Coda Change

Neuro Imaging Nibble: Subtle Subarachnoid haemorrhage on CT by Jordan Bonomo

Jonathan and his wife Anna thought they were coming to the emergency department for a routine sickle cell pain crisis. However, his illness takes him down an unexpected spiral of multi-system organ failure and critical illness. What was a routine patient encounter becomes a much more personal human interaction that causes the provider to question her perspective on chronically painful conditions and realise the effect our words and subtle actions have on our patients. Jessica Mason utilises the powerful tool of narrative storytelling, adapted to a live lecture format, to tell Jonathan’s story from his own perspective. In doing so, Jessica makes Jonathan the teacher. Jessica hopes you will remember the story and remember the medicine. In 2016 Jessica received an email from Jonathan’s wife. The email was to inform her of Jonathan’s death, from complications of sickle cell disease. He was 43. This stark note gave Jessica pause, and prompted her to reflect on her interactions with Jonathan and his wife and wondered what lessons could be learnt about how we view chronically painful conditions and the unconscious biases we carry. By reliving her interactions with Jonathan and utilising interview audio with Jonathan, Jessica highlights the struggles that face patients with painful, chronic conditions. They are often burdened by fear of judgement or fear of being undertreated when accessing medical services. Concurrently, healthcare providers can be afraid of turning people into heroin addicts or be fearful of having their compassion exploited. Jessica posits this is all driven by the stigma of opioid use in emergency departments. Jessica used to believe pain crises from sickle cell disease were relatively easy to manage. However, Jonathan’s powerful narrative provides a wonderfully effective teaching opportunity about sickle cell disease and other chronically painful conditions and how they are managed. Join Jessica Mason as she mixes medicine with the human condition to pass on valuable wisdom from the patient’s perspective. In the words of the Jonathan’s wife Anna, “If you don’t teach others about what you have, no one will know.” For more head to: codachange.org/podcasts/ 

Trauma is an epidemic so what is the future for prehospital trauma resuscitation? The statistics are shocking – 14,000 people a day and 5 million people every year die from trauma. Injuries accounts for 9% of deaths worldwide and they are the biggest killer of under 40s across the world. Incredibly, these numbers are only rising. Dr Brian Burns describes what is largely a silent killer… many critical care doctors and nurses may never get the chance to see, treat or save the patient, because they often do not make it to the emergency department. Death often occurs in the first hour post trauma and 90% of trauma deaths are due to exsanguination. We pick up the story of Paul. Paul is driving alone when he loses control and crashes his car. There are no witnesses. No one to call for help. No emergency responders. Paul bleeds and dies. The emergency system that is currently used is not specific or sensitive enough – and we need to do better. The meercat is the animal world exemplar of the early warning system. Meercats knows where danger is, know how to look for it and on finding danger, they sound an alert that raises an immediate and appropriate alert from the collective. Brian applies the meercat model to Paul. Brian describes a new response, one driven by data, and fast and accurate access to that data. He draws parallels to the data gathering and sharing of Formula One teams. Brian takes a deep drive on predictive algorithms to calculate the likelihood of injury, automate the response and alert the dispatchers. He describes a response that utilises real time images, biosensors sending biometric analysis and the use of drones to deliver equipment ahead of retrieval teams – all while being supervised by a trauma team leader in a trauma centre. Brian re-tells Pauls tale in the future, the future of prehospital resuscitation. He describes a situation where technology is used to do better for Paul, and the countless others like him. Join Brian as he makes the case for computerised algorithms and decision-making assistance in medicine and implores the pre-hospital community to do better by utilising technology.  For more head to: codachange.org/podcasts/

Dying is not very sexy, but sometimes, dying is the right thing to do. Death is one of the many things that we only get one shot at. There is no second chance at death. Dr Alex Psirides discusses death from a patient, family, doctor and economist perspective. 400 years ago, death was everywhere. Everyone was exposed to dying on a regular basis and people were encouraged to prepare for their death. Things have changed thanks to the intervention of the medical profession. Resuscitation teams, pain killers and the concept of “dying in comfort” have altered the trajectory of dying, leading to a mystique surrounding the concept. Dr Psirides argues that death has replaced sex as the new taboo – and the result is a society removed from death. This has led to poor choices in medical interventions towards the end of life. Furthermore, Inappropriate decisions made by medical teams are likely to delay death, decrease quality of life and cost money, all without changing the ultimate outcome… death. This sparks a discussion around a new perspective on “doing everything”. Medical Intensivists have been shown to be bad at knowing the outcomes of their patients. They also overestimate the benefits and underestimate the harms of the interventions they prescribe. Alex discusses the affect that “doing everything” has on families. Families of patients that had received more life sustaining treatments towards the end of life had higher rates of depression following the death. Finally, the financial cost of extending lives is explained. Alex questions the efficacy of spending greatly to advance life trivially. Underpinning these hard decisions around death is the enormous importance of early discussions of death and dying with patients and their families. Is doing everything the best thing doctors, families and society can do for patients? Alex asks you to give patients the death you would want and make dying great again. Tune in to a discussion on The Ethics of Death by Alex Psirides. For more head to: codachange.org/podcasts  

For more head to: codachange.org/podcasts

Sarah Yong is an impressive person. Advocacy, Training, Representation and being a new fellow of the College of Intensive Care to boot.   Theres a lot to talk about when you sit down with Dr Sarah Yong. Let’s make it easy by focussing on three big issues;   Gender issues; Women in Intensive Care Network. www.womenintensive.org Training issues; The Critical Care Collaborative and the Victorian Primary Examination Course for CICM. www.vpecc.com Representation issues; New Fellows Rep on the Board of the College of Intensive Care Medicine. www.cicm.org Where to start? Women in Intensive Care Network www.womenintensive.org @WomenIntensive If my sources are correct there pretty much the same number of women and men out there in the world. Further it seems that there are roughly the same number of women and men presenting to intensive care units. This pattern does not repeat itself in terms of the Intensive Care doctors. Let’s talk about this. Let’s listen to the people that are raising awareness about this. The Women in Intensive Care are talking about it and publishing about it too. You may have heard about the Medical Journal of Australia article; “Female representation at Australasian specialty conferences”.

Darren Braude discusses the concept of Rapid Sequence Airway (RSA). The evolution of this concept goes back to the start of the 21st century. Here, the practise of ‘archaic’ airway management was common. This involved getting that plastic tube down the patient’s trachea no matter what. However, gradually, the risks of hypoxaemia during airway management become evident. This led to a movement towards extraglottic airways. If the oxygen saturation was dropping and there had been two failed attempts. This movement continued to involve towards operators deciding to move to other methods when only one attempt had failed. This was largely due to the increased training and skill of clinicians. The thinking being if they could not get it in one shot, they probably weren’t going to get it at all. This evolution was the catalyst for the movement towards faster airways, and less emphasis on intubation. Rapid Sequence Airway is pharmacology and preparation as in RSI, with the planned placement of an extraglottic device, without any intention to intubate. Moreover, in this talk Darren takes you through the advantages and disadvantages of RSA. It is a fast and highly successful technique with minimal airway trauma. On the flip side, some patients are not good candidates for extraglottic devices. RSA necessitates a secondary procedure and it does not provide a ‘definitive’ airway. RSA is an alternative airway management strategy that may be ideal for preoxygenation of hypoxemic patients as well for prehospital and in-flight use. Darren provides the ins and outs of Rapid Sequence Airway in this talk, as well as providing the data and his real world experience of using this concept. Finally, for more like this, head to our podcast page. #CodaPodcast

The podcast discusses the Difficult Airway Society Guidelines, highlighting the importance of airway management and the risks of mismanagement. It explores cases of medical errors, the role of human factors training, and the guidelines for difficult airway management in anesthesia. The chapter also emphasizes the need for standardization and simplification of guidelines.

Reuben Strayer presents a masterclass on airway management with laryngoscopy. In the past two decades, airway management has been revolutionised by the development of video laryngoscopy, hyperangulated blade geometry, optical stylets, laryngeal masks, and a host of advances in airway pharmacology and technique. The core skill of airway management, however, remains laryngoscopy. Reuben provides his take on how to perform this procedure with success. Firstly, Reuben talks about positioning which is a critical step. This includes the common mistakes made in patient positioning. Reuben shares a proposed set of parameters that the provider can use to guide positioning that is optimal for laryngoscopy. He also guides you through his take on the grip to use throughout the procedure. Reuben talks about the effect of the grip on the operator’s catecholamine production and what to do to avoid excess catecholamine levels which will be detrimental to performance. Next, Reuben confronts one of the core principles of RSI, the delay between medication administration and commencement of laryngoscopy. He proposes an alternative approach that emphasises early laryngoscopy with deliberate slowness. Reuben highlights the value of the jaw thrust – as performed by an assistant – during airway management. Then, he moves into a step-by-step analysis of laryngoscopy as the blade moves into the mouth, down the tongue and ultimately to the glottis. Further, Reuben talks about the utility of suction. This is an under-utilised device in his view. He discusses the two most important intra-laryngoscopy optimisation manoeuvres. First, optimisation of the position of the head and then, optimisation of the position of the larynx. Reuben concludes by discussing the value of using the gum elastic bougie for both difficult and routine intubations and describe pitfalls encountered when using the bougie (and how to manage them). In this presentation, Reuben Strayer breaks down laryngoscopy into its discrete components and describes best practice techniques at each step. For more like this, head to our podcast page. #CodaPodcast