SMACC

All biomarkers are awesome predictors of badness. Elevated hS-troponins after non-cardiac surgery or an acute exacerbation of COPD are associated with increased mortality. In seemingly healthy people elevated D-dimer levels are associated with increased mortality, just like NT-proBNP levels predict mortality in patients with end-stage renal disease.

A biomarker, in its broadest sense, is defined as ” a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention” (NIH Biomarkers Definitions Working group, 2001). This definition includes everything from laboratory tests to blood pressure measurements or an ultrasound scan. The clinical assessment in the emergency department is based on the subjective history of the patient in combination with all available biomarkers and their change over time. Yet the notion that biomarkers are ”objectively measured” can lead to an overestimation of their individual importance in the bigger clinical picture.

Overtesting and overdiagnosis have serious consequences not only for patients, but also for the health care system. In a clinical context the ease of getting a laboratory test leads to a lower threshold for testing, which has been shown to increase testing without affecting relevant clinical endpoints. Also, when a biomarker becomes part of the standardized workup for a certain symptom, primary care centers and emergency telephone services will refer patients to the emergency department for testing, even when the pretest probability is low.

This bias is not an inherent problem of biomarkers themselves, but of the decision making process of clinicians. The human brain fears uncertainty, and anything that adds to the feeling of knowing is rewarding, which is the most probable explanation of overtesting in settings where medico-legal risks for the clinicians are low. The ever increasing numbers of patients seeking emergency care to rule out serious conditions is a development driven by medical professionals and is fueled by the perceived increased certainty provided by biomarker testing.

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

The vocabulary of elite teams is changing. Understanding the roots of grit, resilience and poise under pressure requires a deep dive into the challenging, sometimes ugly world of our emotions, fear, anxiety and expectations. This is the good news: the science of human performance has evolved as well, and offers insight on how to train for a focused and enlightened team mindset. Emotional regulation, environmental manipulation, stress inoculation, mental preparation -- these are the concepts that define the new resuscitative collective unconscious. In this session, we will discuss how the science of human performance and psychology can inform the development of expert teams, from heart rate and tactical breathing to emotional valence and cortisol surges.

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

Our attempts to improve safety and quality in healthcare have tended to focus on learning from error. Intuitively, this seems like a good idea: if we make a mistake, we would like to learn why it happened and how to stop it happening again. But errors only occur in a minority of clinical encounters, so our focus is quite narrow. We may be missing learning opportunities from the episodes when things have gone very well. Furthermore, by focussing entirely on learning from adverse events, we run the risk of creating a culture of negativity, fear and avoidance. In this presentation, I will challenge the deficit-based approach to learning (i.e. learning from error) as the sole instrument to improve quality. I will also introduce the following concepts: our innate negativity bias - why we can't help spotting errors, and why tend to overvalue their significance; the second victim phenomenon; Safety-2; intrinsic vs. extrinsic motivation; and Appreciative Inquiry. I will describe a complementary approach to learning in healthcare: Learning from Excellence, and how our team established an Excellence Reporting system in our intensive care unit.
www.learningfromexcellence.com @adrianplunkett

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

Is there a specific time during our shift when we are too fatigued to safety practice? That was the question that led to a research project comparing the clinical performance of providers during the first hour of a day shift and the final hour of a string of night shifts. These providers were pulled out of their real-time clinical duties and video-taped while performing simulated critical care cases. The hypothesis was that the day shift providers would out-perform the night shift, but the opposite proved true. Blinded reviewers assigned the day shift providers lower performance scores and noticed some surprising medical errors committed during these simulated cases.
So are we “awake” when we come to work? Should some type of case-based warm up exercise be encouraged just prior to a shift? Also, upon reviewing the data, it was found that the majority of the providers studied had been off the day prior to their morning shift. Jan Paderewski, a famous pianist said, “If I miss one day of practice, I notice it. If I miss two days, the critics notice it. If I miss three days, the audience notices it.” Perhaps clinicians, similar to others who are elite in their field, truly need daily practice or some type of deliberate exercise prior to a shift to perform at the highest levels of care. How can we determine when we are not at our maximum level of mental sharpness during a shift? Can anything be done to improve our abilities in real time?
This lecture will review the available literature surrounding mental fatigue and critical care based shift work and focus on techniques both before and during shifts to recognize and potentially mitigate any clinical sluggishness and improve patient care.

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

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

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

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

Motorcycle Trauma Simulation and discussion

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

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

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

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

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

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

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

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

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

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