Coda Change

James Anstey provides his thoughts on the recent developments in delayed cerebral ischaemia following a subarachnoid haemorrhage (SAH). Unlike TBI, where outcomes have plateaued after 20 years, outcomes have steadily improved for aneurysmal SAH. Early intervention, with an increasing amount of coiling as opposed to clipping as well as ICU all likely playing a part.   However, there is still a subsection of patients who deteriorate three days or more post their event. This is likely due to delayed cerebral ischaemia (as opposed to pure vasospasm). This is a diagnosis of exclusion in a patient who deteriorates after three days post bleed and without hydrocephalus, seizures, infection or another identifiable causal pathology.   There are several pathophysiological factors at play. Firstly, microcirculatory problems, including vasoconstriction in capillary beds and clumping with endothelial damage. This is perhaps why treatments to improve perfusion have had little success. Next, a combination of cortical spreading ischaemia and angiographic vasospasm.   Gold standard diagnosis of vasospasm remains the catheters angiography. Transcranial Doppler and CT angiography are both being used more and more and certainly have a role to play. CT angiography in particular stacks up reasonably well to catheter angiography and has a negative predictive value approaching 100%. One potential problem is overcalling the narrowing at times and has occasional artefacts. Transcranial Doppler is used occasionally however has challenges with reliable operators, is user dependent and only visualises a part of the cerebral circulation.    Patients deteriorate, and we of course want to make sense of it. But what do we do thereafter? Hypertensive therapy with the aim to improve cerebral perfusion is often the go to method. James shares his thoughts on this technique, with reference to the current literature. Similarly, we diagnose vessel narrowing as the problem, however therapies that reverses this does not seem to confer good clinical outcomes. There is a large list of failed therapies because of this fact.    This raises lots of questions about this patient group. Jame’s main messages are to not become obsessive with vasospasm, use CT angiography as a good substitute for catheter angiography and be cautious of vasodilator therapies as they generally do not seem to affect long term prognosis. This #CodaPodcast was recorded in November 2018 as part of Brain, a CICM Neuro Special Interest Group meeting. For more like this, head to our podcast page. #CodaPodcast

Peter Brindley joins you again to bring you The Great Re-Engagement, alongside Pelesa Motshabi Chakane, Silvia Perez-Protto and Andrew Shaw.   This episode explores the future of healthcare, and the ways to utilise the global community, research, and technology to enable greater contentment for clinicians to enable excellent healthcare at a global level.   What will successful medicine look like in 10 years’ time if we get it right? It is a daunting prospect to consider. Palesa hopes that the positivity that has been borne out of the Covid-19 pandemic continues. She believes it will be the capacity for the healthcare system to utilise the unity that has been exhibited over the last two years will be the driving force for ongoing positive change. Ideally, this leads to healthcare for everyone, prevention of sickness and disease and exceptional care for the whole person. Silvia speaks of her dream of the abolition of healthcare disparity and universal access for all.   Andrew hopes that the medical community will engage both science and art to make these dreams reality. Andrew speaks about the integration of technology into the practise of medicine and explores the potential benefits and disadvantages. Further he speaks to the changing nature of healthcare to be servicing customers as opposed to patients. This comes with greater choice for individuals accessing healthcare. He sees this “relationship based” healthcare as key to ensuring technology does not become all consuming.   Prevention, rather than cure, is a key tenant to the development of healthcare in Andrew’s opinion. This sentiment is founded on an agreement to a moral contract by the medical community. The moral contract contains within it a right to affordable and accessible healthcare for all.   Silvia feels poor data collection, especially in terms of underrepresented groups, is hindering the design and implementation of health care systems. The way forward is meaningful engagement with all patients to better design systems. Palesa provides a viewpoint from a system in lower income countries. Whilst the medium and high-income countries are faced with challenges surrounded by the rising use of technology and perhaps patient disengagement, Palesa makes the point that for most of the world, burden of disease is still the major challenge to be faced. Utilising technology in an appropriate way to bridge the gap between low- and high-income countries is the way forward   Balancing education, research and clinical care is another challenge that is becoming more and more apparent. Andrew thinks that clinical care is, and must be, at the forefront of medical practise. It is what the patients hold most highly and for good reason. Whilst education and research are important, these pursuits may be best to be left to those who are legitimately good at them. The team discuss the best ways to balance being pulled in multiple directions whilst keeping the patients at the forefront.   For more like this, head to our podcast page. #CodaPodcast

Climate change is a real and accelerating existential danger. Urgent action is required to halt its progression, and everyone can contribute. Pollution mitigation represents an important opportunity for much needed leadership from the health community, addressing a threat that will directly and seriously impact the health and well-being of current and future generations.   Inhalational anaesthetics are a significant contributor to healthcare-related greenhouse gas emissions and minimising their climate impact represents a meaningful and achievable intervention. A challenge exists in translating well-established knowledge about inhalational anaesthetic pollution into practical action.   This new guideline is designed to provide a platform that engages health professionals as an active learning community, and invites sharing of success stories and evolving solutions across varied global practice settings.   For this podcast, @GongGasGirl interviews @jessahegedus about how they did it and why it is important.    This podcast was recorded for the Anaesthesia Journal. For more like this, head to our podcast page. #CodaPodcast

In this episode of the #CodaEarth podcast about reducing harmful gases in anaesthesia, host Laura Raiti is joined by Jessica Hegedus - an anaesthetist working in Wollongong, New South Wales, who is also a member of Doctors for the Environment.   As someone passionate about environmental sustainability within anaesthesia, Jessica starts by telling Laura that the one thing that motivates her the most when it comes to the climate crisis is the fact that it’s an emergency that will end up impacting us all; as both citizens living in the community, and professionally as healthcare workers responding to its impacts. This puts many of us in the unique position in that we’re contributing to a crisis inadvertently as healthcare professionals, that we’ll also be on the frontline responding to.   They talk about the importance of reframing climate change as a health problem, and how as healthcare professionals we have the responsibility to protect and preserve health.   Jessica notes that while reducing healthcare admissions won’t resolve the climate crisis, that our leadership is essential, and that healthcare professionals are an important and trusted voice for action. She believes that we can send a powerful signal by getting our own house in order and that all contributions towards a low carbon society are important, however small.   Focus then shifts to the #CodaEarth Action – reducing harmful volatile agents used in anaesthesia - which not only make a significant contribution to CO2 healthcare emissions, but whose use is also directly within our control. Collective attention to reducing the impact is both meaningful and achievable opportunity for healthcare providers to demonstrate their leadership.   Laura and Jess also discuss six evidence-based actions to reduce anaesthetic gas usage that are practical and don’t compromise patient care. The actions include removing Desflurane from clinical use, de-commissioning Nitrous oxide piping, rationalizing Nitrous oxide where possible, advocating that healthcare workers use the lowest possible fresh gas flow, prioritising alternatives that have less environmental impact, and tracking progress, sharing results, and engaging with others.   Jess was inspired due to frustrations with slow progress on climate change, combined with increasingly visible effects of the crisis on the community and her practice, and has found that it can be both empowering and rewarding to exercise advocacy and effect change within her patch.   Jess also tells Laura that she believes there are meaningful actions we can all take that will contribute to a greater whole, and that the potential for healthcare providers to do this is immense. Jess believes that all contributions are meaningful and all roles are important, and that people shouldn’t be deterred by how big the problem is; perfect is the enemy of good and something is better than nothing.     Join Coda Earth now to safely reduce pMDI usage in your own practice.

In this episode of the #CodaEarth podcast, host Laura Raiti speaks to Brett Montgomery, a Perth-based GP &  senior lecturer at the University of Western Australia. As someone who is passionate about the climate emergency and the role each of us play in reducing the carbon footprint of healthcare, Brett is also the lead author of our Coda action plan to reduce usage of metered dose inhalers (pMDIs).   To kick off the podcast, Brett touches upon the fact that while much of society sees climate change as a political or environmental issue more commonly associated with polar bears and icebergs melting, he believes it’s important that we begin to see it as a huge public health issue to cultivate real change. Brett believes that by reframing it as an issue that has real and serious health consequences, it will ensure people who aren’t currently concerned by its effect are motivated to act when it comes to both climate change and their own health.   Brett then goes on to discuss in further detail his particular point of focus, which is the overuse of inhalers in healthcare. They discuss that while inhalers may appear to be a minor contribution to our impact as a whole when compared to the likes of aeroplanes and cars, in actual fact they have a disproportionate effect on health system’s carbon footprint.   In fact, the healthcare system in Australia contributes about 7% of our entire national footprint – so not an insignificant number - and within the 7% about a quarter is down to prescriptions, of which, a fair chunk can be attributed to these inhalers.   Laura and Brett then go on to talk about ways in which the Coda community can get involved, and Brett highlights that it’s important that everyone is more mindful about prescribing inhalers and that they employ critical thinking when it comes to ensuring that an inhaler is the right choice for both the patient and the environment.   They explore alternatives such as dry mist or powder inhalers, and consider a study that shows that between a third and a half of people who are prescribed these inhalers struggle to find evidence of the diagnoses.   Finally, they look at what the future could look like for Australia, should we work towards a collective movement against climate change, and discuss leading countries such as the UK and Sweden, both of whom are working towards eradicating overall health emissions.   To close, Brett shares his key piece of advice for those wanting to make change: the best climate action is what you’re good at, what you enjoy and what the world needs.   Join Coda Earth now to safely reduce pMDI usage in your own practice.

In this special podcast focused on the ‘Reduce Pathology Test Ordering’ step of the Coda Earth Action Agenda, host Laura Rati is joined by Forbes McGain. Forbes is an antitheist and intensive care physician who works at Western Health Melbourne and is also an associate professor of medicine at the University of both Sydney and Melbourne. He is passionate about making seemingly small, environmental financial and social sustainability changes to how we practise medicine, and is currently examining ways in which we can make hospitals more sustainable.   To open the podcast, Forbes and Laura discuss exactly what it is that makes Forbes most passionate about championing change when it comes to the environment. Forbes credits two main driving factors – the first being that he is a strong believer that nature truly is extraordinary and delicate, and thanks to his childhood spent growing up on a farm - he’s really been close to nature, and he believes that loosing that would be deeply sad for people the world over. He also cites that as the father of two children, it’s really important that they get the chance to experience the things he has experienced in his life. Forbes also touches upon the fact that climate change is just a single example of our overwhelming use of resources on the earth.   Forbes is a passionate advocate of Coda, and believes the global community of healthcare professionals are fantastic in exploring and taking the next step beyond research. He speaks to Coda’s ability to translate medical evidence and data to influence beyond the work practise of just one person.   When discussing how the Coda community can work collectively to make a huge impact on the environment, Forbes states that pathology testing – and the frequent overuse of these tests - is something everyone can be involved in; highlighting that millions of tests around the world can be reduced to lessen the environmental impact.   Laura and Forbes explore the unnecessary amount of atrial blood gas tests (ABG) that are done each year. They examine a hospital case which saw a third of over 65k blood gases performed annually ultimately deemed unnecessary. They consider the fact that everything healthcare professionals do has a carbon footprint, from a single pathology test right through to a new MRI scanner; meaning that reducing these tests has an impact on patients, finances and carbon footprint.   Finally, Forbes offers his advice to those who haven’t yet made climate change a priority, simply stating that educating oneself is the first step, and that while there are certain things you can do alone; there’s a lot more that can be done by collaborating with others.   Join Coda Earth now to reduce unnecessary pathology testing in your own practice.

In part 2 of this episode of the Coda podcast, Coda co-founder Roger Harris is again joined by Sydney-based Chris Anderson and Lausanne-based Frederic Michard, as they discuss how we can do better when it comes to deteriorating patients. In part 1, the three intensive care specialists explored precisely what a deteriorating patient is, how big a problem they are and exactly why we should care – in this episode Harris, Anderson and Michard now look at ways in which the problem can be resolved.   Hosted by Roger Harris, he is joined by guests Frederic Michard - a Critical Care MD, PhD and Chris Anderson - a fellow intensive care specialist. Roger speaks to Frederic and Chris about ways in which healthcare professionals can recognise deteriorating patients sooner, and how they should be responded to, as well as discussing both solutions and how deteriorating patients can be better detected.   By way of a resolution, the three experts explore the idea of wearable, mobile solutions and – imagining the future of patient monitoring – they discuss what said solutions might look like, and how they will help nurses monitor deteriorating patients.   They also address the question that arises regarding which patients are most in need of monitoring, concluding that it’s those at the greatest risk of clinical deterioration.   Harris, Anderson and Michard also agree that there is reason to believe that new, future techniques will be able to ensure accurate detection of deteriorating patients, and that smarter software will make such a task more streamlined.   Michard finishes by noting the importance that healthcare professionals focus on individualising not only the monitoring that is on offer, but – equally important - precisely who is going to be monitored and when.   For more like this, head to our podcast page. #CodaPodcast This podcast is sponsored by GE Healthcare.

In this episode of the Coda podcast, Coda co-founder Roger Harris is joined by Sydney-based Chris Anderson and Lausanne-based Frederic Michard, as they explore precisely what a deteriorating patient is, how big a problem they are and exactly why we should care.   Hosted by Roger Harris, guest Frederic Michard is a Critical Care MD, PhD, based in Lausanne, Switzerland, who trained in Paris University Hospitals and in Boston and is well known for his research work and publications, while Chris Anderson is a fellow intensive care specialist, also based in Sydney. Roger speaks to Frederic and Chris about why it is that many patients who are admitted to hospital for surgery end up staying due to complications, and the implications this has on both hospitals and nurses as a whole.   Also touched upon within the podcast is failure to rescue – or FTR – which is the failure or delay in recognizing and responding to a hospitalized patient experiencing complications from a disease process or medical intervention. They discuss the two main components – the failure to detect deterioration at an early stage and the failure to react appropriately and in a timely manner and the impact this can have on patients.   Addressing startling statistics – which suggest an alarming number of patients will die within 30 days of surgery - the three intensive care specialists pose the question: how do we better detect and monitor deteriorating patients?   They discuss everything from the unreliable recordings of respiratory rates to other inaccuracies that can impact both the treatment and detection of deteriorating patients, to the effect older patients on hospital wards are having on the complexity of cases and conclude that there is absolutely room for improvement regarding how patients are monitored.   Reflecting on the influence that Covid has had on hospitals, the three experts note that many health care systems are under strain in the post-pandemic world, and that the subsequent nurse shortages are a huge issue, particularly on hospital wards. They conclude that this too, is a reason to upgrade the way in which our patients are monitored.   For more like this, head to our podcast page. #CodaPodcast This podcast is sponsored by GE Healthcare.

Following on from the Commit step episode, in which the Coda team discussed turning anxiety into action as a way to start bringing about change, host Dr Laura Raiti - who is both a paediatric oncology fellow, and a Coda team member – speaks to Dr Fintan Hughes, an anaesthesiology resident, about the next step we should be taking as a collective Coda community.   In this episode, Laura and Fintan start by discussing the urgent need to come together to bring about necessary change, which forms the basis for this step – which is to examine our behaviours and the impact they’re having on our own carbon footprint. They touch upon how using a carbon footprint calculator (such as the one on our website) is the first step when it comes to identifying areas in which we can do better by looking at our own personal footprint, and the importance of doing so, without feeling guilty.   From committing to change to examining where that change should start, the podcast explores the idea of flipping the script, and using the calculator to cultivate change and co-ordinated action.   Fintan also talks about how completing a fellowship at University College London inspired him to get involved with Coda; and how he thinks the entire Coda community can get involved to bring about maximum change.   From taking measures to becoming a more ethical shopper, to paying more attention to where you bank, Fintan examines seemingly small and easily accessible steps that every listener can take to make a huge impact on our carbon footprint.   Fintan also shares with listeners his key piece of advice for those who haven’t yet started taking climate action but want to help contribute to bringing about change, and explains how it’s the small things that can make a big difference.   For more head to our podcast page.

In the first episode of Coda Earth’s unmissable new podcast, listeners will hear Coda co-founders Roger Harris and Oli Flower discuss a wide range of topics from exactly how and why Coda came to be, to how each and every one of us can make small, simple, and actionable changes that will make a real difference to the planet.   Hosted by Dr Laura Raiti - who is both a paediatric oncology fellow, and a Coda team member - she speaks to Roger and Oli about just how easy it is to commit to change – and why it’s the first step toward more sustainable healthcare delivery. The three of them discuss everything from the pandemic, to the bigger issue of climate crisis, and exactly why it’s the biggest threat to global health.   They also touch on the fact that while many of us feel helpless as individuals, and that there is a real sense of anxiety in the community, that together, we can turn that anxiety into action.   From committing to adding your voice to the movement, to acting together as a community to have a real impact on our collective carbon footprint, the podcast explores the climate change actions heath care professionals can get involved with, on both a macro and micro level.   Coda is all about taking action wherever possible, and about making such action fun and enjoyable for the whole community, and ensuring both action and advocacy are accessible to as many people as possible. And so, in this podcast you can expect to hear practical pointers on exactly where to start, templates for each action which are very simple to follow, and a selection of simplified tips that really will make a difference. Designed for people at all stages of life, the tips will draw on expertise from all over the world and will give listeners the best possible starting point to make meaningful change.   For more head to our podcast page.