Coda Change

Reuben Strayer and Duncan Grossman discuss all things airway. Specifically, how the introduction of many airway technologies at once–some of them revolutionary, some not–have confused our airway strategy. So how can we incorporate the best of these technologies into contemporary airway management? They begin with a big question – what equipment should you choose? There are many options, including direct or video laryngoscopy as well as multiple versions of the laryngoscope blade itself. As Reuben explains, all these terms can be confusing and are often imprecise. Direct laryngoscopy clears a line of sight between one’s eyes and the glottis to visual it. This is unlike video laryngoscopy which uses a camera to visual the glottis. The next distinction is the type of blade – standard geometry versus hyperangulated blades. The differences between - and the varying uses of – standard geometry blades and hyperangulated blades are discussed. This discussion will clear up confusion about the nomenclature for all clinicians. The long and the short of it is that a camera can be attached to both standard geometry and hyperangulated blades allowing video laryngoscopy with both. It depends on the clinician’s comfort and training as to which one you will reach for. However, using a hyperangulated blade does make viewing the cords easier. The hyperangulated blade also requires less force, which is favourable in instances of cervical spine injuries or tongue masses. But, there are downfalls, and Reuben takes us through what to expect. The standard geometry blade on the other hand is faster, and easier to utilise suction. It is also easier to use a bougie when using a standard geometry blade. Moreover, the standard blade video laryngoscopy uses the same skill set as a direct laryngoscopy and this is beneficial for new learners. With all the new, wonderful technology available to us, should trainees bother learning traditional techniques? Reuben contends they should for a few reasons. The first being that technology is fragile and can let you down at any moment. The second being that standard geometry video laryngoscopy contains within it the older technique – just with the addition of a video. Therefore, the way to get good at direct laryngoscopy is by getting very, very good at video laryngoscopy. Jump onboard and join Reuben and Duncan as they provide a masterclass on airways. For more like this, head to our podcast page #CodaPodcast

Please note this episode was recorded in November 2018 as part of Brain, a CICM Neuro Special Interest Group meeting click here  Terry O’Brien presents the evidence and recommendations around the use of continuous EEG. EEG is an old technology, first introduced clinically in the 1920s. As we move deeper into the 21st century, Terry argues that this technology should be brought to the forefront in ICUs around the world.  EEG works in a simple manner. Electrodes are placed on the scalp, measuring the potential difference between two points, and displaying the trends over time. EEG has a high resolution, providing information that no other investigative modality can provide. How does this apply to intensive care? Continuous EEG (much like continuous ECG or oxygen saturation monitors), Terry insists, has a place in the monitoring of critically ill patients. It exists as the best way to diagnose a seizure and can provide information regarding treatment effect. Moreover, EEG gives real time information about depth of sedation and prognostication. Although EEG is standard care in ICU in the United States, Australia is lagging behind. Patients frequently seize in the ICU, particularly after a brain insult or injury. To make matters more complicated, these patients are often sedated, and hooked up to ventilators and other monitoring equipment. This makes the seizure hard to appreciate.  If seizures are unrecognised, the treatment cannot be targeted. This leads to under or over treatment. Terry likens treating seizures in the ICU without EEG monitoring to treating cardiac arrhythmias without an ECG. Depth electrode recording (in addition to scalp electrode recordings) have been used with interesting results. Looking harder proves to find more seizure activity with the more intense monitoring. Terry describes this as the tip of the iceberg. Does the rest of the iceberg matter? Seizures have been correlated with increased mortality. Seizures may be a prognostic marker in patients with brain injury. There may also be severe long-term morbidity in those patients who experience prolonged non-convulsive seizures in the ICU. Randomised controlled trials are difficult to perform in this group due to difficulties with ethical questions. This means the majority of evidence is circumstantial. With that being said, the evidence seems to suggest the in-hospital mortality is less for certain populations with the use of continuous EEG without adding significantly to length of hospital stay. Experimental data also shows promise, as Terry explains. He elaborates on the most recent studies looking at continuous EEG. Who should get continuous EEG, and how should it be used. Terry proposes the continuous EEG be used in the diagnosis of non-convulsive seizures and the treatment of non-convulsive seizures in the comatose patient – especially in the first 48 hours. Similarly, the use of EEG should be prioritised in patients with a history of seizures. In doing so, Terry believes that ICU patient outcomes and survival will be increased. Please note this episode was recorded in November 2018 as part of Brain, a CICM Neuro Special Interest Group meeting.

Alex Rowell, Fahad Ashraf, Greg Selkirk & Luke Torre continue their discussion stroke management. In this talk they tackle imaging and treatment of stroke, including mechanical thrombectomy. Imaging is an enormous part of the process of stroke management. It is critical for diagnosis and stratifying patient treatments. The first imaging modality to order is a non-contrast CT head. As Greg explains, not everyone with neurological symptoms has an ischemic stroke. Other diagnoses to consider include Todd’s paresis and intracranial haemorrhage. The CT will also inform the clinician how much established infarct is present and give an indication of where the clot is. Moreover, carotid angiogram should be used to assess the intracranial vessels. It also allows one to plan the fastest way to remove a clot, should it be present. Transradial and transfemoral thrombectomy are two options. The imaging provides the clinician with valuable information about the most efficient and fastest way of reaching the clot for removal. Lastly, the team discuss CT perfusion. A word of warning. This exists as a problem-solving test. It is a good idea to interpret with caution! Evidently, geographical location and the availability of imaging resources restricts imaging. Where CT scanning is available, this modality combined with a thorough history and assessment of deficits can lead the clinician towards the most appropriate treatment options – including thrombolysis. The question then becomes, does the use of thrombolysis in a rural or remote location preclude the eventual use of thrombectomy? As Greg explains, thrombolysis works well in conjunction with thrombectomy. Receiving thrombolysis does not preclude the use of thrombectomy and does offer advantages. Furthermore, Greg will provide a detailed description on the procedure of thrombectomy, including the various methods used and the care of the patient after a thrombectomy. He touches on the use of general anaesthesia during the procedure, as well as antiplatelet therapy post-intervention. Thrombectomies are not without risks. Complications include perforation of blood vessels. From a neurological perspective, Fahad describes the use of repeat scanning to ensure the absence of any subsequent bleeding and the implications for ongoing medical therapy. Finally, the discussion concludes with a broader take on stroke services in general. This includes pre-hospital stroke awareness in the community, post stroke rehabilitation and neuroprotection measures. For more head to our podcast page #CodaPodcast Please see the webpage for the images referred to in this talk. 

In this podcast, Alex Rowell, Fahad Ashraf, Greg Selkirk & Luke Torre review stroke management in 2022. Stroke management has changed dramatically in the last 10 years. In 2015, we proved the efficacy of mechanical thrombectomy. In 2018, we established evidence for mechanical thrombectomy beyond 6 hours in patients with favourable imaging. Moreover, there has been extensive research into dual anti-platelet therapy to prevent recurring stroke in minor stroke patients. From a technical point of view, there has been an explosion of the number of suction catheters and stent retrievers on the market. This has made mechanical thrombectomy safer & has allowed us to chase distal clots. So in 2022, it is not just that we are doing thrombectomy, but… we are doing it better. And as a result, we are improving patient outcomes. Next, Fahad & Greg discuss what the patient journey looks like in 2022 from being out in the community, to receiving treatment. They discuss how we have streamlined the process - including creating general awareness of stroke in the public, implementing screening tests like FAST & coordinating with emergency first responders. The challenge in modern day stroke treatment is how to determine which patients get thrombectomy, which patients get thrombolysis & which patients are given conservative treatment? Greg Selkirk suggests that there are five main factors: Does the patient have severe cognitive impairment (what is their pre-existing quality of life?) What is their functional status? Where is the location of the clot and what is the risk of removing it? What symptoms does this patient have? Do the symptoms justify the risk? How much salvageable parenchyma is there? Tune in to a #CodaPodcast by Alex Rowell, Fahad Ashraf, Greg Selkirk & Luke Torre. An informative & interesting update on stroke management in 2022. Finally, for more like this head to our podcast page #CodaPodcast

In the Emergency Management of Chronic Pain podcast, Duncan Grossman and Reuben Strayer discuss how and why patients with chronic pain present to the ED. Managing patients with chronic pain is challenging and often it feels like these patients present to the ED during every shift. But… is it as common as it feels? Statistics suggest that 20% of American adults suffer from chronic pain. Why? Well, opioids are both the disease and the cure. Opioids are effective for managing acute pain. However, when they are used for (even) more than a couple of days they can start to cause pain. Therefore, we have to understand the spectrum of opioid benefit vs harm. Reuben and Duncan discuss a framework that accounts for the relationship between chronic pain and opioid use. Noting that each patient presents a unique challenge. Take for example, the patient who is on daily, low dose opioids but is otherwise unaffected by their pain medication. Or, the patient who has chronic pain but doesn’t take opioids. We need to be careful here as these patients can be more susceptible to developing an addiction from prescribed opioids due to their ongoing pain. What about the patient who takes opioids daily but is buying them off the street... Reuben takes us through some strategies for helping all of these patients. One such strategy is to talk to the prescribers. We need to help these patients by encouraging their prescribers to take the reins and to move the needle from opioid harm to opioid benefit. Tune in as Duncan Grossman grills Reuben Strayer on chronic pain in patients, how to manage them and how to help them. For more like this, head to our podcast page #CodaPodcast

In this podcast, Roger Harris sits down for a second time with South African Emergency Physician, Victoria Stephen (Tori). Tori delves deeper into her first hand experience of the frightening political unrest and violence which erupted during the third wave of Covid-19 in Johannesburg in mid-2021. Managing Covid cases and gunshot wounds simultaneously was incredibly challenging both professionally and personally. In the midst of the violence, Victoria made the courageous decision to leave the safety of her home after curfew and to drive through the riots to get to the hospital. Tori was not rostered on at the hospital that night, but she felt an overwhelming need to help her junior staff manage the chaos that was unfolding. It was a critical and intensely dangerous time in South Africa. Reflecting on this experience, Tori emphasises the importance of a strong foundation of healthcare worker wellbeing. She identifies the need first to look after ourselves before we can look after others. Tori speaks candidly about how she managed her own wellbeing through the three waves of Covid in South Africa. This included personally seeing a psychologist to help her process the situation, a regular exercise routine, meditating, and listening to music. In fact, Tori started a ‘survival’ playlist that other clinicians from all over the country listened and contributed to! We’ve included a link to the playlist here. Ultimately, it is difficult to stay passionate about a job that is physically and emotionally exhausting. Staying focused on clinical medicine helps. But at the end of the day, healthcare is a tough job and it takes its toll! For more like this, head to our #CodaPodcast page

Trauma Resuscitation and the Covid-19 Pandemic in South Africa In this podcast, Roger Harris interviews Victoria Stephen about her experience as an emergency physician in a regional South African hospital. Sadly, trauma resuscitation is a big part of working in Emergency Medicine in South Africa.  Blunt force assaults and stab wounds are regular presentations. However, July 2021 was unlike anything Doctor Victoria Stephen had ever experienced. In July, South Africa was deep into its' third wave of Covid-19 infections. Vaccination rates were low and there was a huge burden of Covid patients in the Emergency Department. The ICU was completely overwhelmed, making this by far the worst of the pandemic that they had seen to date. To compound this, piped oxygen levels were running desperately low. The hospital relied on daily oxygen deliveries to keep Covid patients alive. Moreover, to add to the challenge, political unrest broke out and quickly escalated to riots with extreme violence across South Africa. At the time the violence erupted, Tori had over 120 Covid patients in the hospital. Added to this the Trauma resuscitation was managing approximately 34 patients with gunshot wounds per day. With just four doctors working at night and six doctors working during the day, Tori’s team scrambled to manage an overwhelming number of high acuity patients. For the first time in her career, Tori found herself frightened for her safety. Having grown up in South Africa, Tori was no stranger to avoiding danger but this felt very out of control. The thought of managing a busy emergency department inundated with trauma patients in the middle of the covid pandemic is frightening enough for most of us, but to do so in such a resource-limited environment with so few nurses and doctors is truly incredible. Tori believes Emergency Medicine training in South Africa prepares the team to function under such pressure. She believes that the team knows that the lack of resources means they must all pull together. Their training is diverse enough that they have the mental and clinical skills to step up and of course as an ultrasound geek Tori adds that EFAST scanning has a big role to play. Tori is a humble but inspirational clinician on the frontline of providing care in a volatile environment and she believes we can all learn something from her experience. Tune in to a compelling conversation with one of our favourites. Trauma Resuscitation and the Covid-19 Pandemic in South Africa Finally, for more like this head to our podcast page #CodaPodcast

Tune in to a cross over episode with Simulcast, as Jesse Spurr and Victoria Brazil discuss Safety-II, Drugs and Design Sprints in Intensive Care. In this episode, Vic and Jesse catch up to talk through a human centred design project aimed at improving medication safety in the Intensive Care Unit. Vic and Jesse discuss real world applications of Safety-II approaches, the core philosophy and practices of psychological safety and the importance of clinician led approaches to risk in practice. The episode closes with drawing parallels between this work and the skills and practices of simulation. Safety-II, Drugs and Design Sprints in Intensive Care For more like this head to our podcast page #CodaPodcast Or, head to Simulcast to hear more from Vic, Jesse & the team.

Irma Bilgrami, Alissa Starritt and Paula Lyons believe that the pandemic has narrowed the great divide between ICU and ward care. Covid has put incredible pressure on healthcare systems around the world. This has forced hospitals into overdrive, whereby staff have been redeployed and models of care have changed. Evidently, the pandemic has challenged the strict guidelines which we use to direct patient care and define critical illness. Wards are managing patients with much higher acuity, sparking the danger of normalising the abnormal. How do we navigate these murky waters? Irma, Alissa and Paula take a deep dive into these challenging issues. Irma asks, how are the wards going? How are the staff going? And importantly, what lessons can we take away for the future? Additionally, they address the health and wellbeing of staff in our hospitals after a challenging two years. Evidently, healthcare professionals and nurses have found themselves with increased workloads, providing clinical support, emotional support and teaching support all in one go. Irma, Alissa and Paula explain that there are lessons to be learnt from the pandemic. The pandemic has forced some of the existing hierarchical walls to come down and there is opportunity for us to critically think about how we can work differently in the future. Tune in to hear the full discussion: How the pandemic narrowed the great divide between ICU and ward care. Finally, for more like this head to our podcast page #CodaPodcast

Dr Chris Bowles and A/Prof Nada Hamad discuss gender equity in medicine, highlighting the difference between equality and equity. They explore the impact of gender inequity on women's careers and patient care. The conversation emphasizes the need for leadership training and system redesign to promote diversity and inclusion in healthcare.