Coda Change

Maaret Castren passionately delivers her take on how to improve outcomes from out-of-hospital cardiac arrests. Maaret brings resuscitation back to the basics. Using science, education and local organisation factored together, we can drastically improve the chance of survival in out-of-hospital cardiac arrest. Currently, the best systems in the world only garner 20% survival rates in these situations. Mareet explains that quite simply, education is lacking. She believes the first step is to know your patient. 50% of cardiac arrest patients have signs and symptoms in the preceding weeks before their arrests. However, there is no current sudden cardiac arrest risk prediction tool available! Maaret explains the concept of precision medicine – the idea that medicine practised in a one size fits all manner provides successful treatments to some patients but not all. One must consider individual differences in people’s genes, environments and lifestyles. In resuscitation medicine this can simply mean altering hand position based on a patient’s size. Developing a culture of excellence is crucial in improving survival rates. Maaret challenges you to make the decision to not allow anyone suffering a cardiac arrest to die. She challenges you to not accept failure – and if it is to occur then to scrutinise why. Maaret goes on to assert that while people have been trained and equipped with skills to deal with a cardiac arrest, health professionals have been found wanting research. Doctors and nurses have been shown to have less survivors when calling emergency numbers. She wants this to improve through ongoing education and training. Currently there is a huge variation in outcomes for cardiac arrest patients. Measuring your results makes it possible for you to know what to improve. Benchmarking shows you where you need to learn. You need to build a culture of excellence in your own system. Patients are not the same, so we need to also individualise resuscitation. Maaret implores you to make the jump from the current culture to the desired culture and in doing so improve the resuscitation outcomes from out-of-hospital cardiac arrests. For more like this, head to https://codachange.org/podcasts/ 

Resuscitation is complicated, but the solutions don't have to be. Chris Hicks brings you four psychological strategies that will help you manage complex resuscitations. It is a fascinating time to be a resuscitationist with ROBOA, ECMO and EPR. Chris explains that as we learn more about critical illness, we learn more about the complexities of resuscitation. Therefore, we need ways to manage and constrain complexity and to simplify and organise problems that will see us through. Chris’s lessons are founded on a case. A 22-year-old female is brought into the Emergency Department. She was an unrestrained driver in a motor vehicle accident. She is agitated, has multiple facial smash injuries, burns to her torso and neck, a right sided flail segment, and a mechanically unstable pelvis. Also, when you ultrasound her abdomen, you realise she is well into the third trimester of a pregnancy. Chris discusses four strategies to cope in a complex situation. The first is grounded in habits. Habits have a lot to do with whether or not we succeed at a given enterprise. They can help break down complex problems into simpler parts. Once a habit has been practiced and rehearsed, it becomes harder to not execute the habit than it is to execute it. Next Chris advises to foster emergent organisation in the team. This is self-organisation in teams whereby individual simplicity can create organised complexity. During periods of high task loads it makes sense to create smaller teams to create divisional lines. This allows semi-autonomous teams to function independently towards a specific goal. Thereafter, try to factor down complex problems. Take a problem as you see it and lead it in a direction you’d like to see it. By simplifying a problem into a few sentences, you assert that you understand it, and you can then begin to manage it. Finally, Chris talks about limiting variability. This is in order to constrain chaos. Eliminate variables and thereby eliminate unnecessary steps. This can sometimes mean cutting down team size – Chris conjects most teams are too big! Join Chris as he takes you through four strategies to manage complexity in a complex resuscitation. Lean on habit. Foster emergence. Factor down the problem and limit the variables. For more head to: codachange.org/podcasts/

Neurologic airway manipulation is unforgiving; errors lead to hypoxia and secondary injury. Managing the airway with an eye towards success, the first time, every time, without allowing sats to drop below 90% is the holy grail of neuro airways. Selection of RSI techniques, DSI techniques, and pharmacologic management is critical for success. The TBI airway with ICP issues and the post tPA airway present unique problems and the failed extubation in the neurologic patient is as common as the day is long. We will explore the latest theories and data (if there are any) and debunk some common myths together during this session.

Interprofessional issues in critical care Meeting of the Tribes brings together clinicians from a broad range of health professions, including medicine, nursing, social work and physiotherapy, to explore interprofessional issues in critical care. In addition to their clinical work, panelists have unique perspectives on education, simulation and resilience in healthcare. In discussing issues related to tribalism and their implications for interprofessional practice, the panel explore what it will take to overcome a tribal mentality in the service of improved patient care. Tune in to this discussion as the panel strive to: (a) present a snapshot of the status quo (b) explore key issues and their implications for clinical practice (c) envision of future of enhanced interprofessional collaborative practice. For more head to https://codachange.org/podcasts/ 

Ronan O’Leary discusses reversing coagulopathy in traumatic brain injury. The PATCH trial was a trial look at the use of platelets to reverse the effects of aspirin and clopidogrel in patients with spontaneous cerebral haemorrhage. Ronan asserts that overall platelets are harming patients. Through his talk he highlights many studies that have been inconclusive about the benefits of giving platelets in traumatic intracerebral haemorrhage. As one study eloquently described, “It was not possible to determine if platelet transfusion was superior, inferior or not different from control interventions.” So why are platelets given at all? In haemorrhage, reduced platelet activity is associated with adverse outcomes. This is demonstrated with larger haematoma size in patients with lower platelet counts. So, it would make sense that replacing platelets should lead to better outcomes. However, this is not the case. Furthermore, as Ronan articulates, sometimes it just feels better to do something over nothing. The aetiology of the condition probably has nothing to do with platelets in the first place. Instead, non-traumatic intracerebral haemorrhages are likely caused by atherosclerotic disease, with changes in microvascular anatomy and brittle vessels leading to haemorrhage. Further, transfusing a patient with intracerebral haemorrhage with platelets may lead to secondary ischaemic change. Platelets have many proinflammatory and prothrombotic properties. So are the harms of platelets outweighed by the benefits… probably not. Ronan will go on to discuss the potential to extrapolate this evidence to traumatic brain injury patients. He concludes, probably not, mainly due to the mechanism of haemorrhage being the transmission of kinetic energy which is at odds with that of spontaneous intracerebral haemorrhage. For more like this, head to https://codachange.org/podcasts/ 

Moderate panel discussion on FOAM Open Access Medical Publishing Data sharing

The door to needle time for acute stroke in Critical Care is a key variable when striving for good outcomes. Rhonda Cadena answers the question - Who should pull the trigger on tPA for acute ischemic stroke? Medical management of acute strokes has changed dramatically over the years. We used to rely on clinical exams for diagnosis, prescribe strange medications and undertake interventions that were scary! This has changed in recent times. We have now evolved to advanced imaging techniques, new medications and interventions including endovascular treatments. These advances have dramatically increased the likelihood of positive outcomes in stroke patients. The new problem coming to light is time. All the modern treatments that exist do wonderfully well in achieving what they are supposed to. However, the longer it takes for a stroke patient to be get the treatment equates to more deficits and less chance of having a complete recovery. The process as it currently exists can take time. A patient will notice symptoms. They then call emergency service. An ambulance is dispatched, the patient undergoes an initial assessment and is then transferred to the hospital. Here they will be triaged, connected to monitoring, have bloods drawn, have a history taken, be examined… all taking time! Stroke guidelines say the door to treatment time should be 60 minutes or less. Rhonda explains that the focus should be on reducing the time that the process takes. She highlights that most of the time savings should occur before the patient hits the door. That is in the pre-hospital setting. We should be focusing on emergent treatment in the pre-hospital period. Rhonda runs through practical examples of time saving techniques utilising technology and a few simple changes to processes to cut time and improve outcomes. The basics of tPA are spelled out and Rhonda steps you through how a lot of the steps can be expedited along the patient’s early treatment journey. So, who pulls the trigger? Rhonda explains it does not matter! So long as we are saving time in the pre-hospital period, the door to needle time for acute stroke can be reduced and outcomes improved. For more like this, head to https://codachange.org/podcasts/ 

Claire Park delivers a riveting talk, bringing military trauma lessons from MERT (Medical Emergency Response Team) back home. Claire tells two stories from her tours in Afghanistan. The first begins in the early hours of the morning when the MERT team is tasked on a job. They receive word of five casualties including two above knee amputations and one unconscious without a radial pulse. On arrival to the scene the paramedics leave the helicopter to triage and bring the casualties aboard to Claire and her team. They begin to take enemy fire. The second experience was delivering care to an Afghan national soldier with a gunshot wound to the neck. He was alert when he came onboard the helicopter but quickly deteriorated. Claire decided he need to be intubated. However, there was an expanding haematoma across his cricoid area with a deviated trachea. An extremely difficult airway in an extremely difficult environment. The lessons from her experiences as a part of the MERT? Do the basics well. This means prioritising the problems as a team. The hinderance here is becoming too tasked focus. That is why Claire alongside her colleagues developed a time out. With eyes up, they would ask themselves two questions. What have we got? What are our priorities? She advises – trust your clinical decision making in the moment. Experienced clinicians will have “blink” moments – where they make unconscious conscious decisions. The importance is learning from them in the aftermath. On that theme, Claire has experienced firsthand how different people remember events in vastly different ways. She calls them different black box recordings. This makes the debrief essential. Use it as an opportunity to learn from mistakes and errors. Finally, Claire speaks about passion. Passion can eliminate fear. It can turn threats into challenges. Her thoughts are if you do not feel and do not care – you should not be doing the job. Take these military trauma lessons from Claire’s time in MERT and use them to strive to do your best for your patients, every time. For more like this, head to https://codachange.org/podcasts/ 

Join the debate between Bill Knight and Fernanda Bellolio as they go head-to-head, discussing diagnosing subarachnoid haemorrhage in neuro critical care headache. Should you rely on CT and lumbar puncture or, CT followed by CT angiogram. Why should you care? Acute headache accounts for 4% of all visits to the emergency departments. These patients will often describe the “Worst headache of life” – a phrase which can ring the alarm bells in the clincian’s mind. 88% of these will be from benign causes including migraine, tension and cluster. However 10% will have a subarachnoid haemorrhage, of which the vast majority are caused by an aneurysm. These are frequently missed - up to 51% of the time in all settings and 6% of the time in the emergency department. It is in face one of the largest sources of US litigation claims and settlements. So – what is the best way to diagnosis subarachnoid haemorrhage? Bill asserts that the lumbar puncture (LP) following the CT is the way to go. He stresses that the “miss rate” needs to be 0% for subarachnoid haemorrhage. He argues that with the combination of CT and LP the sensitivity for subarachnoid haemorrhage is 100% Fernanda on the other hand is a big proponent of using the combination of CT followed by CT angiogram (CTA). She discusses the very low incidence of subarachnoid haemorrhade and takes this into account when calculating the pre- and post-test probability for her patients. She argues that if the pre-test probability is higher for a patient, then a CTA can be utilised. Bill Knight and Fernanda Bellolio present a compelling case for both sides when identifying the best way to diagnose subarachnoid haemorrhage in neuro critical care headache. For more like this, head to https://codachange.org/podcasts/ 

Prehospital high acuity transport by air rescue has the capability to deliver the sickest of patients to high quality, advanced care, and support. However, not all patients are transferred. Why? Per Bredmose tells the tale of Emma. Emma is a 12-year-old girl who developed a cough. She is admitted to local peripheral hospital, correctly diagnosed with pneumonia, and treated with IV antibiotics. Emma continues to deteriorate and is transferred to an ICU where she fails a trial of BiPAP and is intubated. She continues to deteriorate. She requires high pressure ventilation and vasopressor support – advanced, high end, specialist interventions. The truth… this never happened. This talk from Per is about all the future Emma’s. Someone in the hospital system (either the sending or receiving hospital) decided that Emma was too sick to be retrieved. Per challenges this notion of “Too sick to be retrieved”. He says it is rather a case of being in the wrong place at the wrong time. Or getting the wrong disease in the wrong place. Patients will inevitably be in hospitals that lack essential equipment or knowledge for a given condition. Small hospitals do have some deficiencies. Per advocates for the development of retrieval medicine teams and systems that can assist these patients and bring them to centres that can provide the best care. This requires a team including paramedics, pilots, flight nurses and yes, retrieval doctors who have high end specialist training and experience. The teams need to understand the system, the equipment and be able to calculate the risk-benefit ratio of retrievals. They need access to hardware – whether this be ambulances, planes, or infusion hardware. And they must be able to work within the system in which they are operating. Per advocates for a strong retrieval system, comprised of well support and trained happy teams. This leads to safe retrieval and transport and better outcomes for patients. For more like this, head to our podcast page https://codachange.org/podcasts/