Coda Change

Dr Suman Biswas is a UK based anaesthetist known for his musical talents. He and a fellow medical student began performing hilarious medical parody songs, perhaps the most famous is his 'London Underground song'. The two students were catapulted to fame as the "Amateur Transplants" but sadly parted ways in 2011. Suman works full-time as an NHS EnglandAnaesthetist. Here he performs live on-stage at the enormously popular medical conference SMACC (Social Media and Critical Care) in Berlin Germany 2017. The audience of over 2000 medical delegates goes wild. Tune in to hear some of your favourite songs masterfully re-purposed for Suman's medical parody. You are guaranteed to to laugh at the wit and irreverant humour. For more head to: codachange.org/podcasts/

Clare Richmond discusses medical simulation and its ability to provide a safe working environment anywhere. Simulation is a tool which allows us to rehearse our skills and scenarios before they happen in real life, to real people, our patients. Many clinicians dislike simulation, they know it is good for them, but find it challenging to drop into a world of manikins, fear performing in front of their peers and find debriefs uncomfortable. This talk will consider the purpose of simulation and its role in providing a safe working environment for clinical care anywhere. As a junior doctor Clare always found simulation hard. A combination of talking to a plastic model, having to debrief, and trying to figure out the endemic of cardiac arrests in mannikins were all challenging. However, Clare now provides a useful overview to medical simulation and some handy tips into making the most of the simulation experience. The beginning, or pre-brief, provides an opportunity to improve learning. Here there should be consideration of psychological safety for the participants. It is a chance to immerse the learners for their improved learning. The scenario is where all the learning migrates from. It is central to the exercise. The case must come from reality. However, Clare cautions against a case that has truly come from real life. Instead draw from a real case a condition and cause, complications, and co-morbidities. Add to the case a sense of humanity, be it a husband, a child, a family, or a story. This reflects the complexity of real life. Do not forget to challenge participants to remove them from the comfort zone and into the learning zone. Every twist and turn must have a reason for being there. Keep it real and authentic and align it with the objectives of the experience. Keep the simulation somewhat real. This means real equipment and real collaborations with other health care professionals where possible. Also consider using humans as real patients. Lastly, debrief and reflect on the learning experience. This should be approached with curiosity. Re-run scenarios if need using the ‘pause, reflect, repeat’ model. Clare finally advises all to prepare for the expected and rehearse for the unexpected. Things do happen. Medical simulation ensures you will be as prepared as you can be. For more like this, head to our podcast page https://codachange.org/podcasts/ 

Michelle Johnston presents her thoughts on acute myocardial infarction, thrombolysis and haemorrhage. She delves into David Foster Wallace, evolution, and what do when the thrombolysis bisque hits the fan. Michelle’s interest into acute myocardial infarction, thrombolysis and haemorrhage began one day when she received a call from a peripheral hospital. A local farmer has presented to the Emergency Department with what turned out to be a big anterior infarct. As Michelle points out, he quite appropriately underwent thrombolysis. The gentleman’s symptoms and ECG trace began to settle and a transfer to Michelle’s hospital was arranged. Then he developed massive haematemesis. And to make matters worse, the gentleman turned out to be a dear friend of Michelle. Not to worry she thought… we will just reverse the effects of the thrombolysis. However, after a brief panic, a quick review of the guidelines, and consultation with the colleagues, Michelle realised that a massive knowledge hole existed! Even after getting the opinions of a haematologist, a neurologist, a respiratory physician, a cardiologist, an intensivist and an emergency physician on how to reverse thrombolysis – no clear and satisfying answer was forthcoming. Michelle was left with a big, fat, pile of questions. This led Michelle down the path of investigating how to reverse thrombolysis. This quest took her on a deep dive into the mechanism of tissue plasminogen activator (tPA), and the coagulation-fibrinolysis system. All this via the dinosaur museum, Carl Sagan, human evolution and irreducible complexity. She provides an entertaining and fascinating tour of what is known (or rather not known) about this human physiological mechanism. Through her pursuit of knowledge, Michelle comes to recognise that we either know an incredible amount or absolutely nothing. Michelle concludes that the future of thrombolysis reversal probably lies in not having to reverse it at all. Rather it would be better to have something that removes the clot more effectively and safely in the first place. For more like this, head to our podcast page: 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.

For Trish Henwood, ultrasound use in resource limited settings is a perfect fit. Nowhere has Trish seen ultrasound have more of an effect on patient care and outcomes, and save more lives, than in resource limited contexts. Trish uses the example of a training program in Zanzibar to highlight the scope that ultrasound provides. Using ultrasound on a daily basis to the medical centre is able to screen for antenatal complications that may necessitate transfer to a setting with a higher level of care. Trish also leans of health professions recounting their experience with ultrasound. Fatma – a nurse/midwife – recounts her tales of finding many cases of molar pregnancies, placenta previa, eclampsia and ruptured ovarian cysts. Through the available resource of ultrasound, she has saved many lives (of both mothers and babies.) Gabin in Rwanda has taken the basic ultrasound training he received to diagnose a multitude of cardiac conditions in his centre and Olivier tells the story of a young man with an altered mental status on whom he diagnosed infective endocarditis using ultrasound. These real-world examples show a tiny fraction of the benefit of ultrasound in resource limited settings. Although there are challenges to initiating training programs including resources and equipment limitations, focusing on the bright spots is important. Similarly, the scale of need, wide burden of disease, and complex systems challenges can at times be overwhelming in the global health arena. Focusing on small wins and long-term investment is key to programmatic success and sustainability. Training clinicians in bedside ultrasound effectively uses the same human resources to help shrink the gap between the broad imaging needs of a population and limited consultative capacity of radiology. The result is enhanced patient care, provider empowerment, and improved job satisfaction. Growing point-of-care ultrasound trainees into trainers themselves allows for local solutions to ongoing education needs and helps develop and address the most relevant home-grown research questions, results of which may have broader international practice implications. Building broader networks for bilateral point-of-care ultrasound training and research opportunities will be of global benefit. For more head to: codachange.org/podcasts/

Marcelo Amota makes the case for why driving pressures matter during mechanical ventilation in critical care. Sao Paulo, Brazil, experiences flooding every year. This exposes locals to Leptospira bacteria. The severe form of disease this causes – leptospirosis - sees patients end up on mechanical ventilators. These machines were traditionally complicated, with a huge number of settings and buttons. Marcelo Amato trained in this setting. He, alongside his colleagues, developed methods to halt bleeding in leptospirosis by manipulating ventilator settings. He calls it “protective ventilation”. It was not long before the same principles were being applied to patients suffering acute respiratory distress syndrome. Through research, Marcelo and his team concluded that driving pressures, above all other ventilator settings, were most important for patient survival. Driving pressure is the oscillation of alveolar pressure or variation of pressures inside the lungs. It is what your lungs are sensing. Although there is an obsession with tidal volume, which is displayed on ventilators, Marcello explains, driving pressures are easily calculated and more important. Marcelo discusses the increasing mortality with mechanical ventilation. The medical community, especially physiologists, are traditionally wrapped up in the concept of volutrauma. However, it is the gradient of pressures oscillating inside the lung (the driving pressure) that is causing lung injuries. So, the question became - would the lessons learnt the study on mechanical ventilation for leptospirosis be transferable to reducing risk in acute respiratory distress syndrome? Marcelo presents over twelve years of research. In doing so he highlights the changing dogma of the protective role of small tidal volumes. Research shows that the size of the tidal volume does not matter in terms of mortality. What matters is the pressure that is generated. The force with which the lung is deformed is much more important than the size of the deformation. The message: Do not look at absolute pressures, rather look at the swings in pressure. The only way a patient can survive is through a decrease in driving pressure, and not through a decrease in tidal volume. For more head to: codachange.org/podcasts/

The healthcare ethics of alcohol related harm and driving change by Diana Egerton-Warburton Diana Egerton-Warburton talks about how to be a hero by championing healthcare ethics of alcohol related harm and driving change through stories and data. Have you ever saved a life? Many doctors and nurses have. But, how do you save a life without putting scalpel to skin or picking up a laryngoscope… or even having to go to a hospital? Diana Egerton-Warburton answers this question through the powerful tool of stories. Diana was put on the path of healthcare ethics over twenty years ago. She describes an emergency department shift that changed and shaped her. She sets the scene in the Western suburbs of Melbourne… Heroin bathed the streets and ocean of alcohol. One Australia Day sticks with her. In one Emergency Department shift, Diana saw seven separate episodes of alcohol related family violence. The stories still haunt Diana to this day. Broken bones, abdominal pain, an overdose, a cut lip – these were the faces and tales of the alcohol related violence that arrived in the Department that day. They were all survivors of domestic violence on Australia’s National Day. Through this experience, Diana was motivated to make a change. However, what she thought was a potent advocacy tool in research left her feeling frustrated and thirsty for more. Any one research project only applied to a small portion of patients. To make matters worse, policy makers did not listen, to the results, even in the face of clear data. There was just no traction in policy change. Diana’s answer? Use stories to make data real and to give it superpowers. This is the story of the ACEM Alcohol Harm (AHED) project. For the first time on a national scale the project quantified the level and effect of alcohol harm presenting to Emergency Departments (ED) in Australia and New Zealand. Over 100 EDs and more than 2000 ED clinicians have been involved. AHED provided an evidence base to advocate for measures to reduce alcohol harm through using evidence and clinician anecdotes. Through this strategy, clinicians are placed in a powerful position to influence culture and policy change The change in approach has yielded fantastic results in other areas. Needle and syringe exchange programs and naloxone prescribing Melbourne, decreasing blood alcohol driving limits New Zealand and data sharing amongst emergency providers to reduce alcohol related violence occurring in Cardiff have all been driven by individual clinicians with a story. So, the challenge is there. Draw your sword, raise your shield, and become everyday heroes through the power of stories and data. For more head to: codachange.org/podcasts/

Annet Alenyo Ngabirano was enjoying the community medical placement in the 4th year of medical school. Placed 60km from the nearest hospital, in the lush hills of Uganda, the days were filled with vaccination drives, local outpatient clinics and lazing about. That was until a frantic nurse burst into the room and rushed the three medical students to the bedside of a severely sick and dehydrated infant. There was no doctor. There was no senior nursing staff. They no training, no equipment, no backup, and no resuscitation area - yet this small group of 4th year students were the only hope this small baby had. After trying to gain IV access for over 30 minutes, Annet felt exhausted, overwhelmed, under equipped, under resourced and alone. This is emblematic of where Emergency care in Africa has come from. Over 85% of the world’s population live in Low and Middle Income countries. Health statistics in these countries are characterised by numerous deaths from treatable time-sensitive illnesses and injuries resulting from inadequacies in health systems, particularly Emergency Care. However, across the world, Emergency Care continues to grow, and every country has a story to tell. There are similarities in our stories: the overwhelming sense of responsibility, the exhaustion and feeling of being undervalued. But there are also glaring differences in quality. Africa can be better and it should be. 2017 marks 10 years since the first Emergency Medicine Physician graduated in Africa. From one single Residency program in 2007, there are now 11 more in 9 of Africa’s 54 countries. 2009 saw the formation of The African Federation for Emergency Medicine (AFEM) supporting Emergency Care development across Africa. AFEM’s projects include: - The biennial African Conference on Emergency Medicine (AfCEM), the only scientific conference on African emergency care. - The Annual Consensus Conference that addresses various aspects and challenges of Emergency Care in Africa. - A quarterly international, peer-reviewed journal, publishing original research on topics relevant to Africa, freely available online and offering free publication support to African researchers through Author Assist. - Supadel, a peer-to-peer sponsorship program funds attendance of practitioners to AFEM-affiliated conferences on African soil, allowing them to network and learn valuable lessons in Emergency Care to improve systems in their countries. Emergency Care is a specialty that allows our humanity and compassion to touch and connect with people - not just patients, families, and communities but the whole of humanity. It brings us together. By recognising Ubuntu - the belief in a universal bond of sharing that connects all humanity – Annet knows that Emergency Care in Africa can, should and will be better. For more head to: codachange.org/podcasts/

Trial design is the biggest problem with Evidence Based Medicine in the Intensive Care Unit. Paul Young wants to change that paradigm completely. He argues for research as we know it to change and to focus on clinical care with systemised and optimised treatments that reliably improves outcomes over time for all patients. Mortality measured at a particular time point (landmark mortality) is often regarded as the gold standard outcome for randomised controlled trials in Intensive Care Medicine. An important limitation of many Intensive Care Medicine trials is that they hypothesize large and potentially implausible reductions in absolute mortality. This is a major problem in trial design for two reasons. Firstly, it makes false negative trial results more likely. Secondly, the less plausible a postulated mortality reduction is the more likely that a statistically significant mortality difference will represent a false positive. This is because a p-value is defined as the probability of finding a result equal to or more extreme than that actually observed, under the assumption that the null hypothesis is true. This means that the greater the pre-trial chance or prior probability that the null hypothesis is correct, the lower the chance that a p-value below a particular significance threshold will represent a true positive. In Paul’s words, p-values suck! The biggest single problem with the current evidence base is that most hypotheses being tested have low prior probability. This leads to the two most likely results being 1) no difference or 2) a false positive. We need a new research paradigm to address this problem, particularly in relation to the fundamentals of Intensive Care Medicine. Paul argues for an approach based on the Bayesian approach, utilising big data sources about patients under current care and then randomising treatment in real time. Intensive Care therapy is fundamentally about providing supportive care, including airway support, oxygen therapy, ventilation therapy and haemodynamic support amongst others. These treatments can be uncertain. Under such conditions of uncertainty and idiosyncratic practice variation, treatment should be randomised. Randomised treatment is likely to be the best treatment is these situations due to inherent cognitive biases. Using this data, Paul stipulates that we will rapidly learn from every patient, ensuring improved outcomes for each subsequent patient. As knowledge grow, prior probability can be adjusted, skewing the randomisation process. This continues until the treatment has either proven effective, or been shown to be equivalent. Every patient contributes information that enhances the care of every subsequent patient. And, importantly, p-values no longer matter. Effective research is important. As Paul states, “Optimising ICU care is a priority for global public health.” By increasing the probability that patients will get the treatments that work even before we know what those treatments are the Intensive Care Unit can not only save money, but most importantly and critically, save lives. That is the way research should work. For more head to: codachange.org/podcasts/

David Carr delivers an “old fashioned” talk, presenting his approach to the diagnosis and treatment of endocarditis in acute medicine. Whilst some may turn their nose up at what David describes as esoteric bedside medicine, the rare diagnosis of endocarditis is a bad diagnosis. It carries with it a mortality rate of between 15-30%. David attempts to rebrand endocarditis and make it sexy again. Who? There are four main suspects of getting endocarditis. If you turn up to David’s Emergency Department having had a cardiac valve replacement, the assumption is that you have endocarditis. 1% of these patient per year will develop endocarditis. A valve replacement plus fever or feeling unwell should raise the suspicion even higher. People who inject intravenous drugs are the second population of suspects for endocarditis.15% of people who inject IV drugs entering the hospital with a fever will have endocarditis. You must respect this population, and they need to come to the hospital in these instances. Marantic endocarditis (or nonbacterial thrombotic endocarditis) occurs in patients with active cancer – making this group the third group in whom you should consider the disease. Finally, lupus patients can develop endocarditis - Libman–Sacks endocarditis – related to their antiphospholipid syndrome causing a hypercoagulable state. Four patients, four suspects. These patients present with an association. David presents this as “fever PLUS one”. Fever plus any one of stroke, back pain, heart failure or arrhythmias should raise suspicions of endocarditis. So how should these patients be examined? Well first measure and confirm the fever. Secondly, dust of the stethoscope because up to 90% of patients with endocarditis will have a murmur. Forget the classical signs and look in the mouth at the teeth. Dental procedures in the two weeks prior to presentation is highly suggestive in the right patient. David concludes the talk with management principles. Blood cultures – three sets, three sites! Resist the temptation to give antibiotics in the first hour while you are doing this. Look up or ask colleagues about the blood culture results, and if the bacteria doesn’t fit the crime, be nervous! Lastly, managing endocarditis is a team game so involve the team early including cardiologists, cardiac surgeons, and the infectious disease doctors. Join David as he rebrands endocarditis providing you with the framework to identify the disease and avoid the pitfalls in preventing you nailing down this diagnosis.  For more head to: codachange.org/podcasts/