Coda Change

From DAS SMACC, Vera Sistenich explains why it is critical that we care about the global refugee crisis. The global refugee crisis exemplifies some of the greatest challenges facing our global institutions and liberal world order today. From human rights, to xenophobia, sexism and economic protectionism, terrorism and climate change. National and international responses to the refugee crisis are sculpting moral and political norms around the globe. It is critical that we care about the refugee crisis today because it exemplifies some of the greatest challenges to our social order. As Hannah Arendt, the German-born Jewish political theorist wrote, "The manifestation of the wind of thought is not knowledge but the ability to tell right from wrong, beautiful from ugly. ...[T]hinking gives people the strength to prevent catastrophes in these rare moments when the chips are down". It is now critical that we not only care, but think deeply, about our attitudes and policies towards refugees, wherever we come from. Tune in to an engaging and informative talk by Vera Sistenich, as she challenges us to consider how the global refugee crisis threatens liberal world order. For more like this, head to https://codachange.org/podcasts/ 

John Greenwood discusses the use of vasopressors in the emergency room. His talk focuses on three areas. First, he reviews vasopressors and categorises them based on resuscitation end points. Secondly, he addresses the concept of “pressor angst” and how it can significantly impact patient mortality. Finally, he will empower you to start vasopressors early in patients with distributive shock and sepsis. The tale of a 45-year-old lady with sepsis in the context of pneumonia is retold. John asks - what do you do? Initial fluid resuscitation has improved the vitals somewhat, but she is still hypotensive. Continue to give fluids? Sure – it seems to be what happens commonly. Starting vasopressors starts a cascade of events that will consume time and resources. It impacts flow, timing, and ability to see other patients. Often, the clinician knows it the right thing to do but does not want to pull the trigger. This process of having two conflicting beliefs in your brain at the same time is cognitive dissonance. In the context of using vasopressors, John terms this “pressor angst”. The hesitation to use vasopressors even when perhaps you know it is the right thing to do. It is a complex confliction of behaviours, beliefs, goals, and practices. Regarding vasopressors specifically, the clinician will be considering the logistics, bed crunch and procedures amongst other things! Why does the time matter? As John explains with reference to the literature, the time to the decision to commence vasopressors is hugely important in influencing patient mortality. There is a clear mortality benefit to starting vasopressors early. Norepinephrine started early can aid in adjusting preload, cardiac output, and afterload parameters. John steps you through the effect of norepinephrine on all metrics that contribute to. The conclusion is that early norepinephrine administration improves both macro- and microcirculatory function in vasoplegic shock. John wants you to avoid pressor angst! Do not be afraid of vasopressors and pull the trigger early. Finally, consider norepinephrine early in sepsis. For more like this, head to https://codachange.org/podcasts/ 

Luke Regan presents the emerging evidence for prehospital ultrasound and telehealth in his talk from the SMACC stage. Luke has a personal interest in improving prehospital care. He lives in the north of Scotland. It is an austere and challenging environment, far from technology. Compounding this, it is underserviced and there is an absence of critical care with no critical in reach. Unfortunately, the morbidity and mortality of the area does not match the spread of care. Therefore, it is one of the motivations for his research. That being said, he is not alone in his desire for this research. Pre-hospital ultrasound topped the list of technology-based research priorities in pre-hospital critical care, as determined by a European research collaboration. This is in large part because much of what is done in pre-hospital care still exists in an evidence free zone. Luke discusses the extended pre-hospital patient journey in his practice. This presents a challenge, but also an opportunity. If time zero is further back, testing a pre-hospital intervention becomes very achievable. There is precedent for this. Benefit of pre-hospital interventions have been highlighted by the relative benefit of stopping and performing roadside ECG in transit. This has allowed road crews to receive updated treatment advice based on that ECG. This bundle of care is similar to what is possible with pre-hospital ultrasound. Currently, there is a very apparent practice creep when it comes to the use of ultrasound. This means there is an increase in the use of pre-hospital ultrasound around the world. However, it remains an evidence poor area. Luke describes two studies conducted in Scotland looking to answer the big questions in pre-hospital point of care ultrasound (POCUS). Firstly, can it make a difference? Secondly, does it take too long? Finally, who should do it and how long does it take to train them? This is done in large studies, with lots of patients and inputs from a diverse meeting of minds. Join Luke Regan as he discusses the evidence behind the application of pre-hospital ultrasound and telemedicine. For more like this, head to https://codachange.org/podcasts/ 

Sara Gray discusses the complex topic of prognostication post cardiac arrest in neuro intensive care. There is a short list of things that keep Sara up at night. She describes a specific cardiac arrest nightmare she has. She is looking after a patient post cardiac arrest. They remain in a coma after cooling. As they meet brain death criteria and they are an organ donor, they are transferred to the operating room. Whilst there, they regain spontaneous respirations. Although this is terrifying, these situations do happen! And cases like this defy all efforts at accurate prognostication in post cardiac arrest patients. Prognostication matters. It matters for the patient, their family and got judicious resource management. The trouble is, that varying guidelines around the world do not agree. In patients who have not been cooled, then you may start prognostication 72 hours post return of spontaneous circulation (ROSC). Before that time the brain may not have had adequate time to heal from the arrest and the clinical indicators may not be accurate. In the hypothermia group there is differing guidelines. Some guidelines suggest doing it the same way – prognostication after 72 hours. Others suggest 72 hours after achieving normothermia. This equates to 4.5 days. Why the difference? Different medicolegal environments may play a part. However, as Sara explains, some guidelines may be guided by concern over the emerging data about people who wake up late. Sara fears looking a family in the eye and telling them the patient won’t wake up and being wrong. Her advice is to wait 4.5 days. She then recommends starting with a subgroup of patients with a low motor score on GCS. From there you can use indicators with the best accuracy which are bilateral absence of pupillary response, corneal reflex, and somatosensory evoked potentials. Bilateral absence of all three equals a dire prognosis. For more like this, head to https://codachange.org/podcasts/ 

A no-holds barred series of 6 provocative medical interrogations. We challenge the state of research, social media, pharmacology, social work, women in medicine, medicine in the developed work, and the health of healthcare workers. It should be novel, it may get heated, and it is not scripted. Sometimes to comfort the afflicted you also need to afflict the comfortable. This is why no prisoners will be taken, no topic is out of bounds, and no ego will be pampered. It may even offend: you have been warned.

Raed Arafat describes the amazing lessons he has learnt about functional systems for emergencies, mass casualties and disasters. SMURD (Mobile Emergency Service for Resuscitation and Extrication) is in Emergency Rescue Service in Romania. It was set up by Raed Arafat in 1990 to respond to a largely non-existent and broken system. By doing so, he created a pre-hospital care system that he could be proud of. SMURD has today transformed into an integrated, country wide, emergency response system providing high quality care. Romania is one of the only countries in Europe where you have a right of emergency care. That is, you cannot be charged for being rescued or accessing emergency healthcare. This is largely due to Raed Arafat. He has created a functional system that deals not alone with daily emergencies, but also disasters and mass casualties. The national monitoring system and coordination service responds to fires, emergency incidents, critical transfers, and supports the whole country with resources from a national level. To highlight the amazing work that SMURD does, Raed describes in detail the service’s response to two tragedies involving Romania. The first happened in Montenegro, in 2013. A Romanian tourist bus fell 40 metres off a cliff. 19 people were killed and 28 were injured (12 of whom were in a critical condition). What followed was a large scale patient transport and casualty repatriation effort that included local ambulances, SMURD vehicles and military aircraft. The second incident was a tragic fire in a nightclub set off by fireworks. 400 people were trapped inside. The emergency response was mobilised an arrived in 11 minutes. In the minutes, hours and days that followed, SMURD coordinated the mass rescue, treatment, and transfer of patients. This included sending 41 patients to other countries, due to the high number of them that were critical. Despite these extraordinary efforts, SMURD consistently faces backlash and criticism. Raed takes the opportunity to answer his critics from the stage. Listen in to Raed as he demonstrates the enormous capability of SMURD. From disaster response to resource management and deployment, their reach is impressive. As Raed says – it all boils down to teamwork and functional systems that work both from the bottom up and the top down. For more like this, head to https://codachange.org/podcasts/ 

Haney Mallemat states the case for ultrasound in cardiac arrest resuscitation. He tells the story of Stephen, a 43-year-old male who suffers a cardiac arrest. Unfortunately, whilst looking for reversible causes with a transthoracic echocardiogram (TTE), chest compressions stopped, and Stephen died. Enter the trans-(o)esophageal echocardiogram (TEE). A trans-esophageal echocardiogram is an amazing diagnostic tool. It works in exactly the same way as any other ultrasound – there is a transducer on the end of a handle. The difference is that the stem is flexible and inserted down a patient’s oesophagus. This provides fantastic clear images in any patient, with no soft tissue or bones in the way. The beauty is, if you already know how to look at transthoracic echocardiogram, then there is no learning curve. The images are just flipped. TEE can rapidly identify reversible causes of cardiac arrest, for instance a pulmonary embolism, a clot in transit, aortic dissections or papillary muscle ruptures. It can do this without causing any interruptions to the resuscitation effort, including the chest compression. TEEs can also demonstrate the effectiveness of CPR in real time – goal directed chest compressions. In a similar vein, TEE can measure the depth of compressions providing valuable information for the team involved in resuscitation. Back to Stephen. Instead of interrupting chest compressions, a TEE was used instead. A TEE echocardiogram elicited fine ventricular fibrillation that was not picked up on telemetry. This led to a lifesaving intervention, and Stephen walked out of the hospital a few weeks later. Henry will convince you that TEE is a game changer in cardiac arrest resuscitation. TEE provides high quality images of the heart without interruption in CPR. Additionally TEE provides useful information about compression depth and quality that no other diagnostic tool provides. For more like this, head to https://codachange.org/podcasts/ 

Pik Mukherji will change your mind on assessing risk and benefit in resuscitation. There is a bent towards action in the Emergency Department. This is for a few reasons. We are risk adverse – we do not want to miss the acutely sick patient. We do not want to miss the patient that “falls of the cliff”. In fact, as Pik discusses, in emergency medicine and critical care, training is focused on looking for the sharks, even when the waters appear friendly and calm. This is highlighted acutely well by Pik in a story about an elderly gentleman. The man presentedto the ED after a minor trauma. On history and examination there was nothing to find, apart from a minor scrape. Due to the risk adverse nature of the ED, the patient got a CT scan. It showed an acute subarachnoid haemorrhage. This meant he stayed in hospital for observation. The next day he fell off a bed being transported back to the scanner and disaster followed. On review, the original CT showed no abnormalities. This story highlights the risk of the devastating harm that can come to patients in the medical system. Every time a test is ordered there is risk of incidentalomas, biopsies, and repeat visits – to name a few. Pik wants to drive the message home - not every patient can be helped. Every patient can be hurt. Time and time again, doctors overestimate the benefits of their treatments and underestimate the harms. Even armed with this knowledge and knowing the guidelines does not seem to change behaviours. Pik demonstrates this fact with the live SMACC audience where he shows this “cover my backside” mentality in real time. Unnecessary testing and over cautious approaches flying in the face of the evidence. As health care professionals we are taught to “do”. We are programmed to act. The trouble is that sometimes the only person this is benefitting is the clinician. After all, we feel better having done something over nothing. Hippocrates was wrong! “Do no harm” is impossible. So, take a step outside of your comfort zone and try to do less. For more like this, head to https://codachange.org/podcasts/ 

Brandon loves wavy lines. He will draw the curtain on the use of continuous EEG in neuro critical care. Brandon will first take you back to medical school with some neuroanatomy and physiology to underpin you understanding of the EEG. He then steps you through what an EEG is telling you. Bumps, lines, amplitudes and hertz are all demystified. With this knowledge, there is a lot you can do with continuous EEG. A few examples: EEG can be reflective of external stimulus – be it a shock, a sound, or a pinch. This is used to test for reactivity and is useful at the bedside. Reactivity demonstrates whether a signal is getting from the body to the brainstem, to the thalamus and to the cortex. Reactivity is one of the most conserved, independent prognostic indicators in coma – making it important to capture using EEG. EEG is fantastically active when you are asleep. In the ICU, an EEG can show atypical sleep – indicating they are very unwell. Due to sleep being a network heavy, very complicated phenomenon. If sleep is generated on Day 3 post TBI – you have the capacity to recover. With this in mind, Brandon wants you to interact with your patient’s EEG and remember that EEGs are not just for seizures. For more like this, head to https://codachange.org/podcasts/ 

Cliff Reid, an expert at Sydney HEMS, shares his insights on effective crisis resource management in extreme medical situations. He discusses the critical role of structured training, especially non-technical skills often overlooked in medical settings. The concept of the 'zero-point survey' is introduced as a planning tool to prepare for emergencies by assessing Self, Team, Environment, and Patient. Cliff emphasizes the importance of team dynamics and psychological readiness, ensuring teams function smoothly even under pressure.