SMACC

Tom Bleck - Subarachnoid haemorrhage: what matters?

Tom Bleck gives an overview of the pertinent facts regarding the complications and management of aneurysmal subarachnoid haemorrhage (SAH).

The complications of aneurysmal SAH can be divided into immediate, early and late. The risk of re-bleeding is maximal on the first day, it is fatal in 75% of patients and the best management is to secure the aneurysm by coiling or clipping. Blood pressure control is utilised widely but parameters are arbitrary and the data is scarce.

Early complications (days 1 - 3) include early brain injury in its various forms, stress cardiomyopathy, neurogenic pulmonary oedema and cerebral salt wasting. The most important late complication (day 4 onwards) is vasospasm.

Tom briefly discusses the mechanisms and manifestations of SAH-associated brain injury including ischaemia, blood brain barrier breakdown, sustained depolarisation, hydrocephalus, vasospasm, seizures, hyperglycaemia and fever. He goes on to discuss in more detail the management of vasospasm, the associated evidence and the importance of distinguishing between clinically detectable and subclinical vasospasm.

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

Dr. Brian Burns of Sydney HEMS, facilitates a global discussion on blunt abdomino-pelvic trauma 30 minutes away from ED, leading this incredible panel of experts on a hypothetical trauma case. Participants include: Dr Gareth Grier, Dr Howie Mell, Dr Thomas Dolven, Derek Sifford, NREMT-P, Dr Clare Richmond.

 

Direct download: Trauma_Panel_22Hole_in_the_Bucket22-2.mp3
Category:general -- posted at: 1:00pm AEST

Veteran Airforce Pararescueman turned critical care paramedic, Mike Lauria discusses the

Direct download: Mike_Lauria-_Pre_Hospital_CRM.mp3
Category:general -- posted at: 12:00pm AEST

Rob MacSweeney and Paul Marik debate whether the assessment of fluid responsiveness in the resuscitation of patients with shock a waste of time? Both Marik and MacSweeney agree that many of the traditional methods of assessing patients volume status are flawed and of no value. Marik goes on to argue that the only clinically meaningful outcome that we should measure in response to a fluid challenge is Stoke Volume. In at least 50% of patients there is no improvement in stroke volume and further treatment with fluid boluses will only likely cause harm. Marik goes on to argue that we must know where our patients are position on their Frank-Starling curve to predict whether they are fluid responsive and we can assess this with passive led raise.

Direct download: Cage_Match_3.mp3
Category:general -- posted at: 5:00am AEST

Pretty much everything I learned as a resident in terms of the sequencing of airway management in ED has changed over the past 15 years. No longer is there simply RSI or stick a laryngoscope in with nothing and use pure brute force to intubate a patient; we have a host of different options and pathways when approaching airway management in the emergency department.

 

This lecture discusses some of these updated ways of getting from a sick patient requiring airway management to a tube between the cords…with only minor technical mishaps.

Direct download: Scott_Weiggart_Emergency_intubation_Resquence.mp3
Category:general -- posted at: 1:30pm AEST

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 AEST

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 AEST

TBA

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

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 AEST

TBA

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

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 AEST


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 AEST

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 AEST

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 AEST

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 AEST

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 AEST

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 AEST

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 AEST

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

Advances in understanding the cardiopulmonary physiology during CPR, perfusion and reperfusion of the brain, and advancing technologies have made possible directed and customised resuscitation of cardiac arrest. We will present where current CPR fails, and what it may look like in the future.

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

Phil Hyde vs Greg Kelly - We Should Perform Therapeutic Hypothermia (T32– 34C) for Children After Cardiac Arrest

The recent publication of THAPCA-OH filled an important gap in our knowledge. THAPCA does not support cooling children after cardiac arrest which was a common practice until recently in many units. It is illustrative to look at how a practice became routine with no supporting evidence at it raises questions about what questions we ask and how we operate in the absence of good evidence.


Working in a remote hospital often means working without the aid of formal medical imaging or Labs. So does this mean that we must compromise on our patient’s care? No.

Bedside Ultrasound has changed the way I diagnose, treat and care for patients in this paradigm.This talk will explore the utility and a practical approach to bedside sonography for range of clinical situations: trauma, fracture management, sepsis diagnosis and resuscitation, Paediatric fever and bowel obstruction – all without X-rays.

Ultrasound can allow us to provide faster, more accurate and compassionate care – regardless of where you work.

Direct download: Casey_Parker_-_No_X_ray_No_Problem.mp3
Category:general -- posted at: 1:30pm AEST

Preparing your hospital for a disaster

Sara Gray Synopsis: This talk will highlight essential components of hospital-based disaster planning.

We will discuss tips for planning training exercises, getting funding, and effective debriefing. Preparedness really matters, find out why!


Objectives:1.
Discuss essential components of a disaster plana.All hazardsb.IMS structures. Should your plan be long or short?
2.Talk about training exercisesa.Low fidelity versus high fidelity exercises.Getting funding
3.Review why debriefing mattersReferences and Links1.Canada’s national preparedness site, pitched mostly to individuals http://www.getprepared.gc.ca/index-eng.aspx
2.Ontario’s Emergency Management Office site includes some training tools and resources for organizationshttp://www.emergencymanagementontario.ca/english/home.html
3. The CDC Emergency Preparedness Site http://emergency.cdc.gov/hazards-all.asp
4. FEMA’s site has some good resources for organizations.
Also has an interesting text message program about hurricanes and other natural disasters, where people can sign up for text updates about local disasters. https://www.fema.gov/
5. A good site for improving debriefing skills: http://thoughtleaderzone.com/2013/03/11-questions-and-prompts-for-insightful-debriefing-sessions/

Direct download: Day_3_C27_Sara_Gray.mp3
Category:audio -- posted at: 6:00am AEST

Improved patient outcomes as the goal of training. With this philosophy in mind, Bill Hinkley shares his three pillars of training; train yourself, train as a team, train others.

Advice from an inspiring educator on how to build a personal learning network, tips on training as a team and how influential passionate educators are to teaching others.

Direct download: Bill_Hinckley-_The_Right_Stuff-_Training_in_PHARM.mp3
Category:audio -- posted at: 6:00am AEST

Sonowars continues to find new ways to make Ultrasound teaching exciting, inspirational and most importantly informative. The team of James Rippey, Matt Dawson, Mike Mallin and Andrian Goudie are back with an all-star supporting cast. Keep an eye out for the light sabre, simulating ultrasound guided venous canulation as well as the mechanical bull ultrasound challenge. Things are bound to get a little crazy when these guys get fired up.

Direct download: SONOWARS2015.mp3
Category:general -- posted at: 6:00am AEST

The host response to injury is inflammation.

The inflammatory response may have been naturally selected over millions of years of evolution to give the injured tissue the best chance of healing and recovering. On the other hand, over the last 50 years animal models of traumatic brain injury (TBI) suggest that fever, occurring as part of the inflammatory response, may be harmful to neuronal recovery. Some observational clinical studies support this. However we lack high quality clinical trials.At present clinicians commonly use drugs and physical cooling techniques to suppress fever after TBI and stroke.

These approaches have costs and can be resource intensive, as well as be associated with side-effects. We will share with you some of the results from our program in this area. We will discuss ...

What is normothermia?

How effective are the interventions we use?

What temperature do/should we target? What do we achieve?

Surely we need a reliable answer to the question of whether the strict maintenance of normothermia (36-37°C) reduces disability and death after TBI?

References1.Saxena M, Andrews PJ, Cheng A, Deol K, Hammond N. Modest cooling therapies (35ºC to 37.5ºC) for traumatic brain injury. Cochrane Database of Systematic Reviews 2014.2.Saxena M, Young P, Pilcher D, et al. Early temperature and mortality in critically ill patients with acute neurological diseases: trauma and stroke differ from infection. Intensive Care Med 2015:1-10.3.Young P, Saxena MK, Beasley CRW, et al. Early peak temperature and mortality in critically ill patients with or without infection. Intensive Care Med 2011;38:437-44.4.Saxena MK, Taylor CB, Hammond NE, et al. Temperature management in patients with acute neurological lesions: an Australian and New Zealand point prevalence study. Crit Care Reusc 2013;15:110-8.5.Saxena MK, Taylor C, Hammond N, et al. A Multi-Centre Audit of Temperature Patterns After Traumatic Brain Injury. . Crit Care Reusc 2015 (June);17:129-34.

Direct download: Manoj_Saxena_-_Temperature_and_TBI-_Time_for_PARITY.mp3
Category:general -- posted at: 6:30am AEST

Making Transitions of Care Safe - Pat Croskerry

Summary by: Pat Croskerry

It is now well recognized that transferring the care of a patient from one caregiver to another is a vulnerable point in a patient’s care and a potential threat to patient safety. There may be many intra-disciplinary and inter-disciplinary transition points in the ED during an individual patient’s care. The process requires that each participant communicates well with others to establish an accurate shared mental representation of the important issues.

To minimize transition failures, the process should be trained and standardized, recognized as a multi-professional activity, defined by who should be present, where and when it should occur, and have an end-point that is a clear plan for the ongoing care of the patient. The reliability, consistency, and efficacy of the transition should be a hallmark of departmental culture.


Training should be provided in how the process works and how it fails. The broad distinction between the transfer of poor information (unwarranted opinions, stereotyping, stigmatization, gratuitous comments, overconfidence, and other cognitive biases) and poor transfer of information (unstructured, casual setting, rushed/fatigued, interruptions/distractions, limited input from others, verbal only, degraded narrative skills) should be recognized. It is important to reliably express the amount of certainty attached to what is actually known at transfer so that recipients clearly understand what is expected of them.


The vulnerability of human memory should be recognized and strategies used to deal with it (SBAR, I-PASS and others). There should be awareness of particular biases in communication at transition time. Serial position effects describe how primacy (information presented at the beginning) and recency (the last information to be presented) may influence what is perceived and retained. It is important to be aware of specific biases that operate at transition time: framing, fundamental attribution error, search satisficing and others) and consider strategies to mitigate them.

 

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

The master of Dogmalysis himself, Cliff Reid, challenges current practices in prehospital and emergency medicine. Warning listeners to be skeptical, Cliff dissects the dogma of acute crush injuries and spinal immobilization. He also explores the false dichotomy of “scoop and run vs. stay and play”. Cliff reminds us that “not to challenge current practice is intellectually lazy”.

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

Kevin Fong is an astrophysicist, astronaut and anaesthetist who gives an incredibly entertaining talk about human space exploration and our dreams of a manned mission to MARS. This is a mission that stands on the boundary between science fiction and science fact. A mission that would be a minimum of 1000 days in length and which would be twice as long as any previous manned space mission.

Fong focuses on the the incredibly destructive effects of such prolonged weightlessness on the human body. He outlines the somewhat predictable effects of this on the muscles and bones, but surprises us with the changes in vestibular balance, linear acceleronomy, baroreceptor calibration and probably most frighteningly the psychological effects of prolonged isolation in space. Despite considerable work in the area of human adaptation for space and the ongoing development of counter-measures these physiological challenges remain largely unsolved.

In essence Fong explains, to overcome the detrimental physiological effects of prolonged weightlessness engineers need to design a craft capeable of generating 1G of gravitational force to mimick earth's gravity. This could require a craft the size of the London EYE rotating four times per minute. Perhaps if this can be achieved, astronauts might arrive at MARS after 30 months in space in a physcial state capeable of allowing them to stand upright and walk from the landing craft.

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

A pair of outrageously high heels next to a pair of tattered combat boots, set the stage for Ashley’s talk on the stress of PHARM.

Ashley draws on lessons learned in combat to support her theory of mental health survival. She emphasizes the importance of critical incident recognition, response and elimination of stigma associated with seeking help.

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

Bouncing Back from the Beach – Cutting to Air to secure an Emergency Surgical Airway

Summary by: Thomas Dolven

To handle airways means being prepared to handle them all the way. You need to be prepared for a cannot intubate cannot oxygenate CICO scenario. The common, final end point of airway management in a is the emergency surgical airway, the cricothyroidotomy.

So how to prepare?
Often, it is not being taught right. This is a rare procedure under high stress and time sensitive. And most importantly, it is a bloody procedure that will be blind. You cannot use your eyes. So it needs a simple technique without fine motor skills, and it must be tactile. Your finger is the perfect tool for this task, and will guide you through it. The video of my personal real world experience is backed by available empirical evidence and lab training. There will never be an RCT, this is the best evidence we will have. So read NAPP4 and the case series article on the scalpel-finger-tube technique.

Read these available articles, train, and remember these two key points:
1) There will be blood. But that’s OK, because.
2) Your finger can see.


Tox-Dogmalysis is a talk about evidence in Toxicology. It’s been said that 50% of what we learn is incorrect; we just don’t know which 50%. As the complexity of medicine increases, it is of the utmost importance for clinicians to be skeptical of old data and new data alike.

Many in the FOAM community have made huge strides in busting myths that have persisted over time.

However, sometimes we may declare myths busted too prematurely based on incomplete or misunderstood data. This talk will explore three topics in toxicology for which the perceived myths may actually be true, or at least not completely busted.

Direct download: Day_1_C5_Bryan_Hayes.mp3
Category:general -- posted at: 6:30am AEST

Fluids in Critical Care: Time to SPLIT With Normal Saline?

Summary by: Paul Young

Intravenous fluid therapy is a ubiquitous treatment for critically ill patients and has been used in clinical practice for over 175 years. Despite this long history, the majority of intravenous fluids have not been subjected to the same level of scrutiny as other drugs. That said, large-scale fluid trials evaluating albumin and starch solutions compared to 0.9% saline have been conducted and their results have changed clinical practice around the world so that crystalloid fluid therapy is now predominant in many parts of the world.

While 0.9% saline is the world’s most commonly prescribed crystalloid fluid, increasingly clinicians are turning to buffered or balanced crystalloid solutions as an alternative to 0.9% saline. This practice change from 0.9% saline towards balanced crystalloids is not based on high quality evidence but is supported by observational data suggesting that saline may be associated with an increased risk of renal toxicity and mortality compared to buffered crystalloids.

This talk gives an overview of the data comparing the comparative effectiveness of 0.9% saline and buffered crystalloids, provides an overview of the historical context of intravenous fluid therapy (and proctoclysis), and describes the design of the Saline vs. Plasma-Lyte 148® for Intravenous fluid Therapy (SPLIT) trial which has now been completed and was recently published in the Journal of the American Medical Association.

External Links
• [The Bottom line] SPLIT trial reviewed
• [article] Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit The SPLIT Randomized Clinical Trial
• [editorial] Editorial accompanying paper
• [videocast] Presentation of SPLIT trial at ESICM by Dr Paul Young
• [Further reading] Association Between a Chloride-Liberal vs Chloride-Restrictive Intravenous Fluid Administration Strategy and Kidney Injury in Critically Ill Adults
• [St Emlyn's] SPLIT trial published. Saline or Plasmalyte on the ICU?

Direct download: Paul_Young_-_Fluids_in_Critical_Care-_Time_to_SPLIT_With_Normal_Saline.mp3
Category:general -- posted at: 6:00am AEST

Mark Wilson hosts an all-star cast!
Summary By: Mark Wilson

Traumatic brain injury (TBI) is a hugely important topic in critical care. It is a major cause of morbidity and mortality throughout the world with hospital presentations totaling over 2million in the US, 1 million in the UK and 700,000 in Australia each year. Not only do they represent a huge proportion of injuries, but they are a unique in their potential to fundamentally change “who a person is”. As critical care and trauma practitioners there are many aspects of management that can change outcomes for patients in the short and long term.

Dr Mark Wilson (@MarkHWilson) is a neurosurgeon and doctor for the Air Ambulance in the UK. In this session from SMACC Chicago entitled “It’s a Knockout”, he expertly leads a discussion which holds a magnifying glass to the current practice guidelines for managing TBI as taught in ATLS.  On the discussion panel is a star-studded international cast including: Pierre Janin, Andrew Dixon (@DrAndrewDixon), Karim Brohi (@karimbrohi), Karel Harbig (@karelharbig), Deb Stein, Michael McGonigal, Bill Knight, John Hinds and Ralph the Janitor (who looks remarkably like Cliff Reid @cliffreid).

In this discussion forum, international specialists from the fields of neurosurgery, intensive care, trauma surgery, emergency medicine and radiology engage in a discussion of the step-by-step management of a real case of a patient with a head injury. This discussion highlights the many management controversies including how to manage the c-spine, whether or not to oxygenate, whether or not to intubate, when to extubate, if and how to sedate the patient, when to CT and how to monitor the head injured patient. In typical SMACC style this discussion demonstrates the approach to the management of a patient from different vantage points and demonstrates why it is so difficult to come to a consensus of the approach to this type of injury.

Panelists delve into the features of TBI that you won’t find in textbooks including impact brain apnoea, multi-compartment syndrome and more. Watch out for the a segue into the Good Sam Appa smartphone app which alerts registered medically trained personnel to nearby emergencies to minimize downtime when medical emergencies occur.

This forum has everything you have come to love and expect from SMACC including international experts, heated debates, controversial #hashtags, guest speakers and more!

Direct download: Its_a_Knockout_.mp3
Category:general -- posted at: 9:30am AEST

Summary by: Paul Young

The febrile response to infection occurs in most animals and is regulated by a common biochemical mechanism involving prostaglandin E2. This common mechanism suggests that the response may have evolved in a common ancestor more than 350 million years ago. As the febrile response comes at a significant metabolic cost, its persistence across a broad range of species provides circumstantial evidence that the response has some evolutionary advantage. Furthermore, it logically follows that the components of the immune system would have evolved to function optimally in the physiological febrile range.

There are a number of historical examples of dramatic responses to treatment with therapeutic hyperthermia in some infectious diseases, including neurosyphilis and malaria. The relevance of these historical examples to the modern era is unclear. Furthermore, arguments based on the evolutionary importance of the febrile response do not necessarily apply to critically ill patients who are, by definition, supported beyond the limits of normal physiological homeostasis. Humans are not adapted to critical illness. In the absence of modern medicine and Intensive Care, most critically ill patients with fever and infection would presumably die. Among critically ill patients, it seems likely that there is a balance to be struck between the potential benefits of reducing metabolic rate that come with fever control and the potential risks of a deleterious effect on host defence mechanisms. Where this balance lies is very unclear as there are very few interventional studies of fever management in critically patients.

Remarkably, although paracetamol is very widely used in ICU patients with fever and infection, only one RCT, the HEAT trial, has investigated the safety and efficacy of administering paracetamol to critically ill patients with fever and infection. This talk gives the background to the HEAT trial which has now been published in the New England Journal of Medicine.

Links

• [The Bottom line] HEAT trial reviewed
• [NEJM article] Acetaminophen for Fever in Critically Ill Patients with Suspected Infection
• [NEJM supplement] Supplementary reading • [podcast] Paracetamol improves recovery in critically ill patients. Radio interview with Paul Young
• [other studies] Paracetamol therapy and outcome of critically ill patients: a multicenter retrospective observational study


What is it that enables some physicians to step into a high pressure situation with poise, presence, and consistently perform to their capabilities?

What else is there beyond technical knowledge and clinical skill that can be developed to help immunize the person that is a physician from some of the more human challenges that can present?

In a field so ripe with immense performance pressures, demands, and expectations what are those people doing who seem to thrive amidst it all?

In this session you will be introduced to a variety of strategies rooted in the principles of performance psychology, and their application in high-pressure performance environments such as medicine. Learn how the top performers I have observed through my extensive collaborations with physicians, and others in high-pressure fields (e.g. elite athletes, business leaders and military/tactical officers) have come to gain efficiencies in how they focus, stay perceptive, maintain equanimity, process their experiences, create and sustain an optimal “feel” in their work and ultimately, perform to their potential when it matters most.

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

Kevin Fong is an astrophysicist, astronaut and anaesthetist with an interest in medical error and safety. In this talk he focuses on lessons learnt from his time at NASA which can be applied to medical practice. Fong believes that key to safer practice is in the collection of accurate data. He outlines some aspects of the famous communications between Sully Sullenberger (pilot) and the Le Gardia air-traffic control tower as Sullenberger miraculously lands a commercial airline on New York's Hudson River - Fong's point is not in the words said or in the calmness of the communications, but that we can go back and analyse every word spoken because the data is collected so accurately. 

He goes on to discuss some of the failures surrounding both the Space Shuttle Challenger and Columbia accident's. More importantly he stresses not so much the lessons learnt but the lessons forgotten and the need to ensure organisational memory. We only protect ourselves and our patients through technology and the systems of operation we create.

Direct download: Day_3_Safety_Lessons_from_Space_Kevin_Fong.mp3
Category:general -- posted at: 8:30am AEST

 

Is the care you deliver to critically ill patients in your ED the same as the care delivered in your ICU? And if not, why not?

Consider the challenges facing the delivery of excellent care in the ED, and be inspired to make changes at your hospital to improve your system. Learn ten strategies for optimizing the care of critically ill patients in your ED.

References:
1. Learn more about ED-ICU’s at Scott Weingart’s excellent site http://www.emcrit.org
2. Consider a resuscitation fellowship like this one: http://www.resuscitationinstitute.org/index.cfm/education/resuscitation-fellowship1/
3. There are zillions of articles about the benefits of simulation and training, here is a link to just one, if you only want to dip your toe in the water: http://qualitysafety.bmj.com/content/19/Suppl_2/i34.full
4. Audit and feedback around quality outcomes are a potential strategy. Read more about the pros and cons from the World Health Organization here: http://www.euro.who.int/en/data-and-evidence/evidence-informed-policy-making/publications/2010/using-audit-and-feedback-to-health-professionals-to-improve-the-quality-and-safety-of-health-care
Direct download: Day_2_C13_Sara_Gray.mp3
Category:general -- posted at: 8:30am AEST

When settings outside the hospital are taken into account (ED, primary care), the overall number must be considerably higher. While many factors contribute to diagnostic failure, a variety of sources suggest that physician’s thinking has a lot to do with it.

Dual Process Theory describes how the brain makes decisions in one of two modes: through fast, unconscious, intuitive processes (System 1) or through slower, conscious, analytical processes (System 2). Mental short-cuts (heuristics) and biases are predominantly located in the intuitive mode where we spend most of our conscious time, and this is where the majority of decision failures occur. Thinking straight essentially means achieving a good balance between System 1 and System 2 decision making, and much of our cognitive effort needs to go into monitoring what our unconscious brains are doing in System 1. This is referred to by a variety of terms: metacognition, reflection, mindfulness, and others. They all involve cognitive de-coupling from System 1 and characterize the process of cognitive de-biasing. This is not easily accomplished in the ED or any environment where decision density is often high, throughput pressure exists, resources may be limited, and where decision makers may be fatigued and/or sleep deprived.

While medicine has acquired a variety of strategies over the years for de-biasing clinicians, added benefits can be obtained by developing specific mindware to tackle particular biases. Clinicians need to be aware of the operating characteristics of the dual process model of decision making, of the prevalence and nature of biases, and of how to apply and sustain de-biasing mindware in their decision making.

Direct download: How_to_Think_Straight-Pat_Croskerry.mp3
Category:general -- posted at: 8:30am AEST

The human circulation is a complex system that has evolved over millenia, primarily designed to promptly respond to conditions of stress - the fight and flight response. The traditional physiological approach focuses on the heart as a pump, adapting to changes in volume and metabolic states.

These principles are underpinned by the Starling equation and incorporated into an adaptation of Ohm\'s law. These principles have been maladapted, punctuated by an increasing reliance on surrogate and derived variables that have little to do with teleological haemodyanamic responses.Insights into the central role of the autonomic nervous system are provided by Guytonian theory that in part explain the physiological fallacy germane to many clinical protocols and practices.

These fallacies have been amplified by commercial studies directed at short-term physiological improvements that have little to do with patient-centred outcomes in the medium and longer term.Such effects have been demonstrated in recent high-quality RCTs that force a re-appraisal of seductive short-term physiologically-based gratification.

Direct download: Forgotten_Cardiovascular_Physiology_by_Myburgh.mp3
Category:general -- posted at: 8:30am AEST

The Force is strong with this one… Despite years of research and new technology, the adjusted mortality rate for traumatic brain injury remains near 25%. Currently, primary injury occurs before we can intervene, and all our pre-hospital, ED and ICU care is directed towards preventing remarkably complicated and poorly understood secondary injuries.

TBI is a heterogenous group of diseases often treated homogenously. You too can master the ways of the Force, by reviewing the Top 10 items you need to know to care for your next patient with a severe traumatic brain injury. Topics covered will include the most up to date evidence, anticoagulation reversal, early aggressive care, and future directions. Become a master of this complicated disease process in your clinical practice.

Direct download: 10_Things_you_Need_to_Know_about_TBI_by_Knight.mp3
Category:general -- posted at: 8:30am AEST

Neurologically intact recovery after out-of-hospital cardiac arrest remains dismal. In the United States, an 8% meaningful recovery rate is hopeful at best. The introduction of extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR) is not new but has been shown to provide upwards of 27-30% meaningful recovery, when applied to the appropriate patient population. In 2011 we began extracorporeal CPR (ECPR) in our emergency department - a suburban non-academic center in San Diego, California, USA; the results have been very promising. As a result, we also began refining all aspects of resuscitation. What specific things did we change about the way we do resuscitation?
Proper preparation of the resuscitation suite: If we assume the patient will end up on ECMO, then early femoral vessel access is the priority. Traditional paramedic offloading was problematic for many reasons. To address that we:
attempt transfer of the patient from medic gurney to hospital gurney in the ambulance bay, where there is more room.
When ‘CPR ala fresca’ isn’t possible, we bring the patient into the resuscitation room on the right side of the room, which allows the doctor accessing femoral vessels to be sterile-prepped with ultrasound in-hand.

Early femoral arterial transduction to guide the resuscitation
Hemodynamic-Directed Dosing of Epinephrine intra-arrest
Nurse Code-Team Leader: assign the rote elements of the code, the ACLS protocols, to a trained nurse code team leader. This provides physician cognitive offload.
Use a mechanical chest compression device

Use an Impedence Threshold Device:
increases venous return
decreases intracranial pressure (ICP)
increases coronary perfusion pressure (CPP)

Does any of this make a difference? Well, review of CARES data (U.S.-based cardiac arrest registry) shows that the 2014 arrest recovery rate, with meaningful neurologic outcome, at our hospital was almost double that of the nationwide data. And of the 50 patients included in the CARES database for our hospital, only 4 of those were resuscitated with ECPR. Perhaps we are just paying better attention and providing better overall care throughout the resuscitation. Perhaps we can all improve our resuscitation outcomes.

Direct download: Cutting_Edge_Resuscitation_in_the_Community_ED_Joe_Bellezzo.mp3
Category:general -- posted at: 12:30pm AEST

Reuben Strayer takes us through the myriad uses of Ketamine, and dispells some myths in the process. A Special K classic.

Direct download: Ketamine-_How_to_Use_it_Fearlessly_For_All_its_Indications_by_Strayer_OF.mp3
Category:general -- posted at: 11:24am AEST

Is Suspended Animation only in the realms of science fiction, or is this a realsitic treatment option? Mervyn Singer questions if we can prevent secondary reperfusion injury following cerbral ischaemia.

Direct download: singer.wav
Category:general -- posted at: 2:30pm AEST

In Coping with Isolation - All alone on Kangaroo Island, Tim talks with brutal honsety about the reality of being a rural doctor.

Direct download: 24_Leeuwenburg.mp3
Category:general -- posted at: 3:00am AEST

Oli Flower brings lessons from cage fighting that are relevant to all health care professionals. Be open minded about this one!

Direct download: 23Flower.mp3
Category:general -- posted at: 10:20pm AEST

Christine Bowles takes on the big issue of Sex in critical care. In 2015, why is sexual equality in the workplace even an issue and how can we address it?

Direct download: 21Bowles.mp3
Category:general -- posted at: 3:00am AEST

Roger Harris shows us just how complex decisions about resuscitation can be and when stopping can be the right thing to do.

Direct download: 19Harris.mp3
Category:general -- posted at: 3:00am AEST

Chris Nickson challenges us to examine lessons that are 150 years old

Direct download: 18Nickson.mp3
Category:general -- posted at: 3:00am AEST

ENT surgeon Georgie Harris takes you through a logical approach to managing the horrific scenario of a transcected airway

Direct download: 17harris.mp3
Category:general -- posted at: 3:00am AEST

Guess or Gestalt? by Simon Carley. The secret to being a great Emergency Physician lies in Skill, Knowledge and Clinical Acumen!

Direct download: 16Carley.mp3
Category:general -- posted at: 3:00am AEST

Failure is a fundamental part of learning, and growing. Michelle teaches us about failing better and the benefits and freedom this brings.

Direct download: 15Johnston.mp3
Category:general -- posted at: 3:00am AEST

Rob Orman drills down on what suicidal ideation really means and how you can tell if your patient really has it.

Direct download: 14Orman.mp3
Category:general -- posted at: 3:00am AEST

An all-star panel of world sepsis experts discuss the controversial areas. Expertly hosted by Scott Weingart and lubricated with on-stage alcohol.

Direct download: 13SEPSIS_SMACCDOWN.mp3
Category:general -- posted at: 7:00am AEST

Hemorrhage is the leading cause of preventable death following trauma. Deborah Stein talks REBOA - who, what and why...

Direct download: 12Stein.mp3
Category:general -- posted at: 2:00am AEST

Beating sepsis in Latin America is a serious challenge. Flavia Machado descibes the 5 major issues & how they're being tackled.

 

Direct download: 11_Machado.mp3
Category:general -- posted at: 2:00am AEST

Education Theory for the Clinician - Jonathan Sherbino will improve the quality and efficiency of how you teach.

Direct download: 10Sherbinoi.mp3
Category:general -- posted at: 2:00am AEST

Shreves shows palliative care providers how to re-align with their patients and provide the highest quality end-of-life experience.

Direct download: 09Shreves.mp3
Category:general -- posted at: 2:00am AEST

Karim Brohi on tranexamic acid in trauma. With the "TXA denier's handbook" laminated with sarcasm, Karim's talk is a must-hear.

Direct download: 08_Brohi.mp3
Category:general -- posted at: 2:00am AEST

Roger & Oli go through the latest information about registration for smaccDUB, discussing the program, workshops, student rego, the ticket release, why Dublin, other pre-confernece events, the social program and accommodation. See you in Dublin!

Direct download: smaccdub_registration_info.mp3
Category:audio -- posted at: 4:23pm AEST

The battle is on...who will win out? The heroic healthcare individual or the faceless safety checklist? Brindley takes saftey talks to a new level. A true SMACC highlight.

Direct download: 07_Brindley.mp3
Category:general -- posted at: 2:00am AEST

John Hinds shows us why he will be so dearly missed in this superb talk from SMACC Chicago. This is about resuscitative thoracotomy but really so much more.

Direct download: Hinds-_Crack_the_Chest._Get_Crucified.mp3
Category:general -- posted at: 10:49pm AEST

Opioids are extraordinary agents that have been used for millennia for the relief of pain and suffering; however, the history of opioids is also one of abuse and addiction. In the US, we are in the midst of a devastating iatrogenic chapter in this history, a prescription opioid epidemic that kills 15,000 Americans per year by overdose and destroys hundreds of thousands of lives and families.

In this presentation we will consider the magnitude and consequences of the current epidemic; describe how clinical organizations and clinicians were appropriated by the pharmaceutical industry so that Americans–5% of the world’s population–consume more prescription opioids than the rest of the world combined; and discuss strategies for managing patients who present to emergency departments with acute or chronic pain complaints that account for our competing mandates to palliate and protect.

These strategies center on an assessment of the likelihood that using opioids will deliver benefit or cause harm. For patients at low risk to be harmed by opioids, utilize aggressive multimodal analgesia, including opioids as needed to control acute pain, and prescribe optimal outpatient non-opioid analgesia with a small number of breakthrough opioids if indicated. For patients at high risk to be harmed by opioids, including patients with chronic pain and patients with flags for opioid misuse, avoid using opioids in the ED and outpatient settings, utilize non-opioids to manage symptoms, and, when misuse is suspected, nudge the patient to addiction treatment. The goals of optimal opioid stewardship are to provide effective symptom relief while preventing de novo cases of addiction, to control the supply of opioids in the community, and to protect existing addicts from further harm while promoting recovery.

For slides, the HELPCard treatment referral business card, and phraseology to use when managing patients at risk for opioid misuse, go to http://emupdates.com/help

Direct download: 06Strayer.mp3
Category:general -- posted at: 2:00am AEST

Kath Maitland, the author of the FEAST study, talks about where we go now with fluids in kids, following FEAST

Direct download: 05Maitland.mp3
Category:general -- posted at: 2:00am AEST

Personal tragedy will touch all of us. Rob's talk is an incredibly personal story but offers much practical advice for dealing with the inevitable.

Direct download: 04Rogers.mp3
Category:general -- posted at: 2:00am AEST

Amal Mattu gives Career advice with help from The Princess Bride

Direct download: 03Mattu.mp3
Category:general -- posted at: 3:00am AEST

Liz Crowe talks on the role of religion in coping with devastating life events, such as those whitnessed in critical care

Direct download: 02Crowe.mp3
Category:general -- posted at: 3:00am AEST

John Hinds gives his last talk - on the subject he was most passionate about. Back with popular demand, More Cases from the Races.

Direct download: 01Hinds.mp3
Category:general -- posted at: 10:11pm AEST

 

Chris Ross & Oli Flower discuss the latest update on SMACC Chicago - an incredible cadaver workshop with small group expert tuition on a huge range of critical care procedures. At a hugely discounted price. This will sell out so get in there fast.

Direct download: Chris_Ross_on_SMACC_Cadaver_Workshop_for_iTunes.mp3
Category:general -- posted at: 12:03pm AEST

A long time ago in a galaxy far, far away.... Watch our fearless masters of Sim battle for galactic supremacy on the SMACC main stage. 

Direct download: 98SimWars2014.mp3
Category:general -- posted at: 5:55pm AEST

Own the ventilator! Irma Bilgrami lays down a framework for analysis of ventilator settings and waveforms to enhance your daily practise.

Direct download: 97Bilgrami.mp3
Category:general -- posted at: 12:55pm AEST

Integrity, Reflection and Professionalism. Stuart Lane examines how we respond to mistakes, errors and poor outcomes in clinical practise.

Direct download: 96Lane.mp3
Category:general -- posted at: 1:04pm AEST

Treating the mind AND the body. Imogen Mitchell on putting the 'person' back in 'patient'.

Direct download: 95Mitchell.mp3
Category:general -- posted at: 12:24am AEST

Penny Stewart's enthralling tales of high acutity cases in rural and remote Australia. A unique take on consistently challenging case-mixes.

Direct download: 94_Stewart.mp3
Category:general -- posted at: 11:30pm AEST

The quest for normality. Chris Nickson reflects on our perpetual number chasing. What constitutes 'normal' in critical care patients.

Direct download: 93Nickson.mp3
Category:general -- posted at: 8:14pm AEST

Cracking the chest. Michaela Cartner on the nuances of cardiac arrest post cardiac surgery.

Direct download: 92Cartner.mp3
Category:general -- posted at: 1:53pm AEST

Richard Levitan on 'conquering the fear'. Tips and tricks for emergent paediatric airways.

Direct download: 91Levitan.mp3
Category:general -- posted at: 3:05pm AEST

Setting up for Success. Anthony Lewis highlights the importance of preparation and planning to minimise emergent airway failure.

Direct download: 90Lewis.mp3
Category:general -- posted at: 10:35pm AEST

Tools for success. David Pilcher examines the plethora of available tools for outcome prediction in critical care.

Direct download: 89Pilcher.mp3
Category:general -- posted at: 12:22pm AEST

Levitan, Weingart, Hind, May, Neil - The Airway Experts discuss all things cricoid, BURP and checklists. Airway Q&A

Direct download: 88Airway_Clinical_QA.mp3
Category:general -- posted at: 10:50pm AEST

Bilgrami, Westafer, Gatward, Rogers, Brazil, Roland - FOAMed and the future of medical eduction. The education Q&A.

Direct download: 87Education_QA.mp3
Category:general -- posted at: 5:10pm AEST

O's in the Nose. Richard Levitan's tips and tricks for optimising the nasopharynx as part of your airway management.

Direct download: 86Levitan.mp3
Category:general -- posted at: 3:49pm AEST

Lipman, Raper, Murphy, Philpot, Myburg, Mitchell - The ICU Q&A panel discuss clinical scenarios.

Direct download: 85ICUClinical_QA.mp3
Category:general -- posted at: 11:00am AEST

Yogesh Apte gets back to basics. How we should integrate physiology into our bedside clinical practise.

Direct download: 84_Apte.mp3
Category:general -- posted at: 10:36pm AEST

The Twitter debate comes to a dramatic conclusion. Should Airway doctors use checklists ?

Direct download: 83leuwenberglecong.mp3
Category:general -- posted at: 12:47pm AEST

Rethinking paradigms. Keith Greenland on the realities of difficult airways; A talk not to miss

Direct download: 82Greenland.mp3
Category:general -- posted at: 4:44pm AEST

The Emergency Medicine panel discuss high sensitivity troponins, stroke thrombolysis and problems facing emergency medicine

Direct download: 81EM_Clinical_QA.mp3
Category:general -- posted at: 10:17pm AEST

Sonophiliac, Justin Bowra highlights strategies for teaching our juniors to become adept at utilising bedside ultrasound in critical care settings 

Direct download: 80Bowra.mp3
Category:general -- posted at: 12:45pm AEST