Coda Change

Daniel Lichtenstein wants to make his past your future. Join him on a journey through the history of lung ultrasound in critical care and resuscitation. The scene is over 20 years ago in the desert of Mauritania. It is a noisy environment full of trucks and planes and motorbikes whipping up sand in a frenzy. You are attending a chest trauma and suspect a pneumothorax. However, in this chaotic environment, chest auscultation with a stethoscope is futile. Daniel describes a visual approach with a portable ultrasound in what was possibly the first extra-hospital ultrasound use. Daniel also has a passion for in-hospital point of care. This stems from a time he “borrowed” an ultrasound machine from the radiology department and reached a critical diagnosis. His journey with lung ultrasound in critical care and resuscitation was born. The usefulness of point of care ultrasound in critical care is far reaching. It is used for subclavian catheter insertion, searching for abdominal blood, and assessing the optic nerve or inferior vena cava. It is even used for assessing the “forbidden” area – the lungs. The use of ultrasound is now ubiquitous; however, this has not always been the case. During its rise to prominence there was a trench war going on and its proponents had to fight claims of ridiculousness! Daniel will highlight the utility of lung ultrasound in critical care, highlighting how proper use of the technology provides a holistic care approach to your patients. He will discuss multiple protocols he has been a part of developing and use them as an example of the philosophy of ultrasound. The ultrasound revolution is certainly happening, but the work that made it possible happened long ago! For more like this, head to https://codachange.org/podcasts/ 

Emotion has a profound effect on decision-making. Chris Hicks demonstrates this as he discusses medical simulation and its ability to teach us skills to manage challenging emotions. As scientists and rational beings, we like to believe that we can control our emotions and make good decisions regardless of the context in which those decisions must be executed – The reality is, that is far from the truth. We rarely take the opportunity to deliberately examine how emotional valence can influence the choices we make, or how we sort and process information as clinicians. Simulation-based training often provokes strong emotions, both positive and negative, whether we intend it to or not. Simulation may be an ideal tool for eliciting challenging emotions – anger, fear, anxiety, joy, prejudice – and developing skills to manage them in real time. Chris highlights a number of strategies to make this process more effective. He recommends starting with developing a fiction contract. This creates by in and ensures psychological safety for all participants. Actors are used in a range of ways in simulation, dependent on the goal. When exploring emotion, Chris demonstrates the benefits of a nuanced character using a technique called immersive experimental roleplay. This creates an environment in which emotions can be really felt and explored. It plays to the idea that the goal of simulation should be to promote the transfer of knowledge to real clinical environments. The use of simulation affords the clinician and opportunity to experience how a rational mind often cannot over emotion. Healthcare is an emotive game. It involves high stakes scenarios under extreme emotional pressure. Recognise that emotion can be used as a heuristic way to make judgements, which is not helpful. Using exercises to provoke emotions better prepares the clinician to make better decision. For more like this, head to https://codachange.org/podcasts/ 

What is New York City style resuscitation? Reuben Strayer and Scott Weingart honed their chops in public hospitals in America’s largest city, where patients come from every country, speak every language, and manifest every physiologic derangement on earth. Preferring to ask neither permission nor forgiveness, Reuben and Scott have long challenged emergency medicine and critical care orthodoxy and developed lateral (though sometimes divergent) strategies in their approach to problems that arise in the care of the sometimes unwashed masses who tend to avoid presenting to medical attention until they’ve fallen off the Frank-Starling curve. Topics that may be discussed (or argued) include the use of epinephrine, the use of noninvasive ventilation, the management of recently intubated patients, the use of ketamine as an induction agent with and without a paralytic, and decision-making in badly injured trauma patients. Ad hominem attacks will be defined and probably employed. Though Weingart has a physical and intellectual disadvantage against the bigger, stronger, quicker, younger, and better-looking Strayer, these disparities will be muted by Natalie May’s capable moderation.

Doctors are usually the ones who rule the resuscitation. They are the ones in charge, the boss, the person giving all the instructions. By design, doctors rule the resus. But what if they didn’t? In order to optimise teams to be seamlessly effective at resuscitation, we need to change the way that resuscitation is done. We need to challenge healthcare to embrace a new model. Ashley Liebig proposes five key concepts for effective resuscitation: 1. Ergonomics should rule the resus. Where are all the people standing? Where is the clock in the room? Where is everything placed? 2. Nurse-led codes should rule the resus. Let nurses run the codes, this is what they are trained to do and it is what they are doing up until the time that the Doctor arrives in the room. For physicians this means cognitive offloading, allowing space to think about the important things and to consider the differential diagnosis. 3. Assigned roles should rule the resus. The importance of assigned roles means that everyone knows what their job is and what is expected of them. 4. Communication should rule the resus. If you are unpleasant to work with, you’ve already changed the scenario. People will arrive at your resuscitation unfocused. Change this. 5. Briefing should rule the resus. Briefing, albeit difficult to coordinate, is important and means that everyone is on the same page. What if in just a few short hours we could take all that we have learned about resuscitation from FOAMed and apply it? What if we could turn an average community hospital ED into a high functioning team? From DAS SMACC, Ashley Liebig delivers an inspiring talk on reinventing resuscitation teams. For more like this, head to https://codachange.org/podcasts/ 

Haemostatic resuscitation of haemorrhagic shock by Wolfgang Voelckel Haemostatic resuscitation of haemorrhagic shock is an area great leaps forward can be made, as Wolfgang Voelckel discusses. Exsanguination and brain injury are the leading causes of death after major trauma. During the last decades, significant progress has been made in the fight against haemorrhage. Nevertheless, the window of opportunity is still small and the golden hour of shock more fiction than fact. Hence, the majority of trauma patients are still lost on the street and during the first hour after hospital admission. Moreover, trauma is an increasing epidemiologic burden worldwide. Pre-hospital emergency care plays an essential role when distances are long and immediate damage control is key. Since evidence of established interventions (such as fluid resuscitation and vasopressor use) is spare, Wolfgang presents his summary of currently available trauma care guidelines. Through this his team has collaborated best practice advice for massive bleeding comprising a five-step approach. First - Identification, on-going monitoring, and appropriate notification of the receiving hospital. Second - Control of haemorrhage by tourniquets and pelvic splints; and advanced interventions, such as emergency resuscitative thoracotomy and resuscitative endovascular balloon occlusion. Third - Target controlled fluid resuscitation within the concept of hypotensive resuscitation in order to prevent hypovolemic cardiac arrest during the pre-hospital phase. Fourth - Pharmacologic interventions employing vasopressor drugs and medication for coagulation management. Fifth - Avoiding mistakes in anesthetised and ventilated patients with critical intravascular volume status, as well as means to counteract inadvertent hypothermia. Finally -  A minimum data set allowing retrospective analysis and system comparison is needed. In conclusion, code red protocols are key in order to reduce pre-hospital care to the max and to pave the way to major trauma care. Current concepts of trauma care with a strong focus on the C-ABC (Circulation-Airway-Breathing-Circulation) approach, hypotensive resuscitation, haemostatic resuscitation, and damage control surgery improve survival after major trauma. For more like this, head to https://codachange.org/podcasts/ 

A no-holes 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.

Leanne Hartnett is a massive fan of bedside ultrasound. Here, she tells a story of using ultrasound for the diagnosis of acute pulmonary embolus and the decision-making process for management. This is the story of a 65-year-old man who was brought into the Emergency Department with acute shortness of breath and chest tightness. This was on a background of motor neuron disease, due to which he was confined to a wheelchair. Despite this he reported a good quality of life. He enjoyed getting out and about with his wife, spending time with his family and reading the newspaper. In saying this, he was aware of the seriousness of his disease, and did not want any invasive treatments or CPR. The history and examination were unremarkable, although Leanne’s clinical suspicion of a pulmonary embolism was still high. She wanted to order a CT pulmonary angiogram. However her patient was sure he would not tolerate laying flat for that length of time. So, Leanne wheeled over the ultrasound machine. Despite the technical difficulties of the task, Leanne was able to obtain reasonable images of her patient’s cardiac structures and function. A parasternal long axis view showed a right ventricle doing not too much. A parasternal short axis view demonstrated a big right ventricle and small left ventricle. It also demonstrated an intraventricular septum that was flattening in diastole. Finally, an apical four chamber view showed a big hyperdynamic right ventricle and something flicking about in the right atrium. It was a cord like thrombus! Leanne was thrilled that she had been able to diagnose the patient using history, examination, and echocardiogram alone. Next, Leanne sought a colleague to discuss the situation and to review the literature of the different treatment modalities for right heart thrombus in transit. They determined that the literature suggested the best outcomes in terms of probability of survival was better with thrombolysis or embolectomy compared to anticoagulation. Armed with the correct diagnosis, and a evidence based treatment Leanne was able to successfully manage this patient. Her message is that patients who present with pulmonary embolism and right heart strain are high risk. Thrombolysis and embolectomy are both effective strategies. Finally, basic echocardiogram skills can make a massive difference to your patients. For more like this, head to https://codachange.org/podcasts/ 

The arrested heart surgery patient is a unique beast in surgery and critical care. Dr Nikki Stamp gives a whirlwind tour of post cardiac surgery resuscitation. She will discuss how to spot the potential arrest, how to manage it and some special situations to be aware of in this special group of patients Post cardiac surgery resuscitation is complex. Nikki describes them as “brown trouser moments”. She highlights this with three cases. A15-year-old girl who exsanguinated on Day 12 after dissection repair in the community. A 40-year-old female arrested within an hour of a re-do aortic root procedure. A 72-year-old lady who arrested after a bradycardic arrest following an aortic valve replacement. Only one survived – this is serious business. Cardiac arrest post cardiac surgery is relatively uncommon. The survival rate is also quite high. This is due to it being recognised and treated early with a high proportion of reversible causes. The key is to think of these causes and treat them as a team. Nikki breaks the causes into four groups. Ischemia, mechanical, arrhythmia and unknown. It is important to recognise that cardiac arrest in this population is differs to a typical scenario of cardiac arrest. As such, there is a different algorithm. This hinges on assessing the rhythm in the first instance and consider defibrillation fist if appropriate. One should also consider the use of pacing wires if they are still in post-operatively. Nikki provides a great number of clinical pearls, discussing care of the right heart, use of chest compressions and cardiac massage, use of ECMO and considerations if a left ventricular assistance device is in place. Her take home points include being alert to these situations but not alarmed! Practice these resuscitations as a team. Shock early and pace early and remember most people should not die with a closed chest! For more like this, head to https://codachange.org/podcasts/   

Management of Status Epilepticus in Neuro Critical care Brandon Foreman talk about the management of status epilepticus in neuro critical care. What are seizures? Why is this important? There are 1 million ED visits due to seizures every year with a quarter getting admitted to the hospital. 1 in 10 people will have a seizure in their lifetime. It is common. Status epilepticus is defined as seizures lasting greater than 5 minutes or recurrent seizures without interval recovery back to baseline. Practically speaking, if the person is seizing when you walk into the room or they remain comatose after they just seized, assume they are in status epilepticus. A key point - the longer the seizure, the greater the mortality. So early and effective management is critical. The first line of defence is benzodiazepines. Give it however you want, give it fast and give it in the correct dose. Brendon stresses dosage is really important. This treatment is effective, with one study showing by following a status epilepticus protocol, 74% of status epilepticus patients had resolution compared to only 29% without adequate treatment. After 20 minutes, the patient is still seizing. Now what? This condition is now defined as established status epilepticus, and you must move to second line treatments. In this category there are a lot of choices. They are of course all intravenous drugs. They all have pros and cons so use what you have available and what you are comfortable with. Again, whatever you chose, use the right dose. If after 40 minutes you are still not winning, move to the next step. At this stage the seizure might look like it is controlled due to electromechanical dissociation. However, this is commonly non-convulsive seizure activity. Get started on the third line of defence… do not muck around with more benzodiazepines or second line agents. You now move to starting an anaesthetic and securing the airway. Use whatever is available and whatever you are most comfortable with. By treating and controlling status epilepticus in under 60 minutes and you have a real chance of reducing mortality and morbidity in these patients. For more like this, head to https://codachange.org/podcasts/