Coda Change

Acts of violence against paramedics is disgraceful but not doing anything about it is much worse. From DAS SMACC, Craig Wylie speaks to us about violence against paramedics in South Africa. In the four years leading up to this talk in 2017, there were 250 attacks against paramedics. In a neighbourhood where there can be up to 100 gunshots in three hours, this almost shouldn’t be surprising. Craig tells a story where he was called out to an emergency where his colleagues were under attack. His first thought? Why didn’t they get a police escort? But in a low to middle income country, it is rarely that straightforward. Where there is a high crime rate and may only be two police vehicles on duty, it isn’t always as easy as waiting for a police escort. Additionally, if paramedics had to rely on police attending their emergencies, is this just introducing another barrier to care? Craig asks three simple questions: 1. Has our management failed our staff members? 2. Have we done enough that the paramedics that we employ can protect themselves? 3. Have we as an EMS system entirely lost the plot towards our paramedics and how we respond to patient emergencies? The solution? Craig suggests it is all in the training. Paramedics need to be trained to understand the situations, to have a strong action plan, to have an exit plan and to involve community leaders. The team need to be trained to understand how to protect themselves so that they can provide care, whilst also looking out for themselves. Tune into a talk from DAS SMACC on Violence against healthcare workers - Paramedics under siege. For more like this, head to https://codachange.org/podcasts/ 

Communication is something that we all do every day. Communication in healthcare however, isn’t the same as communicating in other areas of our lives. The nature of what we talk about is difficult, particularly when we are delivering bad news. This is amplified even further when communicating with children in medicine. How do we make their experience as enjoyable as possible, whilst communicating effectively with their families? One such way is to acknowledge the role of culture in communication. Culture underpins the way in which we give and receive information in all circumstances. It informs the way we think about things and in many cases, our reactions. We could provide two families with exactly the same diagnosis and information but they could respond in completely different ways. Families will react to information within the cultural framework for which they operate. We may perceive a sprained ankle as a minor injury, however for one family it could mean an inability to participate in sports which is a crucial element of their day to day lives. As healthcare practitioners, we should acknowledge that we won’t change people’s way of thinking by arguing with them. We need to recognise the role that culture is playing, be humble, be understanding and be flexible. Furthermore, studies show that children often understand more than we anticipate. So, it is our job to ensure that we are communicating in the best way possible. Natalie’s advice? Be prepared, manage expectations and provide explanation. From DAS SMACC, Natalie May shares her tips for good communication skills in healthcare. For more like this, head to https://codachange.org/podcasts/   

From DAS SMACC, Charles Larson and Andrew Beck discuss intubating sick kids - small holes, big problems. When intubating a critically ill child we fear that they are going to arrest on induction and we consider the skill required to intubate in difficult circumstances. The most important thing to remember is that we will never be so good that we won’t make mistakes. The greatest critical care physicians are those that have good skills but that are also able to identify what might go wrong. Understanding the risks and having a plan for when something goes wrong is crucial. Managing critically ill children is a difficult task. We must understand their physiology, have a plan for induction and have a plan for if things go wrong. Importantly, we need to consider that it takes several minutes for drugs to kick in for children. What matters more than what drug you give is how you give it. Children don’t follow recipes so nor should you. Furthermore, some golden rules in managing airways in children: 1. Simulation and training is key: We don’t want to be educating ourselves on our patients, particularly in rare scenarios. 2. We must know our equipment, know our limits and know our support systems. Being able to call down help early is priceless. 3. Assess, plan and communicate with the team. 4. Don’t repeat without change. Trying to put the same size tube down the same size hole will always lead to problems. 5. Training needs to be ongoing and skills need to be revisited. Confidence does not always equal competence. Charles Larson and Andrew Beck share stories of Paediatric intubation in high pressure scenarios. For more like this, head to our podcast page. #CodaPodcast 

SMACCForce: Silver Care - Panel by Conor Deasy, Gregor Prosen, Mark Wilson, Raed Arafat, Cheryl Cameron

Matt Morgan describes critical care physiology through history. Matt’s story begins in Copenhagen, 1952, when an 11-year-old girl in developed acute and severe polio. The last iron lung had been used. So, a young anaesthetist, Bjørn Ibsen, organised a tracheostomy and positive pressure ventilation (PPV) and changed the world. From that point we have discovered and understood the physiology of traumatic brain injury, mechanics of PPV, HFOV, APRV and echo to name a few. However, Matt contends that this story was not the beginning of our understanding of physiology. Matt will take you back through time to show how giraffes, dogs, fish and even frogs can teach us about physiology. Giraffes can tell us about the delivery of CPP. They utilise massive mean arterial pressures and a complex system of venous valves. The MAP is achieved through massive left ventricular hypertrophy – a completely normal finding in giraffes. High frequency oscillatory ventilation was first used in the 1970s… however, dogs have been doing this for 100s of 1000s of years ago. Airway pressure release ventilation was described in the late 1980s… again this is not new. Frogs and lizards have been using this method for millennia. Finally, Matt tells us about ice fish – who live 1.5 kilometres under the Antarctic Ocean surface. The ice fish CAN transcribe haemoglobin; however, it does not bother. All its oxygen is provided by dissolved oxygen in its harsh environment. Matt will pin his tale of historical physiology on the events around one of his patients – Nathan – who suffered a TBI. During delivering Nathan’s treatment, Matt relies on all these animal lessons. Matt wants you to remember these animals when thinking about physiology. In doing so, he hopes you will educate, innovate, and connect with other medical professionals. For more like this, head to https://codachange.org/podcasts/ 

Join Timo de Raad as he discusses the complexities of CPR in paediatric congenital cardiac disease. Timo introduces the listener to Emma, a 4-year-old cheerful and playful girl. Emma was born with hypoplastic left heart syndrome – a condition where the left side of the heart is poorly formed. As a result, the heart cannot support adequate circulation around the body. 5 out of 10 000 live births in the Netherlands have this congenital heart defect. Timo was there for Emma’s birth, and he was there for Emma’s death. Treatment of hypoplastic left heart syndrome is a palliative three stage repair. The first procedure is the Norwood – within the first two weeks. Subsequently the Glenn procedure is undertaken, and finally the Fontan. In this procedure the pulmonary artery and aorta are combined to create one outflow tract from the heart. In essence, this creates one functional ventricle. As a result, there is a change in the cardiac physiology. This changes the dynamics when considering resuscitation in these patients. In Fontan hearts cardiac output is dependent on the preload which in turn is dependent on how much blood flows through the lungs. Accordingly, spontaneous breathing is critical for these patients. Constriction of pulmonary veins make it difficult for blood to flow back to the heart. When dealing with cardiac arrest in these patients Timo suggests treating it the same as any resuscitation – utilising chest compressions and epinephrine (adrenaline). He does suggest one extra thing, that being abdominal compressions. Timo describes the technique he uses. He pushes between the belly button and sternum. He recommends pushing as hard as if you were palpating the liver. In trials on awake patients, there were no complaints of pain when using this technique. Additionally, Timo discusses the ratio of 1 to 1 chest to abdominal compressions during the resuscitation. In conclusion, resuscitation of a paediatric congenital heart defect is challenging. Consider the growing evidence base on abdominal compressions whilst acknowledging the differing opinions in this space. For more like this, head to https://codachange.org/podcasts/ 

Camilla Strom discusses the outcomes for elderly patients in the intensive care. Camilla recognises a persistent “negative vibe” when people talk about elderly patients. This is inappropriate. We should acknowledge older patients for what they are! They are survival masters. This group of people have experience wars, famines, and recessions. They have seen many failures and successes in their long lives. They have overcome all in their path to be where they are today. Healthcare is facing an oncoming flood of older patients. In fact, this process is already happening across the world. The challenge is that these patients cost a lot of money to care for – especially in the ICU. In the general population, there is a 10% 1-year mortality rate for those 80 years and above. This jumps to 40% if they are admitted to hospital. If a patient older than 80 years is admitted to the ICU there is a 50-90% 1-year mortality rate. Therefore, the question is, should this population be admitted to ICU at all? Camilla argues that age is really much more than a number! Life is a deteriorating process. We pay to live our lives. We pay through the accumulation of DNA damage, through shortened telomeres, diminished physiological reserves and loss of muscle function and strength. These are all unavoidable occurrences. Consequently, it is these things we must consider when caring for the elderly people in our communities. Unfortunately, there is a dearth of data when looking patient outcomes in various settings in the hospital. As a result, we have limited prognostication tools. With more research on the way utilising various scores – more concerned with frailty than age – this will change in the future. With that being said, Camilla urges us to consider the patient as more than their age. Age should not be the limit when deciding who should or should not be admitted to the ICU. Talk to your older patients. Determine what is important to them and use your clinical knowledge to help guide their decision-making process. Finally, set realistic goals and re-evaluate them regularly. For more like this, head to https://codachange.org/podcasts/ 

Manu Malbrain presents the four phases of intravenous fluid therapy. He takes you through the big questions of fluids - What, when, why and how? To Manu, there are four Ds of fluid therapy: Drug, dose, duration, and de-escalation Drug Fluids are drugs. This means, like any drugs, consideration must be taken about the type, indication, contraindication, and adverse effects of fluids whenever prescribing them. The evidence suggests that we should stop using starches in sepsis, albumin in TBI and stop using more than 2L of saline in resuscitation. For maintenance – eliminate the use of unbalanced isotonic fluids, and do not forget to cover daily needs. The bottom line is starting to consider fluids as drugs. Dose As Paracelsus famously said “The dose makes the poison” This holds true when administering fluids. There are different doses for different patients dependent on the indication – whether using fluids for maintenance, resuscitation, or replacement. Duration When do you start and stop? You must weigh up the benefit and risk of fluid administration. Duration should be appropriate – more often than not this means tending towards a shorter duration. Similarly, do not use fluids to treat numbers (such as low CVP or MAP) but rather to treat shock. Finally, fluids can be stopped when shock has resolved. De-escalation Water is a problem. Just as hypovolaemia is bad, so too is hypervolaemia. Weigh up the benefit and risk of fluid removal. Manu describes the ROSE acronym – Resuscitation, Organ support, Stabilisation, Evacuation removal. Essentially, after early management with adequate and goal directed fluids, stop ongoing resuscitation, and move to conservative fluid management (de-resuscitation!) We need to make good fluids better So let Manu guide you through the complex world of fluids. Answer the four questions, address the four D’s and remember the four phases of ROSE. For more like this, head to https://codachange.org/podcasts/ 

When looking into someone’s abdomen, the first thing you'll notice is that it almost looks like there is nothing there. For Dr. Lauren Westafer, the gut looks like a black box. There's a lot of gas which makes it hard to see arteries and organs. In this podcast, Lauren discusses point of care Intestinal Ultrasound. To do an intestinal ultrasound, first, rub the curvilinear probe over the abdomen... That's it as far as technique is concerned! There is nothing  overly complicated for such a useful procedure. Why do we still need an ultrasound for small bowel obstructions when we already have other tools like patient history, a physical exam, and x-ray? Unfortunately, these tools are all unreliable for diagnosing small bowel obstructions. What's more, the training for gut ultrasound doesn't take much time. It takes around 10 minutes to do 5-10 scans. The scanning procedure itself takes less than five minutes to perform. For such a high-value procedure, it takes an incredibly low amount of effort and time!  When conducting a gut ultrasound, you are looking for dilated bowel (greater than 2.5 cm) and abnormal peristalsis. Lauren explains exactly what to look for, especially when recognising patterns of abnormal peristalsis. Lauren encourages us to embrace a gut ultrasound. From DAS SMACC, tune in to a discussion on Point of Care Intestinal Ultrasound by Lauren Westafer. For more like this, head to https://codachange.org/podcasts/ 

Neil starts off by telling us a story about a plane that took off from JFK and flew to Portland. As they approached to land, they realised that they had a problem with the undercarriage. Instead of listening and taking advice from the flight engineer, who was on board and aware of the problem, the pilot chose to continue to fly the plane around in circles. This led to the plane eventually running out of fuel and a subsequent plane crash. Tragically, the plane crash killed multiple passengers on board, including the flight engineer. The moral of the story? Don’t be the captain who doesn’t listen and don’t be the flight engineer who didn’t speak up. Neil defines command gradient error as the actual or perceived difference in rank which inhibits communication, leads to a loss of the shared mental model and ultimately an undesirable event. We as healthcare professionals are doing much more to patients than we’ve ever done before. This sparks the need more than ever, to generate teams that are functional and collaborative. As we go through any single job, we may move between leading and following the situation. We should embrace this model of teamwork. Neil’s advice for those leading is to be receptive. We should develop an environment that allows people to question our actions and decisions. When following, we should be assertive. After all, it is usually the people following that have the bandwidth to identify a problem in the first place. In this podcast, Neil Jeffers explains how Command gradient error in Prehospital Care can ultimately lead to tragic circumstances. We should focus on collaborative teamwork and clear communication to ensure that we avoid tragic outcomes for our patients. For more like this, head to https://codachange.org/podcasts/