Coda Change

Darren Braude and Karim Brohi debate over the utility of hard cervical collars. Darren argues that it is time to do away with hard cervical collars. He raises some assumptions. The first being that movement of the spine is bad. As he explains, movement is not the problem. Rather, energy deposition in the spine causes injury, not simply movement. With that being said, the problem is that the hard collar does not prevent movement! Surely, the benefits of the hard collar outweigh the risks. Darren argues otherwise. He discusses the effects of the hard collar on ICP and venous drainage of the brain. The issue here is that the patients with the highest risk of cervical injuries also carry the highest risk of concomitant brain injuries – and we as clinicians should not tolerate any increased risk to the brain. Finally, Darren argues that the hard cervical collar impairs airway management which is the priority for any emergency situation. Cervical collars are unlikely to help and can cause harm! Karim argues in favour of hard cervical collars. He contends that the lack of quality evidence in this field is problematic. Furthermore, Karim believes it is easier to suggest harm than to prove harm. Likewise, it is also easier to suggest harm than to prove benefit. With that being said, Karim concedes that some of the harm Darren raises are possible and can occur. However, he states that no one recently has practiced medicine in a world without cervical collars. The improvements in spinal care therefore cannot be separated from the use of hard cervical collars. He asks the question; do you want to mess with these improved outcomes? Karim also points out, that patient complaints about spinal care are rarely about the cervical collar specifically. He goes on to discuss how to navigate patient concerns. Tune in to this enthralling debate between Darren and Karim. For more like this, head to our podcast page. #CodaPodcast

PRO: Medicine is a complex craft. Acute medicine is more complex. Excellence is delivering effective acute care depends on recognising the broad base of basic sciences, clinical experience, and results of clinical trials. Central to all decisions has to be how these will benefit the patient – both in the short term as well and longer term so that survivors of acute illness are left with the best possible outcome for that patient, their caregivers and the community at large. This is a daunting concept under time-limited, information-limited conditions. Clinicians are often left with uncertainty about the impact of decisions and rely on short-term surrogate measurements to justify treatment options. Consequently, assessing outcomes are invariably confounded by associations that bear little relationship to causation or biological plausibility. Such confounders are often demonstrated in observational studies and RCTs with low levels of internal validity, particularly those conducted in single centres and/or driven by protagonists of a particular intervention. Carefully conducted RCTs with high levels of internal validity – those that produce believable results from rigorous study design and those that produce results that are generalisble to specific patient populations remain the only way to mitigate bias and produce clinically-relevant answers to improve patient-centred outcomes. Critical Care Medicine leads the way in producing high-fidelity RCTs that have fundamentally changed clinical practice, not only in terms of producing better patient-centred outcomes, but also by producing unequivocal evidence to stop or avoid using of previously harmful treatments that had been enthusiastically embraced by clinicians and guideline developers. Such examples of benefit include the CRASH-2 and ARDS-net trials, and of preventing harm, the SAFE, NICE-SUGAR, RENAL, CHEST, DECRA and FEAST studies among others. The net impact of these pivotal trials has been the prevention of millions of deaths and the saving of millions of dollars. Such is the basis of GOOD clinical practice and these trials must be seen as a source of knowledge, science and pride … that ultimately improve patient outcomes .   CON:  

Martin Smith and Mark Wilson debate whether neurocritical care improves outcomes in severe TBI. Martin argues in favour of neurocritical care. He concedes that longstanding and established practices are not as efficacious or innocuous as previously believed. Very few specific interventions have been shown to improve outcomes in large randomised controlled trials. With the possible exception of avoidance of hypotension and hypoxaemia, most are based on analysis of physiology and pathophysiology. Further, the substantial temporal and regional pathophysiological heterogeneity after TBI means that some interventions may be ineffective, unnecessary, or even harmful in certain patients at certain times. Martin however, contends that improved understanding of pathophysiology and advances in neuromonitoring and imaging techniques have led to more effective and individualised treatment strategies. Ultimately, this has led to improved outcomes for patients. In particular, the sole goal of identifying and treating intracranial hypertension has been superseded by a focus on the prevention of secondary brain insults. This is done by using a systematic, stepwise approach to maintenance of adequate cerebral perfusion and oxygenation. Similarly, multimodal neuromonitoring also gives clinicians confidence to withhold potentially dangerous therapy. Particuarly in those with no evidence of brain ischemia/hypoxia or metabolic disturbance. Mark Wilson on the other hand argues there is no benefit in neurocritical care following severe TBI. The New England Journal of Medicine has published several articles that demonstrate no benefit from classic neurotrauma interventions (ICP monitoring, cooling, decompression). This is because factors such as ICP and CPP associate with bad outcomes by association rather than causation. This debate will demonstrate that critical care just complicates things. Evidently, it is high time for the randomised trial between the very best neurocritical care and NOB therapy (Naso-pharyngeal, Oxygen and a Blanket). Join Martin and Mark as they discuss the pros and cons of neurocritical care in the management of severe TBI. For more like this, head to our podcast page. #CodaPodcast

Anthony Holley and Marietjie ‘MJ’ Slabbert debate the value of prehospital doctors in trauma. Anthony argues that doctors in the prehospital setting add little value. He does so with the upmost respect for prehospital doctors and having worked in this setting himself. He makes the point that across the globe, the employment of doctors in the prehospital setting is a rarity. Working in this environment is diverse and every situation encountered requires a different skillset. This presents a logistical challenge. Anthony continues to discuss the evidence, or lack thereof, in this space. He raises the point of competing interests from paramedics, flight nurses and doctors themselves. This leads to apples being compared to oranges most of the time. Anthony goes on to suggest all the advanced clinical interventions that are necessary in prehospital situations can be competently undertaken by paramedics. MJ argues for the negative. In doing so, she concedes that the evidence base for prehospital medicine is scarce. This is due to inherent biases, the difficulty of gathering data and the issues with methodology. However, MJ believes that care provided outside of the hospital should be of the same level as care received in hospital. This provides a seamless patient journey from the prehospital setting into the hospital and improving the chain of survival. Furthermore, MJ posits that prehospital doctors not only improve care of patients outside of the hospital, but care for those in the hospital and clinics too. Prehospital physicians add value wherever they practise. They bring leadership, knowledge, additional skills, and training as well as innovation and collaboration. Tune in as Anthony and MJ debate over the value of prehospital doctors in trauma. For more like this, head to our podcast page. #CodaPodcast

Resuscitation of the critically ill trauma patient involves a myriad of high-stakes, time-sensitive management decisions. The landscape is shifting rapidly: new evidence on hemostatic resuscitation and component therapy in hemorrhagic shock, peri-arrest point-of-care ultrasound, novel approaches to resuscitative thoracotomy and trauma RSI have at once clarified and muddied the waters. In this rapid-fire, case-based session, Petro and Hicks will debate some of the recent and potentially practice changing literature to assist with key inflection points in the care of the sickest -- and sometimes deadest -- trauma patients, and engage in some trauma dogmalysis in the process.

Alex Psirides and Sara Gray debate over whether ‘Do Not Resuscitate’ (DNR) should be the default choice for all patients. Alex contends that application of ‘CPR-for-all’ is the ultimate evidence drift. A treatment that is completely appropriate for dropping dead whilst running a marathon has almost no place in acute healthcare facilities where chronic irreversible complex co-morbidities abound. 90% of doctors would not choose CPR for themselves, yet 100% are trained in how to administer it to patients. Defaulting to ‘CPR-for-all’ removes a patients’ ability to provide informed consent for assault whilst they die from another disease. Remember – 2 weeks in ICU can spare you 5 minutes of difficult conversation. Sara on the other hand argues that DNR should not be the default position. Across the globe, patients are assumed to be full code to allow for prompt resuscitation, until code status can be discussed and clarified. There are numerous excellent reasons for this. Can you imagine if our systems decreed that DNR was the default? “Let’s not shock that VF, until we can clarify his code status.” Or, “let’s not resuscitate that child, after all, DNR is the default and her mother isn’t here yet!” Making DNR the default is not a good solution to ICU or hospital over-crowding. Let’s not mandate DNR, let’s mandate having reasonable code discussions early and often. Join Alex and Sara for a stimulating, engaging and entertaining debate! For more like this, head to our podcast page. #CodaPodcast

In a 2 min rant about medical tribalism, Dr. van der Velde questions which medical specialty, if any, owns prehospital physician response. What is more important: skillset or specialty? Is there a role for tiers of physician response? Is there a future in a stand-alone specialty?

Marietjie (MJ) Slabbert describes the unseen enemy, fatigue in critical care medicine. MJ does 24 hour shifts every other day with just three to four hours of sleep. Though many would claim that this is more than enough, MJ thinks otherwise. Physicians are killing themselves while trying to save others because fatigue kills. MJ points out that sleep is one of the basic necessities in Maslow's hierarchy of needs. Fatigue often affects the go getters or type A personalities. Among doctors, the critical care and emergency doctors are at a higher risk of being fatigued. MJ points out the dangers of being fatigued. Driving while tired is as dangerous as drunk driving or speeding. Fatigue also puts patients at risk as it increases medical errors and safety compromising behaviour. Studies show that the response time of anaesthetists increased twenty times when they were sleep deprived. Fatigue is the number one problem faced by doctors and MJ wants us to wake up. Doctors are at a higher risk of getting cancer and this has led WHO to consider shift work as a carcinogen. Sleep deprivation increases the risk of developing obesity, depression, compassion fatigue, diabetes, wrinkles due to collagen breakdown, heart attacks, strokes, arrhythmia and even early onset Alzheimer's. It makes people weak and angry as they become less capable of handling stress. According to MJ, there is no one size fits all solution to dealing with fatigue. However, the first step is to acknowledge the problem and to change the "tough guy" medical culture. Doctors have to realise that they are part of the human race and need to rest. Doctors must help themselves so as to help their patients better. Taking breaks must be acceptable. MJ encourages taking naps during free times at work. She wonders if doctors ever notice if their team is tired. She asks if it is measures or if hospitals have fatigue policies. MJ ends by asking everyone to fight the battle against fatigue by waking up and going to sleep. For more like this, head to our podcast page. #CodaPodcast

James Tooley discusses the sheer terror that comes with the challenge of managing children in the pre-hospital environment. As James explains, although many clinicians may think that they do not need to (or may not want to) think about the paediatric population, it is something that every clinician would do well to mentally prepare for. James shows a video clip of a large-scale paediatric trauma and challenges you to consider being dispatched to the scene. How do you prepare for that? Simulation, as usual, is key. Through simulation one can discover knowledge gaps, limitations of equipment and guidelines, and coping strategies. James takes you through some specific pointers regarding equipment that one should carry when anticipating dealing with pre-hospital paediatric emergencies. Next, James discusses pressure and how it degrades performance. A clinician should be aware of where their pressure limit is. The importance lies in recognising when you reach your cognitive overload. Once you recognise this point you can be aware of it, deal with it and train to prevent it. James continues to talk about simple ways to approach the pre-hospital paediatric emergency. The primary survey does not, and should not, go out the window in paediatric cases. Similarly, simple analgesia can be a fantastic starting point to take control of a situation. Lastly, James points out that just because young people are small and can be moved off scene easily, does not always make this the right choice. Stabilise, and then move is his message. James contends that clinicians train and prepare for adult emergency situations and he challenges the audience to treat paediatric emergencies in the same regard. Challenges in pre-hospital management of children For more like this, head to our podcast page. #CodaPodcast

Flavia Machado and Paul Young present the top 10 ICU trials of the recent past SMACC style. Their list of trials includes a number that challenge dogma and establish interesting new lines of scientific enquiry. In addition, they also include all the recent clinical trials that should change your practice. If you want to know what’s new in critical care then this is the talk for you.