Coda Change

Katrin Hruska discusses the usefulness of biomarkers in Emergency Medicine. All biomarkers are awesome predictors of badness. Elevated hS-troponins after non-cardiac surgery or an acute exacerbation of COPD are associated with increased mortality. In seemingly healthy people, elevated D-dimer levels are associated with increased mortality. Similarly, NT-proBNP levels predict mortality in patients with end-stage renal disease. A biomarker, in its broadest sense, is defined as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention” (NIH Biomarkers Definitions Working group, 2001). This definition includes everything from laboratory tests to blood pressure measurements or an ultrasound scan. The clinical assessment in the Emergency Department is based on the subjective history of the patient and all available biomarkers (and their change over time). If we assume that biomarkers are objectively measured, there is an overestimation of their individual importance. As Katrin explains, over testing and over diagnosis have serious consequences. Not only for patients but also for the healthcare system. In a clinical context the ease of getting a laboratory test leads to a lower threshold for testing. This increases testing without affecting relevant clinical endpoints. Also, when a biomarker becomes part of the standardised workup for a certain symptom, primary care centres and emergency telephone services will refer patients to the Emergency Department for testing, even when the pretest probability is low. Katrin contends this bias is not an inherent problem of biomarkers themselves, but of the decision-making process of clinicians. The human brain fears uncertainty. Anything that adds to the feeling of knowing is rewarding, which is the most probable explanation of over testing in settings where medico-legal risks for the clinicians are low. There is an ever-increasing number of patients seeking to rule out serious conditions by relying on biomarker testing to provide certainty. Finally, for more like this, head to our podcast page. #CodaPodcast

Chris Hicks delves in to how to optimise performance in a team environment in emergency medicine and critical care. When teams fail and fall apart, we are quick to analyse the performance. We pick it apart and see what went wrong, and why. Chris suggests that we should do the same thing for over-performing teams. We should analyse how and why they perform at optimum levels. In doing this, in reaching a higher understanding of elite performance, we can harness the techniques used, simulate and train them, and thus improve performance across the board. This is not a new concept. High performance in elite sport is driven by athletes searching to push themselves in new and more extreme ways during training. They do this so when they are faced with stressful situations in competition, they have seen it all before. High performers talk about being ‘in the zone’. This is a state of body and mind where optimum performance comes naturally and easily. Research suggests that when an individual is ‘in the zone’, areas of the brain go quiet. Your ego and your inner critic dampen down. Other more useful and helpful areas light up. These tend to be deeper areas and are related to information processing and linkage between ideas. They often are drawing on prior experiences. These are less conscious processes. Chris contends that conscious thought is expensive and time consuming and by tapping into this ‘flow’ state, you optimise performance. Chris then discusses how to utilise this research and methods used in other industries. He brings the lessons that are apparent from outside sources and describes how these can be implemented in medical training and simulation. He describes a method to play with perceptions. Rather than seeing situations as threatening, Chris highlights the benefits of embracing them as challenging – an opportunity to demonstrate elite performance. Further, he discusses a three-step process to practically implement the lessons he is talking about. So to improve performance whilst working in teams in emergency and critical care medicine, listen in to Chris Hicks discuss all things high performance. For more like this, head to codachange.org/podcasts/ 

For more like this head to our podcast page. #CodaPodcast

Jo Anna Leuck discusses fatigue in critical care. Is there a specific time during our shift when we are too fatigued to safely practice? That was the question that led to Jo Anna’s research project comparing the clinical performance of providers during the first hour of a day shift and the final hour of a string of night shifts. The providers were pulled out of their real-time clinical duties and video-taped while performing simulated critical care cases. The hypothesis was that the day shift providers would out-perform the night shift, but surprisingly the opposite proved true. Blinded reviewers assigned the day shift providers lower performance scores. Furthermore, they noticed some surprising medical errors committed during these simulated cases. Jo Anna examines how performance is impacted by practise, or lack thereof. She raises examples such as coming in to work after a few days off, or after an extended break and posits that performance will be negatively affected in these circumstances. Perhaps clinicians, similar to others who are elite in their field, truly need daily practice or some type of deliberate exercise prior to a shift to perform at the highest levels of care. How can we determine when we are not at our maximum level of mental sharpness during a shift? Can we improve our abilities in real time? Jo Anna concludes by suggesting some strategies to counteract these drops in performance. Allowing more time to get to work to reduce cognitive load, utilising mental rehearsal and taking advantage of checklists are all explored. In this talk, Jo Anna discusses mental fatigue and critical care-based shift work. She focuses on techniques to recognise and potentially mitigate any clinical sluggishness and improve patient care. For more like this, head to our podcast page. #CodaPodcast  

Karin Amrein talks about the challenges for women working in the critical care world. Incredibly, despite female prevalence, Critical Care is considered a man’s world. We've all heard the notion, “big boys with big toys.” The false assumption is that men are more interested in the latest equipment and technology. However, Karin thinks that the “soft factors” like love, care and teamwork are what will make the biggest difference in the future. Moreover, women are judged by their appearance and not their accomplishments. They are subject to questions like “Are you really a doctor?” or comments like “But you don’t look like a professor.” Patients and their families are often insecure when a woman oversees their treatment. Tragically, women are lost on their way to the top, captured by the “Glass ceiling.” One review showed that women have to be 2.5 times more productive to be given the same score in peer review. Another study showed that papers received better reviews when authored by a man. Karin presents statistics regarding women in critical care with 31% of ICU trainees and 21% of ICU consultants being women. However, only 7% of the ICU editorial board members were women which was the lowest among all other departments. Some things can be easily fixed, such as ensuring female speakers are on conference panels. She applauds SMAAC for having an equal distribution of male and female speakers, participants and organisers. Karin encourages everyone to ask themselves the question “What would you do if you were not afraid?” and to do that without worrying about the consequences. Critical care is in fact, a great place for women. For more like this, head to our podcast page. #CodaPodcast

Motorcycle Trauma Simulation and discussion

Ashley Liebig is a senior flight nurse and helicopter rescue specialist with STAR Flight. She talks with passion about her job, her vocation. Ashley divulges a deeply personal and deeply traumatic story from the SMACC stage. Pre-hospital medicine, emergency medicine and critical care are difficult jobs. There is a human toll to be paid when working in these areas. Ashley wonders if the stress, the emotion and the trauma torments all listeners. She believes it does not matter. Because it affects some. And it has affected Ashley. Ashley implores you to be nice. She wants her colleagues to understand her, communicate with her, and respect her. She explores the physiological maladaptive response when humans experience trauma and relates this to her experience. Ashley goes on to share how she has, and is, dealing with the chronic stress she is experiencing. It involved adaptation and behaviour changes. She educated herself on the effects of chronic stress and engaged strategies such as exercise, laughter, and human touch to counteract these. She engaged in communication with her family, so they were aware of what she needed. Moreover, she started having more honest conversations with her colleagues. Through her brave relaying of her own experience, Ashley wants to convey the importance of being aware of chronic stress, recognising it in oneself and others, and continue to strive to face it and deal with it together. Dealing with Chronic Stress in Critical Care For more like this, head to our podcast page. #CodaPodcast

Nikki Blackwell provides an insight into critical care in humanitarian emergencies. Through her experiences in hunger emergencies, epidemics, natural disasters and conflict zones, Nikki has gained a wealth of wisdom and lessons. She shares these from the SMACC stage. Nikki talks about some of the practical things she does when working in resource poor settings. It starts with hospital hygiene to reduce nosocomial infections, and often entails Nikki working alongside the cleaners due to resource limitations. Hand hygiene is difficult without running water and Nikki champions using the WHO Handrub Formulation. Other challenges include cold chain storage, blood donations, limited monitoring and food and nutrition. Nikki also discusses the challenges of working in different environments. Invariable the environment will be too hot… or too cold! On top of this, working in remote locations often entails living with the other medical professionals you are working alongside. This presents interpersonal challenges. Moreover, Nikki touches on the personal dangers of working in some of the more politically unstable locations around the world. Training becomes hugely important in resource poor settings when you are dealing with complex medical and surgical cases. Especially with less-than-ideal resources and equipment. Nikki expands on what is possible with good training, intuition, and a Swiss army knife. If you do not do anything stupid, and you have basic resources backed up by sound training, it is amazing what you can achieve and who you can help. She concludes by touching the future direction of care in resource poor settings highlight the potential for technology to make huge changes and advances. Critical Care in Humanitarian Emergencies: Nikki Blackwell Finally, for more like this, head to our podcast page. #CodaPodcast  

Kathryn Maitland describes the challenges faced with oxygen therapy as an emergency intervention in critical illness in African children. Where Kathryn works, in East Africa, there is no access to intensive care. Caring for critically ill children is all done in the Emergency Department. 70% of the global burden of disease and deaths from pneumonia occurs in Southeast Asia and Sub-Saharan Africa. The WHO has published guidelines as to what classifies as pneumonia, severe pneumonia, and very severe pneumonia. These classifications rely on clinical signs. However, Kathryn in her research has discovered that these classifications are rarely correlated with the actual underlying disease process. Clinical signs are non-specific for the diagnosis of pneumonia. Oxygen is recommended for severe and very severe pneumonia. This has led to calls to prioritise oxygen delivery in African hospitals. However, it has not led to change from a health department or funding viewpoint. There are also oxygen delivery practicalities to consider. Often there is only one source of oxygen on a ward (if at all) with patients clustered around it. The production of Oxygen may only happen in a few places. Poor cylinder quality leads to leaks and therefore, low supply. Concentrators are useful however they need regular servicing. They also rely on power, and in a region that experiences regular power outages, this can be problematic. When the power goes off, there is no oxygen available. Kathryn asks – do all children actually need oxygen? There is still however a hidden burden of hypoxia. Outside of Africa, Kathryn discusses the current state of equipoise on oxygen therapy. Moreover, oxygen can be harmful if given inappropriately. This leads to concerns more broadly on the harms of oxygen therapy. Kathryn concludes her talk by looking to the future. She discusses ongoing research and the implications for future practice in resource poor settings, and indeed the world. For more like this, head to our podcast page. #CodaPodcast

Francesca Rubulotta argues in favour of the ICU being no place for the elderly. She describes the ICU as a horrible monster, a very dangerous place. Furthermore, she suggests the ICU is on par with climbing a mountain in terms of risk and exposure to catastrophise. She continues to make the point that once a person reaches adulthood, the healthcare system is a one size fits all model. This extends to the type of treatment required – whether it be for an acute or chronic condition. Whilst hospitals, and ICU specifically, may be suited to assist those with acute conditions, it is perhaps less appropriate to deal with chronic conditions that avail the elderly. Francesca concludes that for the elderly, there needs to be a new model. One reliable, dedicated to the older patient population and able to provide the dignity they deserve. Karin Amrein provides a counter argument. She bases this initially through a personal story of her grandmother. This provides the basis for her argument that advanced age does not predetermine outcomes in healthcare. ‘Elderly’ is a large spectrum and age alone is a poor individual determinate for health. At an individual level, age cannot tell one how a person will fare in the ICU, and it can be an appropriate setting for the right ‘elderly’ patient. Karin contends that all patients are worthy of care in all settings depending on their personal context. Whilst with elderly patient one might consider conditions such as sarcopenia or dementia, this should not render them unworthy of care. Karin suggests this is discrimination. For Karin, age is just a number, and it is the person that should be treated – including in the ICU if appropriate. Join Francesca Rubulotta and Karin Amrein as they debate whether ICU is a place for the elderly. For more like this, head to our podcast page. #CodaPodcast