Coda Change

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.

South pole...North pole, hot...cold, on earth...in space, below the sea...on Mount Everest, alone and far, far away. Gaynor Prince takes you to Union Glacier in the Ellsworth Mountain Range, Antarctica, to show you how useful ultrasound can be in extreme environments Gaynor relives the story of being in one of the most isolated places on Earth when she gets a Medivac alert. One of her clients, Jack, has become acutely short of breath. With her list if differential diagnoses including high altitude pulmonary oedema, heart failure and pulmonary embolism, Gaynor was presented with an enormously difficult decision. Whilst Jack’s safety was priority number one, in a place like Antarctica, no clinical decision is easy. With the weather closing in, and a huge amount of time and money having been invested in this journey by Jack and his companions, what was she going to do? The answer? Pull out her Phillips Lumify ultrasound machine. A thorough examination with the ultrasound satisfied Gaynor that her patient was safe and stable. Dry lungs, no elevated right pressures, and no signs of DVT of lower limb – meant Jack could stay at the South Pole. Not for the first time, the ultrasound saved Gaynor’s bacon and highlights why it helps her sleep easier at night. Ultrasound will make extreme environments less intimidating for the doctor by enhancing your diagnostic capability, honing your therapeutic management, and fitting into your pocket. This is a brief tale of a journey to Antarctica with a Phillips Lumify ultrasound. Find your passion and reach for the stars. For more head to: codachange.org/podcasts/

Medical education and clinical programs are designed with four pillars - clinical excellence, research, education, and administration. These apply whether you build and design an ultrasound program or division, a simulation program, a toxicology or pre-hospital program or even an academic department Resa Lewiss describes the four pillars of medical education and clinical programs using a quirky anecdote of four tragic, dramatic and ridiculous stories of childhood dog deaths. Clinical excellence is providing good patient outcomes. Ensuring that staff are well educated and surrounded by working and necessary infrastructure to they can provide quality care. It is a strong and tangible pillar. Research is self-explanatory and demonstrates a program’s credibility locally, nationally and internationally. It is more difficult to uphold, including writing, grants, abstracts and writing manuscripts. Education is what the medical community does, occurring in a number of settings including the lecture theatre and bedside. It is fun, interactive and in real time. Administration is less glamorous, and involves making sure processes work, relationships work and things work. Through the stories of her four family dogs and their demise, Resa illustrates the four ways pillars of medical educational and clinical programs fail. They fail through silent, indolent process – cancer. They can be derailed by others, people and processes who do not want you to succeed – homicide. The clinical program can be the architect of it’s own demise, not publishing, not researching and not conforming to standards – suicide Finally, they can become stale, irrelevant and outdated – old age. Join Resa Lewiss as she remembers the tragic dog deaths of her childhood and what they taught her about medical education and clinical program design. For more head to: codachange.org/podcasts/

In this quick, five minute talk, Brandon updates us on Sinus Venous Thrombosis. This includes what it is, what it looks like and how to diagnose it. Brandon starts with a case – a 37-year-old woman, who is 8 weeks pregnant, presents with what she describes as the worst headache of her life. She has a history of migraines, so this is Brandon’s first thought and possible initial diagnosis. But... it turns out to be more than just a migraine... Brandon explains that what we should be looking for here is venous sinus thrombosis. This is characterised by a sub-acute onset of a headache and risk factors. In this case, hormonal changes which are related to her pregnancy, making her at higher risk. The key takeaway? A headache with risk factors (in particular anything that will cause a Hypercoagulable state) plus or minus seizures, usually means we should be looking for this condition. Brandon suggests that we need to be suspicious of this condition and that we need to look for it. Even if it isn’t obvious at first. Next, Brandon takes us through a second case which tells us that bilateral stroke usually means venous sinus thrombosis, until proven otherwise. From DAS SMACC, tune in to an interesting and quick update by Brandon Foreman on how to identify and diagnose this condition. For more, head to https://codachange.org/podcasts/ 

Fernanda Bellolio guides the listener through an approach to the treatment of wake-up stroke in neuro critical care. What time did the symptoms start? This is one of the most common questions that is asked when taking a history from a patient. However, what happens when this can not be answered. This is the case with “wake-up strokes”. A wake-up stroke is when a person goes to sleep without symptoms and wakes up with deficits. Similar problems in management arise when a person cannot accurately tell the clinician what time the symptoms began. Up to 20% of stokes are wake-up strokes and a further in a 10% of strokes the patient nor family can say exactly when it started. This presents a challenge as many therapies that currently exist are time sensitive and therefore not approved for wake-up strokes. Fernanda reviews the current evidence in the quest to answer three questions: 1) What is the evidence for tPA use in wake-up strokes; 2) Can endovascular treatments be used in wake-up strokes and 3) How can these patients be approached clinically? tPA has not been approved for this patient population due to the inability to know the time of the stroke. However, utilising advanced imaging techniques including MRI, it is possible to get a estimation of the temporality. Using these methods, studies have looked at the use of tPA and shown likely benefit, with acceptable rates of intracranial haemorrhage. Despite this, imaging techniques such as used in the studies are not widely available. Endovascular therapy has a wider window of availability, and the early research indicates this therapy can be beneficial. Thrombectomy similarly showed good outcomes in early trials when compared to tPA. Fernanda sums up the overall approach to the wake-up stroke presentation. Treat it as an emergency, get the history, send off labs and request imaging. Be guided by the stroke protocols that exist in your hospital. For management – at this stage Fernanda highlights that no routine therapy can be offered based on the evidence at the time of the talk. However, multiple ongoing trials will guide future treatment selection. For more head to: codachange.org/podcasts/

Rinaldo Bellomo, a leading critical care researcher from Melbourne, dives deep into the complexities of resuscitation practices. He contends that traditional physiological paradigms in critical care need serious reevaluation, as they often do not align with patient outcomes. Bellomo critiques the reliance on manipulative measurements like blood pressure and cardiac output, arguing they lack a true connection to survival. The discussion also highlights the danger of steadfast beliefs in medicine, emphasizing the need for skepticism and evolution in medical practices.

Brandon Foreman gives a practical approach to the diagnosis and workup of neuromuscular disease in neuro critical care. Neuromuscular diseases are common and include chronic autoimmune disorders such as myasthenia gravis, acute demyelinating disorders like Guillain Barre, paraneoplastic disorders, and toxidromes such as botulism. The presentation of many neuromuscular diseases can be subtle: diffuse weakness, subtle swallowing difficulty, or double vision. Many patients do not present until its nearly too late, and timely diagnosis can lead to rapid stabilization of airway, autonomics, and other potentially lethal complications and expedited treatment of the underlying cause. Brandon’s first piece of advice pertaining to neuromuscular disease in critical care? You have to recognise it! There are subtle clues littered through the history and physical exam of a patient. A nasal voice indicates oropharyngeal weakness. This is important to recognise and can tip you off to the likely diagnosis. New onset eye complaints or proximal muscle weakness will likewise lead the clinician to consider neuromuscular weakness. If a patient presents with a history of difficulty rising from a chair or double vision think of disorders such as Guillain Barre or myasthenia gravis. A big question in the early management of patients with neuromuscular weakness is the need for intubation. Brandon advises throwing away some of the traditional methods of answering this question that rely on lung function testing and often involve a respiratory physician. Instead, he runs through a handy list of diagnostics, possible at the bedside to determine the need for mechanical ventilation in this population. Brandon discusses clinical pearls to hone in out what a patient is presenting with. Test such as Simpson’s test or the “ice bag test” are useful addition to any clinician’s toolbox. Finally, Brandon takes you through the initial workup of patients presenting with likely neuromuscular weakness, equipping you with the knowledge to start the process before calling the neurology registrar! For more head to: codachange.org/podcasts/

Sara Gray works in the Intensive Care Unit and sometimes connects with patients. This was especially true for a lady who was in her unit intubated due to pneumonia. When this patient experienced a failed extubation, a tricky re-intubation and subsequent tracheostomy, Sara was kicking herself. She says we have all been there… Have you ever dropped your phone? What was the internal dialogue in your head at the time? Sara calls this out inner voice. She used to think that our inner voice did not matter to high level medical performance or resuscitation skills. That was until the evidence changed her mind. The inner voice is powerful. A negative inner voice can increase anxiety, raise the heart rate, and use up valuable cognitive processing power. So, when running a complicated situation, your inner voice matters! For Sara, the critical soundtrack of the inner voice was constant. Her question was – how do I change this? This led Sara to the concept of self-compassion. She explores how she trained the inner dialogue, which is a skill to learn and practice. Self-compassion has been shown to reduce the heart rate, reduce sympathetic surges, reduce stress induced immune responses and in practical terms make your hands shake less when is high stress environments in the ICU. Sara expands on the benefits. She suggests that once you are a competent clinician with good theoretical and procedural skills, it can be hard to take it to the next level. However, serious psychological skills are all part of excellent bedside resuscitation. When reflecting on her experiences in her practice, Sara highlights how medicine views calling for help as an act of weakness. In a profession where tiny mistakes lead to life and death consequences, staying silent can lead to shame and isolation. This in turn manifests as burnout, depression, addiction, and suicide. Everyone in healthcare is at risk. It is the price of a culture of silence. The answer to reverse this includes self-compassion. Self-compassion is not a light switch – rather it is something you must work at and practice. Sara tells a story that everyone in healthcare will relate to and walks you through examples of useful resources to assess and work on self-compassion. After this talk learn to listen to your inner voice, practice self-compassion and use skills and empathy to take care of yourself and your community. Self-compassion can make work performance and life better.  Resources to consider: 1. www.Selfcompassion.org This is Dr Kristin Neff’s website, complete with a self-compassion quiz, and then exercises and resources for those who fail the quiz! She also has a book if you prefer that format. 2. Pema Chodron. Fail, fail again, fail better. A short, and lovely commencement address with excellent advice for failing better. https://www.amazon.ca/Fail-Again-Better-Advice-Leaning/dp/1622035313 3. Angela Lee Duckworth. Grit. A marvellous book about the essence of perseverance. Or if you don’t like books, consider her TED talk at https://www.ted.com/talks/angela_lee_duckworth_grit_the_power_of_passion_and_perseverance 4. Brene Brown. The Gifts of Imperfection. A book about failure, and acceptance of failure. Again, if books aren’t your thing, she has a hugely popular TED talk about vulnerability: https://www.ted.com/talks/brene_brown_on_vulnerability and a website/online learning community: https://www.courageworks.com/

Rhonda Cadena explains the process of diagnosing and managing meningitis. It is a skill that involves rapid identification, workup, and treatment. In most cases, the diagnosis of meningitis is not a diagnostic dilemma, but the workup and treatment are not as straightforward. Meningitis is inflammation of the lining of the brain and spinal cord. This can be caused by bacteria, autoimmune process, drug reactions, viruses, and fungi. Rhonda delves deeper into bacterial meningitis. Worldwide there are over 1 million cases per year of bacterial meningitis. This equates to 135 000 deaths. Of the survivors, half will be left with neurological deficits. So, the swift identification and treatment of this disease process is crucial. Symptoms include fever, headache, nuchal rigidity and altered mental status with almost all patients having at least two. A lumbar puncture is absolutely necessary. Only insist on a CT first if you suspect a mass lesion or increased intracranial pressure. Otherwise, the delay in antibiotics can lead to an increased morbidity and mortality. Labs are next in the workup. All the common labs should be ordered along with a procalcitonin which can be diagnostic for a bacterial infection (although it will be positive with any bacterial infection so make sure it fits the clinical picture!) Likewise, fungitell can be useful in looking for some of the more common fungal infections. Blood cultures will guide antibiotic coverage. Steroids can be beneficial for prevention of neurological sequalae in patients who are infected with pneumococcal meningitis. They should be started in anyone with suspected meningitis. You can then cease if cultures come back negative for pneumococcus. Importantly steroids must be started before or during antibiotics. Finally Rhonda discusses prophylactic treatment. This is necessary for contacts of patients with Neisseria infections. Think household member, day care contacts, and anyone exposed to secretions. This scintillating talk addresses the challenges during the workup, which labs to send during the initial workup, and how specialized labs such as CSF lactate, procalcitonin, and fungitell may help in the workup along with helpful advice for management. For more head to: codachange.org/podcasts/