SMACC

Myths persist because they are essential to the human experience and our development as a society.

They fill the gap between what we know and what we think we know.

Where does this gap hurt us the most? In our vulnerable populations, for example, in our care of children.

The “myth incarnate” in medicine: defective dogma. Not all dogma is bad – after all, dogma means “that which is believed universally to be true”. The problem with medical dogma is that our critical thought processes are curtailed by wholesale acceptance.

Medical dogma is a special kind of myth, because it’s difficult to define. We repeat defective dogma for three reasons:

“It is known”. Sometimes the dogma is all that is known on the subject, or it is simply the majority consensus. Be careful with this one – because there may be a reason for this specific teaching – not all dogma is bad.

Dogma is sentimental. We learned from our teachers who learned from their teachers. We want to honor those who taught us, and we get attached to some ideas. Sometimes – even subconsciously – we allow our attachment to an idea to give it more credence than it deserves.

The third driver of dogma is insecurity. “I know what I know”. In other words, “don’t make me reveal my limitations.”

Myth: “They’re all fine”
Remedy: Remember to look for the subtleties in children. Early warning signs are there, in the history or in the physical exam. If it doesn’t add up, investigate.

Myth: “Only pediatricians are experts”
Remedy: Don’t delegate decisions. You can do this. You sometimes are the only one that can.

Myth: “I will break them”
Remedy: Children are not another species. Use all of your skills for all of your patients”

Powered by #FOAMed – Tim Horeczko, MD, MSCR, FACEP, FAAP

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

Reflecting on 26 years of frontline practice in paediatric emergency care: while there’s no substitute for knowledge and experience, I can see some common themes to failing to spot a sick child. By sick, I mean injuries and illness that need hospital attention or hospitalisation. This talk tries to draw from all those errors I’ve both made and seen, into a couple of easy-to-apply mantras.

Physiology matters. It really does. Scrutinising a full set of observations/vitals (in the context of the child’s age) will help avoid our feared crime: discharging a sick child. And how to deal with fever, as a confounding factor.

Psychology matters. It really does. Talks on PEM are always popular because as EM physicians, we’re insecure about mismanaging a child. Are children precious? Are adults just big children? Therein lies the problem. Less knowledge, less experience, less confidence? Yes? Then there's less Type 1 thinking.
We’ll talk about the risks in needing to rely more upon Type 2 thinking. How to deal with the time-poor resuscitation situation. How to avoid denial. What makes some staff be over-confident with children (hint - type 2 thinking is hard work!). What stops us applying our usual filters (eg risk stratification).

Finally, I can signpost more specific help with developing your PEM skills, which can be found at www.spottingthesickchild.com , an eLearning package containing hours of videos of real-life cases, endorsed by the NHS in the UK, and https://www.youtube.com/watch?v=N35J3NLJW_s , a 10-minute podcast also endorsed by the NHS.

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

In sub-Saharan Africa, where infectious diseases and nutritional deficiencies are common, severe anaemia is a common cause of paediatric hospital admission, yet the evidence to support current treatment recommendations is limited. The TRansfusion and TReatment of severe Anaemia in African Children: (TRACT ISRCTN84086586) is a 3x2x2 factorial controlled trial involving 3954 children (aged 2m to 12y) with severe anaemia (haemoglobin <6g/dl). The trial has been designed to address the poor outcomes following SA in children in sub-Saharan Africa, which is associated with high rates of in-hospital mortality (9-10%), 6-month case fatality (12%) and relapse or re-hospitalisation (6%) indicating that the current recommendations and/or management strategies are not working in practice. Hospitalised children will be enrolled at 4 centres in 2 countries (Malawi, Uganda) and followed for 6 months. TRACT trial is designed to answer 4 simple questions. Q1 and 2: which children should receive a transfusion (since current guidelines recommend transfusions only in children with a Hb <4g/dl (or <6g/dl if accompanied by complications)); and how volume to transfuse in each transfusion event?. Q3 and 4: Since the major factors related to poor longer term outcome are micronutrient deficiencies and sepsis would post-discharge multi-vitamin multi-mineral supplementation versus routine care (folate and iron) for 3 months and/or cotrimoxazole prophylaxis for 3 months versus no prophylaxis improve outcome and prevent relapse. Primary outcome is cumulative mortality to 4 weeks for the transfusion strategy comparisons, and to 6 months for the nutritional support/antibiotic prophylaxis comparisons.
If confirmed by the trial, a cheap and widely available ‘bundle’ of effective interventions could lead to, if widely implemented, substantial reductions in mortality in African children hospitalised with severe anaemia every year. The trial started in Sept 2014 and currently 2700 children have been enrolled. We expect the trial results to be available in 2017.

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

As patients becomes more complex, the tribal systems we use to look after them remain stuck in the 18th Century when the treatment for everything was amputation and, if you survived, leeches. The large modern hospital is becoming a battleground of competing SODs* and SONs** practising their art in a multi-organ (failure) world. Many staff lack acute medical skills; those with such expertise are siloed far away from the ward in emergency departments, operating theatres and ICUs. Despite disease not knowing or caring what time it is, all hospitals remain solar powered with minimal nocturnal on-site expertise. As nursing & medical staff move more towards rotating rosters where no-one knows more than a single-sentence-summary of their patient’s complex physiological, pathological & pharmacological needs, an ever-present vigilant family member may become the only hope of surviving any acute admission.

The two most dangerous words in healthcare may well be ‘_my_ patient’.
Come listen to a middle-aged intensivist rant about how things were so much better ‘back in the day’*** and bask in the utopian dream of a healthcare system that provides better, safer, patient-centred care.

*Single Organ Doctor
**Single Organ Nurse
***they weren’t

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

Cops and robbers, cowboy and Indians, and military movies have filled the minds of generations of healthcare providers with a vision of what gun fights and combat look like. Unfortunately, real violence looks nothing like any of these. As emergency and critical care providers, we forge additional perspectives as we care for the victims of violence. Yet, views of violence aftermath only scratch the surface of first-hand experience during the brutal, scary, gritty, and dirty realities of real world in-progress violence. It is horrible, and It is quick… really quick.

In this focused discussion, we will talk about prehospital critical care team response to the mass shooting. We will explore how emotional and physiological barriers run amok making the simplest logistical and clinical decisions extremely difficult. We will discuss the importance of staying” left of bang”, incident recognition, initial confusion, and the critical nature of incident acceptance. Next we will review staff and patient safety priorities and basic concepts of tactical combat casualty care (TCCC). Finally, we will conclude with thoughts about your role as care provider when on duty as part of a pre-formed team, and what to do if off duty facing an active shooter.

Today is the day to ponder actions you must take the moment an active shooter begins taking lives at an astonishing rate; THAT moment when the choices you make next will be the most important of your career. The choices you make today will affect the milliseconds and millimeters that determine survival… patient survival, your survival, and the survival of those waiting at home for you to walk back through the door.

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

Scott Weingart discusses Post-Intubation Sedation.

Direct download: Scott_Weingart_2.mp3
Category:general -- posted at: 7:00am AEST