general -- posted at: 12:00pm AEDT

Every Pre Hospital and Retrieval Medicine (PHARM) mission involves a series of complex decisions, which must be rapidly made in a fluid and often pressured environment. Excellent PHARM clinicians are invariably expert decision makers, and 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, and require rapid and accurate cognitive appraisal of a dynamic and often incomplete information set.

Interventions performed on scene, and the order in which they are performed involves a balance of the patient’s immediate requirements against how much it will cost in time and risk. During a mission, each decision to do something leads to another layer of decisions on 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. There is often no single ideal solution to these trade offs, and each decision must be tailored to the circumstances at a given point in time.

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 indispensible.

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

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.

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

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.

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

This session will review the latest evidence for resuscitative hysterotomy (aka perimortem cesearean section), in light of the latest ACLS guidelines. Is there really evidence for the 4 minute rule? How fast do we need to do this? Terrified of this risky procedure? Come learn some practical tips for getting through this as effectively as possible. No time for the whole podcast? Check out these quick links and references:
• http://emupdates.com/2013/10/22/perimortem-cesarean-section-in-the-emergency-department/ This one has many details of the procedure itself.
• http://stemlynsblog.org/peri-mortem-c-section-at-st-emlyns/ Great review of the procedure, nice FOAM resources at the end
• http://emcrit.org/wee/peri-mortem-c-section/ Includes links to the videos below.
• Prefer a review article? This is a great review of the science on maternal cardiac arrest and PMCD (PMID 24797653)
• An excellent review of published cases is here (PMID 22613275), describing the details of timing of PMCD as it relates to maternal and neonatal survival

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

This talk uses a case study approach to discuss why resuscitation practitioners should focus upon technical accuracy when resuscitating, focussing on all of the facets of a resuscitation, compression, decompression, trans-thoracic impedance. It suggests that many of the smallest of subtleties can have a dramatic effect on patient survival.
We focus on the physiological effects of Manual Chest Compression and use historical reference to underpin modern techniques.

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

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.

Direct download: Natalie_May.mp3
Category:general -- posted at: 12:00pm AEDT

For retrieval medicine specialists and pre hospital care providers, terrorist attack is one the new threat! Terrorist attack is not an accident: It is a human activity whose purpose is to kill, injure, the maximum casualties to disrupt society, to spread the feeling of fear of panic and insecurity in the population. Terrorism is not blind, it is an organized strategy, much more complex than any natural or technological disaster. To oppose an aggressive strategy a static plan is not enough, you must develop a counter strategy comprehensive and adaptable to multiple scenarios. Effective leadership, combining the expertise of the Police, Rescue and Emergency Care allows a customized solution using the elements prepared in advance. One of the worst threats is the multiple sites multi-modal attack, like in Mumbai or in Paris. To face such a complex situation you may need:
- Improvement of pre hospital and in hospital organization for massive casualties. Alert shared by all services, close coordination between Rescue Police and Emergency care, backup on a regional basis, strategic allocation of resources and keeping reserve for the next attack are some of the options that may be extremely helpful.
- Improvement of care for injuries related to military weapons: Major penetrating trauma caused by powerful (kamikaze) bombings and assaults riffles. Management of these victims is very different of the care of a multiple trauma patient after a traffic accident. Adaptation of the principles of the military “damage control” to civilian practice is mandatory. 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.
The action of Health Care Services is not limited to medical care, it is also a first step of resilience: By maintaining the quality and the organization of care despite surprise, violence and aggression you oppose directly the objectives of terrorism.

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

Discover how 3D scanning and printing can be used to develop low cost but high fidelity simulation training equipment. An introduction to free, open access Design software and affordable Compact 3D scanners. Cut out the middle men and save your department $$$ by making your own training manikins. Surgical airway trainer, central line insertion phantom, even an ultra-low cost video laryngoscope can easily be created without learning how to use complex 3D software packages.


It’s natural that as doctors we fear failure. In Health, never has so much been asked by so many of so few. Every day feels like a battle zone. Engage a Chief Medical Informatics Officer (CMIO) to introduce technology. That will save us. Established with structure, status and enough support to create and translate innovative models of change in the mindsets of clinicians and healthcare politicians alike, this role could work. However reality is so different. So lets understand failing early to succeed sooner, simplifing and standardising the clinical arena for clinician interoperability, and driving clinician inclusion in the business of health.

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

In the evaluation of an emergency and critical care patient, the provider accounts for the chief complaint, the relevant history and the physical examination. With the evolution of Point-of-Care Ultrasound protocols and algorithms, such as the RUSH protocol or the BLUE protocol, the provider now can organize differential diagnoses and treatment options by integrating point-of-care ultrasound interpretations. However, these are not absolutes. These are probabilities. Although we are following recipes, we must never forget to be creative.

And, we actually crave creativity.

Studies support that handwork such as gardening, wood working, knitting can decrease stress, anxiety, and improve your mood. Perhaps work which requires meaningful hand use may contribute to your creativity- to your following algorithms and delivering more optimal patient centered care. Emergency and critical care medicine can be formulaic- following an algorithm, a pathway, or a protocol. Point-of-care ultrasound may offer the ability to be creative and increase the accuracy of diagnoses and treatment plans.

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

'"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.

Direct download: Lisa_McQueen_-_Shock.mp3
Category:general -- posted at: 12:00pm AEDT

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.

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

Technology (tech) makes our lives in many ways, yet that same technology is lacking from healthcare. Many of the things that are used in our daily lives can be applied to providing better healthcare to our patients and bring specialized care to any corner of the planet. This talk will discuss some of the ways such technology is being used and ideas for care in the future.

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

As many other emerging countries, Brazil has two completely different healthcare systems, a private system restricted to those who are insured and a public system free-of-charge available for everyone. As anywhere, there are lots of boring things in our daily routine. Some of them will piss you off regardless if you are working for a very nice private ICU or for an overcrowded public one. Deal with the assistant physicians, with our own colleagues and other healthcare professionals is not exactly easy and fun. Can you imagine something more repetitive than a checklist? However, some will be different. To decide who will get the last free bed? Put a patient in ECMO knowing how much it will cost? Having a fight after finally finding our ward colleagues to get a patient discharged? To discharge a patient knowing that he will come back because we don’t have step-down units? Yes, that is sometimes just too much! And this just all in a day’s work in a public ICU in Brazil.

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

Providing a service to the critically ill depends on a number of essential building blocks: Trained staff, diagnostics, equipment, drugs, guidelines and processes. Compromise one element and maintaining quality of care becomes precarious.
Jenga is a game of physical and mental skill. Using real cases see how removing one block at a time may see even the seasoned clinician struggle to perform well. Welcome to Fiji Critical Care Jenga.

Direct download: Fiji_Critical_Care_Jenga.mp3
Category:general -- posted at: 7:00pm AEDT

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.

Direct download: Fran_Lockie__Phil_Hyde_.mp3
Category:general -- posted at: 12:00pm AEDT

An eight minute summary of the evidence and clinical considerations regarding decompressive craniectomy, discussion of some controversies, and presentation of a decision matrix to use when considering surgery in your patient with malignant middle cerebral artery infarction.

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

In 2010, 400 children died from lead encephalopathy in the largest lead poisoning outbreak ever recorded, affecting more than 5000 children in Zamfara state, Northern Nigeria. The outbreak is ongoing. The source is dust from artisanal gold mining, a major economic boon to a remote and rural population much in need.

The response to the Zamfara outbreak is unprecedented and requires a nuanced interpretation of 'critical care'. Key life-saving activities include multi-level advocacy to address source control, management of inter-current outbreaks of cholera, measles and meningitis, addressing the logistical challenges of large-scale environmental remediation and navigation of an increasingly difficult security context. The situation is so dynamic and dense that knowing which way is up, or which way might cause inadvertent harm, is an ever present challenge.

This is the story of the Zamfara outbreak and response, but more importantly it is the story of the people affected, whose lives have been changed by a forgotten outbreak and whose deaths’ engender no outrage.

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

The medical non-governmental organisation ALIMA (Alliance for International Medical Action) in collaboration with the Guinean Ministry of Health opened and ran the Ebola treatment centre (ETC), in Nzerekore, Guinea during the recent outbreak of Ebola virus disease in West Africa. This paper will describe the issues faced in treatment of the evolving phases of the illness and the aero-medical evacuation of health workers with suspected Ebola virus disease. The difficulties of participating in a trial of experimental therapy during an epidemic of a highly contagious disease, with a terrified local population will be explored. An approach to working with the local community to optimise engagement and minimise stigma, to allow an appropriate public health response will be illustrated. Issues arising from ensuring safe handling and burial of corpses while maintaining respect and dignity for the dead person and their loved ones will be outlined. The stresses and strains of day to day life for the Ebola treatment team will also be shared. Sadly, the ETC has recently been re-opened due to a new cluster of cases.

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

There is a rich literature showing excess stress - psychological, pharmacological or physiological - results in similar physical and cognitive manifestations. Critical illness is the perfect example of this manifestation of decompensated stress ("allostatic overload"). Failed organs frequently look normal histologically yet are functionally inactive, despite many varied insults/stressors triggering the failure. These organs regain their functionality prior to patient recovery suggesting, in most cases, reversibility. If this hypothesis were true, de-stressing manoeuvres should improve outcomes ... and they do, at least in specific human conditions and animal models. Grasping this concept offers a much more holistic approach than we use at present and may lead to improved outcomes.

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

Recently published national guidelines and case series evidence supports a standardised management protocol for pre-hospital traumatic cardiac arrest (TCA) in adults due to penetrating trauma. However, the pathophysiology of pre-hospital TCA in children is different, as the mechanism is typically blunt trauma with concealed haemorrhage, and as such caution must be applied to direct extrapolation of adult guidelines in this situation. This talk will describe some recent paediatric TCA cases, review of the relevant evidence, and suggest a decision framework to support the pre-hospital team.

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

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. 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.

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

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. Markedly influenced by industry, these interventions and strategies hijacked critical thinking creating a belief in the utiliity 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.

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

Scott Weingart's opening talk at SMACCdub was on meditation: vipassana and stoic negative contemplation. Visit Scott's personal Blog EMCrit http://emcrit.org/wee/vipassana-meditation/

Direct download: 02_Scott_Weingart_.mp3
Category:general -- posted at: 11:00am AEDT

2016 is 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. In theory, remote ischaemic preconditioning can be induced by temporarily interrupting the blood supply to an extremity using a blood pressure cuff.

In experimental models this technique is effective in reducing ischaemia / reperfusion injury when applied after ischaemia but before reperfusion. As a result the technique has a wide range of potential clinical implications including:
1. Heart surgery with cardiopulmonary bypass
2. Planned percutaneous coronary interventions
3. Acute myocardial infarction
4. CBA being treated with lysis or clot retrieval
5. Carotid endarterectomy surgery
6. Hypoxic ischaemic encephalopathy
7. Organ transplantation
8. abdominal aortic aneurysm surgery

While this technique is not yet ready for clinical application, it remains an exciting potential therapeutic modality for the future.

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

Combining academic activity with pre- and in-hospital clinical practice is hard work. So why should you do it? Are you a strong believer that care should be evidence-based and that this principle also pertains to pre-hospital practice? Do you believe that the nature of the pre-hospital environment does not allow automatic extrapolation of in-hospital evidence to the field? Do you believe in the relevance of critically appraisal of practice to identify areas of improvement, areas of harm, and to optimise a resource-effective practice? If so, lets discuss how to do pre-hospital research

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

All diseases exist on a spectrum. Although the pathophysiology and relative illness of patients on the spectrum are different, we often apply the concepts of management of one of the spectrum to the other end. This can be extremely deleterious to our patients. For example, we cannot treat CHF exacerbations, acute pulmonary edema and cardiogenic shock with the same approach (i.e. no role for loop diuretics early in APE). Thin-slicing disease into a spectrum allows us to tailor our management to our patients and maximize good outcomes.

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

This talk will outline the current state of play in terms of the 'silver tsunami' of elderly patients attending our EDs. What the evidence is for managing them effectively within the ED, and how we could manage them better. It will focus on the effective and efficient delivery of services for the elderly within the ED, the need for training and specialist skills and research to deliver improved care.

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

The key to dystopian literature is the backstory. These brutal, terrifying worlds are grim forecasts of the future, spawned from the choices and actions of the present. In critical care medicine we make rafts of decisions everyday - not all of them ideal. This talk looks at a projection into the future, both fictional and real, based on those small decisions, actions, and processes.

Direct download: 1984_Dystopian_Literature_and_Emergency_Medicine.mp3
Category:general -- posted at: 7:00am AEDT

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. Tractors are involved in the vast majority of agricultural deaths. No other industry uses 70-year-old machinery operated by workers whose age ranges from 10 to 90. How can we prevent such incidents?


Today’s presentation is from my viewpoint as a prehospital physician (who is a wannabe farmer & tractor mechanic) and longtime resident of an agricultural community. We will examine the details of a life threatening accident involving one of my neighbors which perfectly illustrates the multifaceted nature of agricultural trauma

Direct download: 04_Mike_Abernethy.mp3
Category:general -- posted at: 3:00pm AEDT

In the busy world of emergency medicine it's easy to focus on the here and now, there is always something that demands immediate attention. What of the future? How will demographics, workforce, technology, finance and politics affect the practice of emergency medicine? This talk explores these issues and charts a future that will be very different to today.

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

John Hinds' tragic death has affected many people all over the world. In the inaugural John Hinds Plenary session at SMACCDUB, John's partner Janet and his mentor Fred MacSorley celebrate John's life in a fitting tribute to the man that has become a legend.

Direct download: FIRST_AMONG_EQUALS_A_TRIBUTE_TO_DR_JOHN_HINDS.mp3
Category:general -- posted at: 1:30pm AEDT

Lets explore dogma and myths about the knowledge and skills of 'resuscitationists', and the way we think we maintain and improve our skills.
BLS and trauma team leadership will come under the spotlight - we often don't do what we think we do.
Resuscitationists are exceptional people - but not necessarily in the way we think we are.
And finally - some thoughts on what we'll leave behind as resuscitationists... with a tribute to John Hinds

Direct download: So_You_think_youre_a_Resuscitationist.mp3
Category:general -- posted at: 9:00pm AEDT

Agitation poses a direct threat to the safety of both patient and staff, as well as being an important manifestation of dangerous conditions that require rapid identification and treatment. Management of agitation consists primarily of physical and chemical restraint, and the details of how restraint is carried out–usually based more on tradition than considered plans or thoughtful protocols–directly determine case outcome. In this talk, we’ll discuss the initial approach to agitation, focusing on the appropriate role of physical restraint, as well as best practice technique for physical restraint. We will then deliberate the options for chemical sedation and propose a menu of the safest and most effective agents for a variety of common agitation scenarios. Some of the questions we will address include: What are the most important dangerous conditions that cause–or are caused by–agitation? What are dangerous restraint holds, and how can physical restraint be accomplished in the safest manner? In the initial management of an agitated patient, should chemical restraint be administered by the intravenous or intramuscular route? How do haloperidol and droperidol compare speed in efficacy when used for calming the agitated patient? How should providers manage concerns around prolonging the QT interval when using butyrophenones for sedation? Which benzodiazepine is preferred, as a treatment for agitation? How should neuroleptics and benzodiazepines be used as monotherapy or in combination? In which type of patient should ketamine be used as a sedation agent? How should ketamine be dosed for tranquilization, and what adverse effects should providers be mindful of when using ketamine for this indication? Can ketamine be used in patients with hyperdynamic vital signs? What is the role of crystalloids in managing the agitated patient? Once the agitated patient has been calmed, what are the primary, secondary and tertiary resuscitative maneuvers (diagnostics and therapeutic)?

Direct download: disruption_danger_and_droperidol.mp3
Category:general -- posted at: 9:00pm AEDT

As our population ages, the complexity of patients seeking care in the emergency department will increase dramatically. Chronic and terminal diseases will be ever-present but increasingly in patients also negotiating challenges like functional and cognitive decline. While their needs are different, in many hospitals, it is business as usual. A highly skilled and well-intentioned staff stands ready to deploy a limitless supply of diagnostic and therapeutic options designed to help patients live longer, not necessarily better.

Relying on default pathways that prioritize life-prolongation at the mercy of comfort and dignity has already left many patients and doctors feeling unsatisfied, while wasting precious healthcare resources. The future should not be more of the same.

If a new and better clinical road is to be paved in the future, it will be with the aid of palliative care, a specialty, philosophy and movement in medicine. Getting patients better access to palliative care should be a priority for our specialty. For some, this will mean partnering with existing palliative care specialists and hospices. Unfortunately, for most of us, the palliative care workforce will never be able to match the increasing demand created by our patients. This means that we must all do the hard, but incredibly rewarding work of learning a basic palliative care skillset. No pressure but the future of healthcare depends on it!

Direct download: Why_we_need_palliative_care_everywhere.mp3
Category:general -- posted at: 9:00pm AEDT

This is a fresh ICH discussion covering controversies in 2015: blood pressure control, reversal of anticoagulation, and prognosis.

Direct download: Bill_knight_nuro.mp3
Category:general -- posted at: 2:57pm AEDT

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.

 

Direct download: tom_bleck_neuro.mp3
Category:general -- posted at: 8:00am AEDT

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.

Direct download: Sub_Hem.mp3
Category:general -- posted at: 11:33am AEDT

SMACC Chicago Beat the Bug Q&A session with Kath Maitland, Mark Crislip, Flavia Machado and Chris Nickson.

Direct download: Maitland_Chris_QA.mp3
Category:general -- posted at: 4:00am AEDT

SMACC Chicago Q & A session on Funky Physiology with Mybourgh, Saxona, Hensley and Perner.

Direct download: John_Justin_Anders_M_Q__A_.mp3
Category:general -- posted at: 5:00am AEDT

Heart, Brazil and Gatward discuss The Future of Continued Medical Education in this SMACC Chicago Q&A Panel Review. 

Direct download: Future_of_Coninued_Medical_education_.mp3
Category:general -- posted at: 3:00pm AEDT

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.

Direct download: Trauma_in_Peads.mp3
Category:general -- posted at: 8:00am AEDT

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.

Direct download: How_to_Stop_Bleeding_Without_a_Hospital_Howie_Mell.mp3
Category:general -- posted at: 4:30am AEDT

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.

Direct download: Day_3_C27_Rich_Levitan.mp3
Category:general -- posted at: 3:00pm AEDT

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.

Direct download: Andrew_N.mp3
Category:general -- posted at: 6:30am AEDT

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.

Direct download: Vic_Brazil_Heal_.mp3
Category:general -- posted at: 12:46pm AEDT

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?

Direct download: Simon_Carley.mp3
Category:general -- posted at: 6:00am AEDT

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!

Direct download: Finfer_on_Controversies_in_TBI.mp3
Category:general -- posted at: 5:00am AEDT

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.

1. Seek out a clinical champion
2. Establish a common purpose/vision
3. Standardise what is standardisable
4. Communication, communication, communication
5. Work out barriers and overcome them
6. Deal with the ‘Whats in it for me?’WIFM

Direct download: Imogen_Mitchell.mp3
Category:general -- posted at: 6:30am AEDT

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.

Direct download: Day_1_C5_David_Juurlink.mp3
Category:general -- posted at: 5:00am AEDT

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;

1. Emotional distress
2. Physical symptoms - including pain (but not restricted to)
3. Information - Included reassurance and explanation
4. Care - Basic care
5. 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?'

Direct download: Rick_Body.mp3
Category:general -- posted at: 2:30pm AEDT

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. 
Direct download: Andrew_healey_.mp3
Category:general -- posted at: 6:00am AEDT

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.

Direct download: raging_hormones_jeremy_cohan.mp3
Category:general -- posted at: 6:30am AEDT

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.

Direct download: trauma_is_risky_business.mp3
Category:general -- posted at: 2:00pm AEDT

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.
Direct download: Walter_Eppich.mp3
Category:general -- posted at: 4:30am AEDT

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!

Direct download: Paul_Marik_-_Understanding_Lactate.mp3
Category:general -- posted at: 6:00am AEDT

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.

Direct download: Justin_Hensley_-_into_the_wild.mp3
Category:general -- posted at: 1:30pm AEDT

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".

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

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.

Direct download: _Mervyn_Singer_-_MOD.mp3
Category:general -- posted at: 1:00pm AEDT

Scott Weingart's lecture at SMACC-Chicago was on OODA loops and the supremacy of System I for resuscitation. Check more here

Direct download: EMCrit-Podcast-20160402-171-OODA-Loops.mp3
Category:general -- posted at: 4:00am AEDT

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.

Direct download: Ashley_Shreves-_How_to_diagnose_the_dying.mp3
Category:general -- posted at: 5:00am AEDT