This talk will cover what we should do for patients who are considered too sick to have emergency surgery. These patients provide major management challenges in Critical Care. Do we admit them to intensive care to optimise them prior to emergency surgery or should we get on with surgery and resuscitate them intraoperatively? Should the surgery, if undertaken, be limited to damgae control surgery or operative resuscitation, or should more definitive surgical procedures be undertaken.

There often isn't good evidence to mandate a course of action either way so the decision will mostly be based on the treating clinicians opinions. In these complex cases, who should decide? These factors and others will be examined

Direct download: Too_sick_for_surgery_-_Steve_Mathieu.mp3
Category:general -- posted at: 5:30am AEST

Error is almost inevitable in our clinical practice so we should be prepared to help and prepare those individuals involved for the benefit of them, our systems and our patients. Do you remember that patient you saw last night?': A phrase the strikes terror into the hearts of all physicians. The prospect of a patient coming to harm as a result of a mistake is terrifying but it can and does happen. The consequences for the patient and their family are often tragic but what of the clinicians who made the error? For many the result of making a terrible error is life changing. Those permanently harmed by error are often referred to as second victims with the consequences of terrible events being life-long.

This talk explores the predictable course for clinicians who are involved in error and asks whether we can prepare and support such individuals through a difficult time.

Direct download: Day_1_C8_Simon_Carley.mp3
Category:general -- posted at: 5:00am AEST

In 2013, ~500,000 children in sub-Saharan Africa died as a direct result of Plasmodium falciparum malaria, accounting for 90% of global malaria mortality. The scale-up of control efforts has led to some reductions in malaria incidence in parts of Africa, but countries where transmission is high malaria continues to be a major public health problem. Early optimism that the most promising malaria vaccine candidate (RTS,S) would reduce the burden of malaria proved premature since following (3-dose) vaccination since immunity rapidly wanes >20 months post-vaccination. Severe malaria remains a major cause of hospital admission and paediatric death across sSA. Nevertheless, clinical research has been fragmented, resulting in only two large Phase III clinical trials - both with landmark results. The AQUAMAT trial, enrolling 5425 children demonstrated significantly lower in-hospital mortality in those receiving artesunate (8.5%) versus quinine (10.9%) (relative risk reduction 22.5%). Second, FEAST a pragmatic trial of fluid resuscitation as a supportive treatment in 3141 African children with shock, of whom 57% had severe malaria; this trial was stopped early due to higher 48-hour mortality in bolus arms (RR increase 45%) than no bolus (control) across all sub-groups.

Even with artesunate as standard antimalarial treatment, overall mortality remains ~10%, but includes large sub-groups with substantially higher case fatalities (15-20%) with 3 key prognostic markers (coma, metabolic acidosis or a high blood urea nitrogen) and/or bacterial co-infection (CF ~24%). There seems little prospect for further reducing the substantial mortality of severe malaria within the foreseeable future without a concerted and strategic effort from funders and researchers. SMAART (a nascent consortium for research and trials) aims to catalyse and accelerate the severe malaria research agenda. SMAART will formulate and coordinate seamless Phase I/II to large multi-centre Phase III trials using efficient trial designs to inform treatment guidelines and ultimately the outcome amongst African children

Direct download: Kathryn_Maitland_-_Malaria-_Can_clincial_trials_help.mp3
Category:general -- posted at: 6:30am AEST

Resuscitation- what's the point.

Cardiopulmonary resuscitation (CPR) is unique as the only medical intervention performed on anyone without explicit contrary documentation. Therefore, CPR need to be understood in terms of societal expectations, legal mandates and professional duties. We also need to understand not just the the likelihood of survival, but also the likelihood of disability and the cost (both literally and figuratively) to patients, healthcare workers, and to an already stretched healthcare system.

Even the term 'resuscitation' means different things to different people...and that's before we even wade into such terms as 'autonomy', 'paternalism' and 'patient-focused care'. In short, doctors, nurses patients and families can no longer shy away from discussing CPR: it's time to talk.

It can be a remarkable way to prevent premature death, it can also squander finite resources and be the beginning of a terrible ordeal for frail patients and frazzled families.

Direct download: Peter_Brindley_-_Resuscitation-_Whats_the_Point.mp3
Category:general -- posted at: 5:30am AEST

The management of the septic patient in ICU is a recurrent topic for debate amongst intensivists. The decision of if and/or when to give blood transfusions is one of the key sources of contention. Dr Anders Perner is one of the most qualified people to weigh in on this debate. In this talk from SMACC Chicago, he delivers his stance on when to pull the transfusion trigger.

Dr Anders Perner is an Intensive Care Specialist at Rigshospitalet and a professor in intensive care at Copenhagen University. He is the chairman of the Scandinavian Critical Care Trials Group and the strategic research program “New resuscitation strategies in patients with severe sepsis’. The contents of this talk are based on the findings of the TRISS trial - Transfusion Requirements in Septic Shock. This trial, Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock was published in the NEJM in October 2014. The aim was to evaluate the recommendations from the Surviving Sepsis Campaign regarding transfusion in septic shock. The recommendation is that after the first 6 hours, transfusion threshold should be a Hb <7g/dL aiming for a Hb between 7-9g/dL in patients who do not have MI, severe hypoxia, acute haemorrhage or ischaemic coronary artery disease. Unfortunately, these recommendations were made with limited supporting data, hence the TRISS trial was born.

The TRISS trial was conducted as a multicentre, parallel-group trial run across 32 ICUs in Denmark, Norway, Sweden and Finland. Patients with septic shock who had a Hb </9g/dL were randomly assigned to either a higher transfusion threshold group (Hb </ 9g/dL) or a lower transfusion threshold group (Hb</ 7g/dL). They each received 1 unit of leukoreduced PRBC when they reached their respective transfusion threshold. The primary outcome was death within 90 days of randomisation. In this SMACC talk, some of the key findings and limitations of the trial are discussed. So check out this talk and then read the full article available here to see if you agree with 7g/dL – the new normal.

What’s your transfusion trigger? Is it time to rethink it?

Direct download: When_to_Pull_the_Transfusion_Trigger_Anders_Perner.mp3
Category:general -- posted at: 6:30am AEST

Simulation is one of the most important advances in healthcare education and skills training of our generation. We now have simulation mannequins that can blink, breath, or even give birth thus allowing us to practice scenarios and skills before we encounter them in real patients. However, these sim dummies are not real people and so it is all too easy to dehumanize the scenario. According to Dr Phil Hyde, Director of Children’s Major Trauma and Southampton Children’s Hospital, it is this lack of emotional attachment that makes pure sim inadequate for training health care professionals in the management of trauma – especially trauma in children.

In his talk from SMACC Chicago, Dr Phil Hyde illustrates why he and his colleagues have developed an educational program that takes sim to the next level. The key difference in this sim program is the incorporation of volunteer children to play the roles of injured paediatric patients. Another key aspect of this program are the incorporation of multidisciplinary teams including undergraduate students for all scenarios.

The benefits of such a program have been far reaching. For the health professionals involved, it humanizes the scenario and induces an emotional attachment to the training exercise which adds an essential component to the training. Furthermore, it teaches professionals from different fields (nursing, medicine, allied health etc) to work together in these scenarios as would normally occur in real life. For the children involved, it is a safe controlled environment where they can learn about the health professionals and the health system, they learn about primary prevention and they can provide feedback to staff from a different vantage point. The community benefits through the improved primary prevention which is the most important aspect of treating trauma, a “man made disease”.

This is a simple, yet powerful program that has so many benefits beyond the training of doctors and nurses to manage children involved in trauma. This is an intriguing, innovative talk that everyone can take something away from.

Southampton Children’s Hospital is part of the University Hospital Southampton NHS Foundation trust. It is one of the largest teaching trusts in the UK. All of the simulation programs developed by Dr Phil Hyde and his colleagues at Southampton are open access and available for all health professionals to incorporate into their practice.

Direct download: Phil_Hyde_-_Paeds_Sim-_Not_for_Dummies.mp3
Category:general -- posted at: 6:00am AEST

Are you ready for this rumble in the urban jungle?? Chris Ho vs Joe Bellezzo in the no holds barred debate about whether ECMO CPR is a step too far? The next cage match from SMACC Chicago.

Chris and Joe are the director and vice-director respectively, of Emergency Medicine at Sharp Memorial Hospital in San Diego, California. They are two of the leading experts in ECPR, with Joe being one of the key players behind EDECMO. On a day-to-day basis, they are friends and colleagues, working together in one of the very few centers around the world to deliver ECPR. However in this Cage Match, friends become foe and there are no limitations to how far each will go to prove their side of the debate.

On the AFFIRMATIVE side, Chris Ho delivers a convincing argument for why ECPR IS a step too far. From lack of evidence to the cost of “re-animating the dead” and everything in between, Chris Ho delivers a practical approach to the argument and demonstrates without a doubt why we are not ready for this to be the next step in resuscitation.

On the NEGATIVE side, Joe Bellezzo delivers an outstanding rebuttal to “Dr Ho’s Nutty Brown Bullshit”. In an inspiring argument filled with anecdotes and occasional facts, Joe Bellezzo makes it impossible to think the ECPR shouldn’t be the next step in our ALS algorithm.

Despite strong arguments from either side, as in all debates, there must be a winner. Do you agree with the outcome?

If you want to find out whether Chris and Joe were able to kiss and make up, check out the exclusive ICN interview with the two, where they discuss more on ECPR.

Direct download: Day_2_C18_Match_2.mp3
Category:general -- posted at: 5:00am AEST

Working night shifts is a part of medicine that we have come to accept. We work these shift because generations of people before us had done it. But could working night shifts have negative consequences? Night shifts have been shown to be detrimental to patient safety by increasing errors in medication administration and direct patient care. Working night shifts may negatively affect our health by increasing the risks of substance abuse, obesity, social relationships, and certain malignancies. Finally, working night shifts may lead to career burnout leading to dissatisfaction and early retirement from the profession.

Several strategies can be used to combat the negative effects of working night shifts and these include a better awareness of the problem, improved sleep hygiene, strategies for better rest, and alternative staffing techniques. The Casino shift is an alternative approach to scheduling, which has been found to combat several of the problems associated with night shifts.

Night shifts will never disappear because hospitals must operate 24 hours a day. We must be aware, however, that there are many potentially negative consequences to this practice as a better understanding of this problem will allow us to develop and research new solutions.

Direct download: Haney_Mallemat_-_Shift_Work-_Thriving_or_Surviving.mp3
Category:general -- posted at: 6:00am AEST

Patients are at risk – from the moment they begin their healthcare journey. They are at risk of bad outcomes (as defined by us) and of bad experience (as can only be defined by them) Patient safety experts like James Reason, and groups like the Institute for Healthcare Improvement (IHI) have prompted us to think about systems and complexity as sources of error – and supported strategies to remove predictable human fallibility as far as possible. This is important to make healthcare safer.

Vic Brazil’s talk suggests there is also a human face to patient safety - in the behaviour and attitude of healthcare practitioners and patients themselves......

We think too little of patients. We feel affronted if patient takes a different view of ‘evidence’ or of ‘risk’. …and they think too much of us....! Every day patients allow nurses (and doctors) to inject drugs into their IV line without asking “whats in that syringe”....

This combination of our subconscious paternalism and patients’ blind faith is a heady mix……but ripe for us to make a difference. Vic suggests there are are small, human ways we can involve patients in safer healthcare, of better quality and with an improved patient experience.

We can ask them.

We often do involve patient advocates at the ‘strategic end’, but when was the last time you invited a real patient to your departmental teaching or consultant meeting (or smacc conference...!)

We can connect with advocates for patient experience and ‘personalised medicine’, especially if we are interested in social media. Follow people like @JenWords and @EricTopol Involve patients as another layer of Swiss cheese. Ask them to be on the lookout for mistakes. And maybe Stop ‘looking after’ patients and start ‘partnering with’.

Direct download: Putting_the_Patient_into_Patient_Safety_Victoria_Brazil.mp3
Category:general -- posted at: 6:30am AEST

In this talk from SMACC Chicago 2015, Larry Chu takes a step back from the clinical side of things to discuss Innovating Medical Education. 

Dr Larry Chu is an Associate Professor of Anaesthesiology and the Executive Director of Stanford Medicine X.  Medicine X is an initiative from the Stanford AIM lab. It is a project aimed at promoting new ideas for the future of medicine, healthcare and education using emerging technologies. It focuses on empowering patients to participated in their own healthcare and improving medical education and training to focus more on patient-centered medicine.

Each year, Medicine X holds a conference in which they explore theses themes. In 2015 the team from Stanford held a spin-off conference called Medicine X Ed. This conference focused on the future of medical education and the role of technology in educational innovation as well as continuing the theme of the changes that are fundamental for establishing more patient-focused health care.  This conference was held in September 2015. At SMACC Chicago, Larry Chu shared a sneak-peak into some of the exciting medical education innovations that were going to be explored at Medicine X Edu.

During his talk, Larry Chu shared insights into why traditional teaching methods don’t work for millennials aka gen Y, the successful educational programs being used in the US for their anaesthetics trainees and new ideas for structuring  the delivery of effective medical education.

For all trainees, in particular those with impending exams, and for all teachers/lecturers/educators this is an interesting and thought provoking lecture to listen to! Yet again proving why SMACC is the most dynamic, well rounded, original conference around! 

Direct download: Day_1_C3_Larry_Chu.aup
Category:general -- posted at: 6:00am AEST

What is the problem?
Delivering bad news and having an end of life conversation are core skills for any practitioner who deals with critically ill patients. Current data show that while 22% of deaths in the USA now occur in ICU, 54% of families surveyed have a poor understanding of patient’s diagnosis, treatment plan and prognosis. Dr. Kate Granger found this out first hand while admitted to hospital in the UK and started the #hellomynameis campaign.

What is the evidence?
While families feel more validated if given longer to speak, doctors speak for 71% of the time in family meetings. -Longer meetings are also associated with greater patient and family member satisfaction. -Patients perceive that doctors spend longer with them if the doctor is sitting down. -Use of a simple mnemonic increases satisfaction and reduced the incidence of PTSD in family members.

What do experts do?
1. Prepare for the meeting. Decide who will attend, what you will talk about and what your goals are.
2. Introduce everyone and explain the agenda.
3. Gather everyone’s understanding
4. Listen and don’t interrupt
5. Empathise (physicians express no empathy in 1/3 of family meetings)
6. Make the patient’s voice heard
7. Make your recommendation to go forward
8. Reflect on the meeting after it concludes

What about the difficult situations?
Hope is an issue that comes up often. Many other specialties emphasise the importance of hope, while intensivists are often seen as being nihilistic. But we can still foster a degree of hope in patients and families without being unrealistic. -Techniques for managing conflict are discussed such as identifying discord in the family and avoiding mixed messages from staff. -The importance of spirituality is discussed.

Direct download: David_Anderson_-_Breaking_Bad_News.mp3
Category:general -- posted at: 6:30am AEST

Pain in children is often under treated due to practitioners lacking the knowledge or confidence to be aggressive enough. This is partly due to the lack of structure presented in pain managment and it is frequently made to seem more complex than it is.

Almost all acute pain in children can be dealt with by a simple stepwise regime using a small number of common, established and easy to use drugs.

Likewise, procedural sedation can be safely and simply performed with simple regimes.

Direct download: Child_in_painGreg_Kelly.mp3
Category:general -- posted at: 6:00am AEST