Coda Change

In this entertaining talk, Ronan O’Leary discusses conflict in critical care. Ronan explains how to make a team decision about whether or not to perform a decompressive craniectomy. Undertaking a decompressive craniectomy is perhaps one of the most challenging decisions we face within critical care. Ronan contends that we do not know if we should do the operation. As he explains, even if we think we should do it, we don’t know when, or even how. Perhaps more importantly, intensivists do not perform the operation, the neurosurgeons do. However, we frequently put them in the position of doing the operation when we are at our wits end. Alternatively, they do the operation without asking us when we still feel we have space to play. Ronan poses the question - how can we resolve this, in a workplace environment which is already fraught with competing interests, beliefs, values and approaches? Evidence based medicine is not going to provide an answer soon and it is unlikely that a superficial approach to improving teamwork will either. An important component will be the future structure of clinical training. Our current systems reflect the way hospitals worked decades ago and the specialties we now have exist almost independently of the training which leads to consultant posts. Ronan posits that training should involve exposure to collegiate decision making and consensus building. However, this will be difficult to achieve within our current nationally co-ordinated training schemes. How to manage conflict in Critical Care: Ronan O’Leary Finally, for more like this head to our podcast page. #CodaPodcast

Martin Smith persuades you that controversies in brain death should not, and do not, exist. Almost fifty years since the concept of brain death was first introduced, some individuals and whole nations still struggle with its concept and justification. Many controversies continue to surround brain death, although there is broad consensus that human death is ultimately death of the brain. Martin provides a history of the concept of brain death. He describes how advances in modern medicine have made the concept of death, and specifically brain death, muddled. This has broad implications on the diagnosis of brain death – and provides the basis to the controversies that exist. The concept of death as a process is explored. The idea, and in fact the truth, is that death does not happen at a discrete moment in time. Alive or dead may be the only two states an organism can be in. However, the transition from one to the other is not instantaneous. Martin contends that the process and the nomenclature has little practical relevance. What is important is the point of irreversibility. He explains how we, as a medical community, can be confident of this point. The main points are 1) fulfilment of essential preconditions, 2) exclusions of reversible causes and 3) clinical evaluation. In his talk Martin elaborates on each and provides some important teaching points. As he explains, this is an important concept to grasp as it has implications for your patients as well as broader societal implications in the context of organ donation. Martin’s talk will discuss the history and development of the concepts and diagnosis of brain death internationally. He examines current challenges and controversies and makes the case for an international consensus. For more like this, head to our podcast page. #CodaPodcast

Hazel Talbot gives her insights from working in neonatal and paediatric retrieval. She delivers her talk with all the passion and dedication that she brings to her work as a neonatal and paediatric transport consultant. Equipment failure, rapidly deteriorating children and miscommunication are all common challenges that Hazel and her team encounter in their line of work. This is on top of the challenge of caring for neonates and children. How are children different? They differ in physiology, in disease profiles and even the way they make clinicians feel! In this talk, Hazel focuses on physiology and disease. The large majority of young deaths in the UK, where Hazel works, are neonates – under 28 days old. 50% of these deaths are due to perinatal diseases. These include congenital malformations, prematurity, sepsis, and congenital heart conditions. Children are small adults. Small airways, small necks, small lungs. Babies however are not small children. They use the majority of their physiological ability to survive. When they breath they use most of their diaphragm, compared with an adult who will only use a small proportion. This leaves babies without much reserve. They have a high metabolic rate, and neonates have a right heart dominance with an inability to change their stroke volume. Hazel urges you to consider this when faced with a sick baby. When thinking about neonatal and paediatric retrieval, Hazel has some key points. Practice, anticipation and knowing your environment and equipment is key to a success outcome. Hazel drives this message home with a case presentation. This example highlights not only Hazel’s skill and knowledge, but also her ability of communication, leadership, and intuition. Join Hazel as she gives an insight into her amazing work in neonatal and paediatric retrieval. Come along as she discusses her experiences and tells you how to ward of the Evil Transport Fairy! For more like this, head to our podcast page. #CodaPodcast

Simon Finfer argues that the transfusion threshold should be 70 g/L. Simon first raises the Choosing Wisely Guidelines for Critical Care. These state that one should not transfuse red blood cells in haemodynamically stable patients with a haemoglobin concentration of greater than 70g/L. He continues to discuss the application of this specifically to patients with an acute brain injury. In doing so he will talk about evidence generally and how one must approach the use of evidence in specific patient subgroups. Simon continues by raising further research to justify his position. Oli Flower on the other hand will take the position that the transfusion trigger should be 90g/L. He makes the point that this is the easy position to take. Essentially, he is just explaining why the critical care community does what it does! As Oli explains, haemoglobin plays a pivotal role in providing oxygen to tissue. In the case of a brain injury, to prevent further injury, one must ensure continued supply of oxygen to said tissue. Oli will lean on animal studies, human studies as well as trial data to support his position. The transfusion trigger is remarkable heterogeneous around the world and even within individual institutions and this drives critical care professionals mad. So surely there must be a “right” number. Unfortunately, there is not, which is where understanding all the relevant aspects to the argument becomes important. Join Oli and Simon as they debate on this important issue. When to Transfuse in Acute Brain Injury: Oli Flower & Simon Finfer For more like this, head to our podcast page. #CodaPodcast

Myths persist because they are essential to the human experience and our development as a society. They fill the gap between what we know and what we think we know. Where does this gap hurt us the most? In our vulnerable populations, for example, in our care of children. The “myth incarnate” in medicine: defective dogma. Not all dogma is bad – after all, dogma means “that which is believed universally to be true”. The problem with medical dogma is that our critical thought processes are curtailed by wholesale acceptance. Medical dogma is a special kind of myth, because it’s difficult to define. We repeat defective dogma for three reasons: “It is known”. Sometimes the dogma is all that is known on the subject, or it is simply the majority consensus. Be careful with this one – because there may be a reason for this specific teaching – not all dogma is bad. Dogma is sentimental. We learned from our teachers who learned from their teachers. We want to honor those who taught us, and we get attached to some ideas. Sometimes – even subconsciously – we allow our attachment to an idea to give it more credence than it deserves. The third driver of dogma is insecurity. “I know what I know”. In other words, “don’t make me reveal my limitations.” Myth: “They’re all fine” Remedy: Remember to look for the subtleties in children. Early warning signs are there, in the history or in the physical exam. If it doesn’t add up, investigate. Myth: “Only pediatricians are experts” Remedy: Don’t delegate decisions. You can do this. You sometimes are the only one that can. Myth: “I will break them” Remedy: Children are not another species. Use all of your skills for all of your patients” Powered by #FOAMed – Tim Horeczko, MD, MSCR, FACEP, FAAP

Ffion Davies gives her take on how to spot the sick child in the Emergency Department. Paediatric medicine is no doubt hard and can at times be scary. There is nothing worse, in Ffion’s opinion, than sending a child home who later represents to the hospital in a worse condition, or even worse, later dies. So, how does one spot the sick child amongst the droves of children who will present with fever and vomiting. In this talk, Ffion gives a lesson on how to spot the sick children in the ‘grey’ zone – those that are not clearly sick and not clearly well. Ffion breaks her thinking into two main areas: physiology and psychology. Physiology matters. Scrutinising a full set of observations/vitals (in the context of the child’s age) will help avoid the feared crime of discharging a sick child. Ffion discusses tachypnoea as a prime example of a simple physiological compensation to raise one’s suspicion of serious disease. Similarly, psychology matters. Ffion talks in depth as to why she considers this to be true. Talks on Paediatric Emergency Medicine are always popular because Emergency Medicine physicians are insecure about mismanaging a child. Are children precious? Are adults just big children? Therein lies the problem. Less knowledge, less experience and perhaps less confidence. Compounding this is the complexities of having to deal with the stressed parents when you yourself are stressed because of the situation. Ffion continues to talk about systems of thinking and decision making. She compares Type 1 thinking which is automatic and instinctive with Type 2 thinking, which is more considered. She explains the risks and benefits of relying more upon Type 2 thinking when considering the sick child in the Emergency Department. Finally, Ffion concludes by talking about strategies to improve your own management of the paediatric population in the Emergency Department. She discusses improving your knowledge base, using resuscitation aids and checklists and training by using stress inoculation simulations. For more like this, head to our podcast page. #CodaPodcast

Alex Psirides discusses the problem with major hospitals and the systems that they use. Throughout he uses a case example to highlight how and why things go wrong. Moreover, he suggests potential strategies to reframe the way care is provided in the hospital system. As patients become more complex, the tribal systems we use to look after them remain stuck in the 18th Century. Back when the treatment for everything was amputation and, if you survived, leeches. The large modern hospital is becoming a battleground of competing specialises, only concerned with their area of expertise. This leads to multiple single organ teams practising their art in a multi-organ (failure) world. Many staff lack acute medical skills. Expertise is found far away from the ward in Emergency Departments, operating theatres, and ICUs. Despite disease not knowing or caring what time it is, all hospitals operate with minimal nocturnal on-site expertise. As nursing & medical staff move more towards rotating rosters where no-one knows more than a single-sentence summary of their patient’s complex physiological, pathological & pharmacological needs, an ever-present vigilant family member may become the only hope of surviving any acute admission. Compounding these issues is the medial education system that is not keeping up with what happens with patients. Advances in medical care and technology mean that patients who would have been cared for in the ICU 30 years ago are now being looked after on the wards by junior doctors with little training or experience in critical care. Unfortunately, junior doctors often call for help when it is too late. Join in to listen to a self-professed middle-aged intensivist rant about how things were so much better ‘back in the day.’ For more like this, head to our podcast page. #CodaPodcast

Anthony Baca provides a focused talk on prehospital critical care response to the active shooter. Coming from the United States of America setting this is unfortunately not a rare occurrence. Anthony will discuss the real-world violence that exists, and what are the most important considerations for first responders in such situations. Anthony speaks about prehospital critical care team responses to mass shootings. He explores how emotional and physiological barriers run amok making the simplest logistical and clinical decisions extremely difficult. Moreover, Anthony provides real world advice should you ever find yourself called to a scene with an active shooter. This includes the importance of staying “left of bang”, incident recognition, initial confusion, and the critical nature of incident acceptance. Further, he reviews staff and patient safety priorities and basic concepts of tactical combat casualty care (TCCC). Finally, Anthony concludes with thoughts about your role as care provider when on duty as part of a pre-formed team, and what to do if off duty facing an active shooter. Today is the day to ponder actions you must take the moment an active shooter begins taking lives at an astonishing rate; that moment when the choices you make next will be the most important of your career. The choices you make today will affect the milliseconds and millimetres that determine survival… patient survival, your survival, and the survival of those waiting at home for you to walk back through the door. For more like this, head to our podcast page. #CodaPodcast

Scott Weingart discusses post-intubation sedation – a topic that tends to aggrieve him on a regular basis. Scott explains in simple terms why he is bemused at the lack of understanding surrounding intubated patients who become agitated or aggressive. How would you like a piece of plastic placed down your throat? The problem, as Scott explains, is that sedation does not blunt pain. Sedation without analgesia leads to delirium. In simple terms delirium leads to poor outcomes and death. Moreover, concerningly, the early sedation strategy of intubated patients has long term and far-reaching outcomes during their course of critical illness. So, what can be done? Scott explains that we need patients properly sedated, however not too deeply sedated. The goal needs to be a patient who is oriented, safe and with a normal sleep-wake cycle. Paralysis is not the answer. What is the answer? Scott walks you through A1 sedation – meaning analgesia first. Once pain is controlled, then sedation comes in to play. Scott stresses with analgesia first, the sedation needed is less. He explains how he achieves this in practice in detail. He then provides some clinical examples and how he would approach them including which specific medications he uses in practice. Scott’s main points are simple. Control the pain and very few patients will need a lot of sedation. In addition, if you adequately control the pain, very few patients will have delirium in the Emergency Department. Join Scott as he passionately discusses post-intubation sedation. For more like this, head to our podcast page. #CodaPodcast