SMACC

Daniel Kornhall's is an introduction to snow avalanche physiology and the realities of mountain rescue.

Dying in an avalanche is an extremely rare cause of death but for us who live in mountain regions and who enjoy winter mountain sports it is a thing that needs to be dealt with. The overall mortality in avalanche incidents is roughly 20% but this increases to 50% in the buried victims, which is why my talk, and most avalanche medicine, focuses on the buried victims. Asphyxia causes the vast majority of deaths, accounting for roughly 80% with trauma in second place at 20%. Hypothermia as the primary cause of death in avalanche victims is extremely uncommon. Asphyxiation causes a dramatic plunge in survival from 80% down to 30% within the first half our of avalanche burial. This is why timely location and extrication of the victim is of vital importance.

Kornhall explains why organised rescue service rarely, if ever, manage to get to the victim within this critical asphyxia phase. Survival rather depends on immediate bystander or companion rescue. Extrication times can be reduced by being properly equipped with avalanche transceivers, quality snow shovels and avalanche probes.

Kornhall briefly discusses the avalanche airbag, a fairly recent innovation that may reduce the likelihood of being buried if you get avalanched. In the last part of my talk i describe modern extrication techniques and how implementing these into rescue training dramatically improves extrication times. 

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

Two legends of medical education, doctors Johnathan Sherbino and Robert Cooney go head to head debating whether assessment is a barrier to learning. Sherbino argues that assessment is in fact a first essential step in the learning process.

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

TBA

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

Making Teams Work - Chris Hicks

In Chris Hicks talk Making Teams work, Hicks discusses the systematic failures in training ourselves and our trainees for chaotic situations. He challenges the assumptions that people learn over time by osmosis (by just watching) and debunks the idea that by watching physicians will become skilled at soft non-technical skills.
 
Hicks goes on to discuss what makes a high performing team - touching on; 
  • Shared mental model of team and task. 
  • Implicit co-ordination/communication
  • And, how to create this in an ad hoc team.  
 
Hicks then discusses emergency specific team training and the results they are seeing by implementing programs such as; CREW Training - Crisis Resources Emergency Workers, Stress Inoculation Training and Mental Simulation Training. Hicks finished by explaining how best physicians and medical staff can implement these trainings and skills into the real world practice. 
Direct download: Chris_Hicks_-_Making_Teams_Work.mp3
Category:general -- posted at: 5:00am AEDT

TBA

Direct download: Day_3_C28_Mark_Crislip.mp3
Category:general -- posted at: 6:30am AEDT

Rapid response systems (RRSs) have become a routine part of the way patients are managed in general wards of acute care hospitals. They have been adopted by national health and safety organisations in North America, Canada, the United Kingdom and Australia and are increasingly being used in other parts of the world.

Studies have almost universally shown significant reductions in outcome indicators such as mortality (up to one third) and cardiac arrest rates (up to 50%). However the validity of these outcomes is questionable as most of these studies are single-centre, before-and-after studies conducted by one or two clinical champions in Rapid Response.

This presentation reveals that the implementation of an Intensivist led Rapid Response Team in an Australian quaternary hospital did not demonstrate such dramatic results. In fact, after one year of service the standardised mortality ratio and the in-hospital cardiac arrest rate remained similar.

The presentation explores some of the operational impacts of a RRS including the replacement of critical thinking with reliance on protocols and the progressive super-specialisation of medical teams. Despite these impacts and relatively static patient outcome data, the service has rapidly become an integral part of the hospital.

Barriers between Intensive Care and ward staff have broken down and quality outcome results have consistently shown ward nurses and doctors feel better prepared, educated and supported in managing clinical deterioration. These surprising results raise the question; should we place more value in quality outcomes?

Direct download: Day_2_C13_Sarah_Webb.mp3
Category:general -- posted at: 1:30pm AEDT


Poisons and novel agents are a moving target in the clinical arena. This talk begins with a historical look at decontamination and pitfalls that have been discovered along the way. The advent of intubation and critical care was a major boon in the improvement in mortality from poisoning. The Scandinavian Method is described and is an important lesion to this day. The rise of antidotes is mentioned.

 

Emerging drugs are highlighted in the context of where we have come from. The phenylethylamine compound structure and corresponding variants are described. The importance of the principles of supportive care as learned in the Scandinavian method is emphasized. Other emerging topics including synthetic cannabinoids, and anti-NMDA receptor antagonists are discussed. Emerging interventions of prescription naloxone, and ED ECMO are outlined. High vigilance for new agents, and innovative treatments will enable clinicians deal with these evolving trends.

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

Is There a Doctor on the Plane?

Summary by: Joe Lex

How Common Are In-Flight Emergencies?
• Occur on one in every 600 flights
• 44,000 of 2.75B airline passengers / year

What Are Most Common Emergencies
• Lightheadedness or fainting ~37%
• Respiratory problems ~12%
• Nausea or vomiting ~10%
• Cardiac symptoms ~8%
• Seizures ~6%
• Other Emergencies
• Laceration ~0.3%
• Cardiac arrest ~0.3%
• Ear pain ~0.4%
• Obstetrical or gynecological symptoms ~0.5%
• Headache ~1%

Who Responds to the Call?
• Physician passenger responds in ~48%
• Nurse passenger responds in ~20%
• EMT passenger responds in ~5%

Minimum first aid kits on commercial airliners
16 Adhesive bandage compressors, 1 in
20 Antiseptic Swabs
10 Ammonia Inhalants
8 Bandage compressors, 4 in
5 Triangular bandage compressors, 40 in
1 Arm splint, non inflatable
1 Leg splint, non inflatable
4 Roller bandage, 4 in
2 Adhesive tape, 1 in standard roll
1 Bandage Scissors
2 Protective latex gloves pair
2 Insect sting relief pad
2 Triple antibiotic ointment
2 First Aid/burn cream, 9 gm.
2 Povidone iodine infection control wipes
2 Alcohol cleansing pads
2 Gauze dressing pad 2" x 2" in
2 Motion Sickness Tab
4 Ibuprofen tablets
4 Non Aspirin Tablets
2 Sunscreen lotion towelette
2 Trauma pads 5 x 9 in (12,7 x 22,8 cm)
1 Survival rescue blanket
1 Pelican case 1170 waterproof
1 Emergency first aid guide (American Red Cross)

Required medications on flights
• Antihistamine – tablets and injectable
• Atropine 0.5 mg injectable
• Aspirin tablets 325mg
• Bronchodilator MDI
• Dextrose 50% injectable
• Epinephrine 1:1000 and 1:10,000
• Nitroglycerin tablets
• Lidocaine injectable
• IV needle
• 500ml Saline injectable

All crewmembers are trained for common emergencies. For each flight attendant
¥ Instruction to include performance drills in the proper use of automated external defibrillators
¥ Instruction to include performance drills in cardiopulmonary resuscitation
¥ Recurrent training … at least once eve

Direct download: Day_1_C10_Joe_Lex.mp3
Category:general -- posted at: 9:14am AEDT

Don't Forget A & B!

Over 500,000 patients per year suffer sudden cardiac arrest. Despite advances in our understanding and management of cardiac arrest, less than 15% of patients survive to hospital discharge with meaningful neurologic survival. In recent years, the focus of cardiac arrest resuscitation has been the delivery of high-quality chest compressions and early defibrillation for those with a shockable rhythm. As a result, airway interventions and ventilation now follow attempts to optimize circulation in cardiac arrest patients. Though high-quality CPR and early defibrillation are essential in the initial stages of resuscitation, advanced airway placement and appropriate ventilation are critical to overall patient survival.

Dr. Winters' discusses the current literature on the timing of advanced airway placement, oxygenation, and ventilation for the cardiac arrest patient. In addition, he discusses optimal targets for oxygenation and ventilation in the patient with return of spontaneous circulation from sudden cardiac arrest.

Direct download: Day_2_C13_Mike_Winters.mp3
Category:general -- posted at: 5:30am AEDT

Lisa McQueen - Pearl or Fecalith?

Summary by: Lisa McQueen

I’ve long been a fan of David Newman’s “Pseudoaxioms,” those medical proclamations handed down from generation to generation despite growing evidence that they are false. In this talk, I turn a critical eye toward common pseudoaxioms in pediatrics. Does aspirin really cause Reye syndrome? Should you routinely use atropine in preparation for neonatal intubation? Join me in an exploration of these and other pseudoaxioms. I may even debunk the notion that “children are not just little adults.”

Direct download: LiSa_McQueen.mp3
Category:general -- posted at: 1:30am AEDT

ECMO or extracorporeal membrane oxygenation has shown promise in the use of cardiac arrest patients. Zack Shinar and his crew from San Diego have lead the way in emergency physician initiated ECMO for patients in cardiac arrest.

In this lecture he explains briefly how ECMO works, what their outcomes have been and where ECMO is moving. Initially 5 of their first 8 patients were neurologically intact survivors. Their first patient had over an hour of downtime when cardiac bypass was initiated. He walked out of the hospital completely neurologically intact nine days later and now has been featured on the film “Code Black”. Physicians from their hospital, Sharp Memorial, were also recently featured on the television show “Untold Stories in the ER” for a save of a 21 year old female arresting from hyperkalemia. Dr. Shinar also discusses some of the latest physiologic questions as the Australians have pushed for smaller diameter catheters that allow for smaller flow volumes.

He also discusses how in Paris pre-hospital ECMO is being done by physicians in various places like the subway, apartment buildings and even the Louvre.

In the end, Dr. Shinar discusses the biggest question in any novel resuscitation technique: cost. Prolongation of life and particularly after a cardiac arrest is expensive and many people do not survive.

Dr. Shinar uses various pioneers in the world of technology to tell how true genius is not in technologic advancements but in making those advancements available to the masses. He ends with a story about Linus Torvalds. Dr. Shinar shows how this man through the use of the collective minds of computer programmers worldwide created one of the best operating systems ever created: Linux. He asks the medical community to endorse this idea and introduces the concept of “free open access medical innovation”.

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

Goodbye GCS!

Summary by: Mark Wilson

Consciousness comprises “wakefulness” (that’s the brain stem, opening your eyes component) and “content” (that’s the supratentorial, thinking, “someone’s home” component). You can have wakefulness without content (e.g. persistent vegetative state) but not content without wakefulness.

Describing a “level” of consciousness, converting this multifaceted human brain ability into a linear scale was possibly the biggest neuroscience break through of the 20th Century. The 1974 Lancet paper in which Brian Jennet and Sir Graham Teasdale proposed the Glasgow Coma Scale (GCS) is certainly the most cited neuroscience paper. We had even put a man on the moon before this had been created. It’s relative simplicity and repeatability meant GCS was rapidly taken up across the world. Now 40 years on, is it out of date?

There are problems with the GCS – it doesn’t include pupil response, it doesn’t look at ventilation or other autonomic functions hence other systems such as the 4 score system have been proposed. But these take longer, and are poorly known so cannot be used like GCS to rapidly convey in a meaningful way the level of consciousness of a patient between clinicians.

In this talk Mark Wilson goes through the history of the GCS and other conscious measures… is it time to say Goodbye to GCS?

 

Direct download: Day_3_C23_Mark_Wilson.mp3
Category:general -- posted at: 6:00am AEDT

One of the many things that we, as intensivists or emergency physicians, do better than anyone in the business is obtain the emergent airway. We are usually introduced to our patients on the worst days of their lives and even though we may sometimes wish for it, we do not have the option to reschedule our intubations. Smashed, bloody, distorted, edematous airways secondary to trauma, anaphylaxis, and GI bleeds are the commonality not the exception. We manage those airways routinely with nary a complaint or even a hither for a better look at the glottis than what we can obtain. We often feel lucky to even get a glimpse of the arytenoids much less something that actually resembles normal laryngeal anatomy.

Personally, if I knew that I would need to be intubated today, that my airway would be a bloody, edematous, traumatic mess and there was only chance for one person to take a shot at placing the tube, then I would pray to God that the last face I saw before the Roc and Ketamine pushed me asunder was the familiar grill of one of my EM/critical care colleagues. Who better to bet all my chips on then someone who deals with the most difficult airways on the face of the planet as part of their daily routine?

The EM doc or critical care provider can not only get that airway, but is so relaxed about it that they will often casually check on the patient in the next bed before and after the intubation. That’s the confidence I’m looking for when it comes to the fast-paced life and death world of emergency airway. Now put a child’s life on the line. Are you ready to intubate what was a perfectly healthy three year old two hours before trauma threatened their life and placed their airway in your hands? You will be...

Andrew Sloas DO, RDMS, FACEP, FAAEM, FAAP Editor-in-Chief: The PEM ED Podcast www.pemed.org

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

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