Coda Change

Anand Swaminathan and Iain Beardsell debate the use of thrombolytics in the treatment of submassive pulmonary embolism (PE). PE is a spectrum of disease. Patients should be treated differently depending on where they are on the spectrum. Subsegmental PE may need no treatment at all, whereas massive PE is unlikely to improve without thrombolytics. Anand argues for the use of thrombolytics. Evidently, time is critical when dealing with patients and Anand posits that thrombolytics gives the physician control over time. Submassive PE can deteriorate, leading to massive pulmonary embolism. A proportion of these patients will die. The data is not conclusive for the use of thrombolytics in terms of mortality, however long term outcomes do improve. Finally, Anand concludes by suggesting that the decision to use thrombolytics relies on sound clinical reasoning and decision making, informed by the available data. He argues for nuanced treatments and use of these drugs. Iain takes a different approach in his reply. Some of the most difficult topics in medicine attract considerable debate. The use of thrombolysis for submassive PE is one of these. In this argument Iain attempts to highlight some of the most pertinent evidence against the use of thrombolysis. And he does so through song! Submassive PE should be Thrombolysed: Anand Swaminathan and Iain Beardsell For more like this, head to our podcast page. #CodaPodcast

Ryan Wubben discusses the standards in Helicopter HEMS. He asks the question, what standards? The development of Helicopter EMS (HEMS, or as the Federal Aviation Administration recently coined it: “Helicopter Air Ambulance” or “HAA”) services in the United States has taken a different path in recent years compared to other countries. The widespread use of single engine, VFR only aircraft, owned and operated by for profit companies is a uniquely American phenomena. This is at odds with most other countries who have developed HEMS programs around the world. This has resulted in significant direct competition between HEMS programs. Additionally, it has drawn attention to highly questionable billing practices. Ryan examines the origins of this development. This includes the use of the US “Airline Deregulation Act” to prevent states from regulating HEMS programs. More recent efforts in the US to tie reimbursement and program accreditation to the levels of care provided and minimum standards of equipment are still nascent at this time. Efforts by the US National Transportation Safety Board (NTSB) to mandate improved safety equipment standards have been met with resistance by the industry and the FAA. This has resulted in wide variability in US HEMS programs. Moreover, it has resulted in the adoption of IFR standards, mandating NVG use, twin-engine aircraft and risk assessment strategies. There is also increasing scrutiny being placed on appropriate utilisation criteria in the face of skyrocketing bills and questionable billing practices by for-profit companies. The Standards in Helicopter EMS (HEMS) For more like this, head to our podcast page. #CodaPodcast

Natalie May & Roisin McNamara discuss a young person’s experience of critical illness. They are joined by Ema, an 11-year-old girl who had a scary time when she was diagnosed with tracheitis. Experiencing critical illness is  scary for anyone. However, when you are a young person, this terrifying experience is amplified. Natalie and Roisin tell us what we as clinicians can do or think about differently to provide a better patient experience. Although she is young, Ema provides some salient points about what doctors and nurses do well and what they can do better. The main take away boils down to clear communication. Medical professionals often think they are explaining things thoroughly. However, the words they use, and the speed of the delivery of those words, leaves a patient feeling confused and scared. On top of that, a patient's experience of critical illness leaves them exhausted, in pain and unable to effectively communicate. Bringing one’s awareness to this can assist when we are deciding how and when to discuss the ongoing treatment. Ema’s mother also provides insights into the experience of the family. The broad themes include the feelings of isolation, fear, and overwhelming concern. Encouragingly, there are simple things that clinicians can do to alleviate these feelings. Whilst the fear and concern for one’s young child will never abate, simply taking the time to listen to all worries and ensuring understanding can go a long way towards improving the experience for both the patient and their family. Similarly, ongoing communication regarding the tests, procedures, and treatments that are planned to be undertaken is highlighted as critical in eliciting the support and buy in of the family. Critical illness in a young person will never be easy for the patient or their families. Listen in to this discussion to discover how to make it more bearable. For more like this, head to our podcast page. #CodaPodcast

Maxime Valois and John Christian Fox argue the role of POCUS in critical care. Maxime makes the case for POCUS being a problem. POCUS changes everything. It has helped physicians throughout the world to make easier, more accurate and faster diagnoses. It has contributed to enhance the diagnostic possibilities in resource-scarce environments However, as it gains more widespread acceptance, its use is becoming more and more common. Maxime contests that this poses a problem. No longer is ultrasound only in the domain of specialists and technology-eager early adopters of the technology. He proposes that this will lead to difficulties as non-specialists take up the technology. Maxime warns against being hypnotised against the seductive nature of ultrasound. Research and use of fancier, new or more advanced applications are likely to help the global advancement of POCUS and even medicine in general. But as POCUS enters fully in its stage of normal science, this will inevitably induce some degree of scientific esotericism. This has been the case of all past scientific revolutions. Point-of-care ultrasound is already generating some important difficulties. If these go unattended, Maxime believe POCUS itself might rapidly be a problem. John on the other hand claims in no way is POCUS a problem. It is maybe only a problem for the radiologist holding down their turf in a small hospital that has been shielded from the world wide web. John argues that POCUS is changing the way medicine is practiced for the better. John makes the point that ultrasound makes the clinician better, faster, and stronger. It does so without exposing patient to harmful radiation. Furthermore, John contends that POCUS enables the physician to bridge the gap between patient and doctor in increasingly complex healthcare system. It allows him to spend more time at the bedside and in doing so deliver better care for his patients. John makes his point with a range of clinical situations, driving his point home that POCUS certainly has a place in the future of medicine. Is Point of Care Ultrasound (POCUS) a problem? For more like this, head to our podcast page. #CodaPodcast

Scott presents the argument that whilst Emergency Physicians are amazing, as it stands, Emergency Medicine is failing. Scott presents the system as it should be. This involves stabilising the critically ill before admission to the ICU, seeing sick patients in appropriate time and seeing the less sick patients as you can. The issue as it stands, is when this system breaks down. He talks about the ‘boxes’ which now includes the ‘not sick at all’ patient. This leads to Emergency Physician’s not doing what they are trained to do. Scott discusses the issues with the outcome measurements of Emergency Departments. Hospitals measure patient satisfaction and wait times. Moreover, Scott argues that a trip to the ED should be the worst day in a patient’s life and measuring their satisfaction is misleading. A good medical outcome should be the indication of success. Scott also discusses the issue of Emergency Physicians not dealing with emergencies for most of their practice. This, in Scott’s eyes, leads to cognitive dissonance, where ED doctors are not doing what they are trained to do. Simon argues that Emergency Medicine is not a failed paradigm. Emergency Physicians are trained to help people, when people feel that they need to be treated. He claims that doctors in this speciality want to treat a wide variety of people across a wide spectrum of disease. Evidently, Simon discusses a ‘revolution’ in Emergency Medicine. An increasing number of people are attending Emergency Departments across the world. The generalist approach of Emergency Medicine is critical in triaging, treating, and helping these people in their moment of need. The skills, breadth of knowledge and wisdom and ability to work across a range of specialties and in uncertainty is what makes Emergency Medicine and the physicians who work in it special. Join in the debate as Scott and Simon argue for and against the place of Emergency Medicine. Finally, for more like this head to our podcast page. #CodaPodcast

There are nearly 100 billion stars in the Milky Way – and almost that many articles published every year. Luckily for you, we read them all – or, at least, the ones in the domain of EM (Emergency Medicine). Catch up with where the new literature is leading you, leading you astray, or just plain bonkers. Sit back and let us inspire you to take your own deep dive into all the great foundational science. We'll swing through new stroke treatments, the ketamine blow-dart, the best medications for reanimating the dead, and many more! Ryan Radecki: It has been exciting and surprising year in the EM literature. We'll be hitting all the highlights and letting you know what's hot and what's not. Topics to be addressed include, but are not limited to, abscess management, medications for renal colic, imaging for subarachnoid, new anticoagulant reversal agents, use of opiates, and the diagnosis of PE

Ben Shippey discusses the important anaesthetic considerations in bariatric surgery. Obesity surgery can induce a strong response in healthcare professionals. These biases must be overcome to facilitate efficient and safe services. Evidently, Bariatric surgery provides many challenges. To begin with, healthcare professionals can associate negative thoughts with obesity. Secondly, these patients present complex respiratory and cardiovascular physiology that must be considered. Ben highlights three important considerations when preparing for, and delivery anaesthetics in the bariatric population. These are Attitude, Assessment and Act. Attitude - Encompasses the attitude of the physicians, theatre team and the patient themselves. One must recognise and change their thinking about the obese patient. Ben’s team does this by realising the complex psychological background these patients invariably have. Assessment - Furthermore, a multidisciplinary team must undertake a broad assessment. Specifically for the anaesthetic team, there is a complex decision pathway, especially with managing the airway. The broad principle should be to shorten the time between the awake, vertical, spontaneously breathing obese person and the supine, anaesthetised, intubated and positively pressure ventilated patient. Finally, Act - As Ben states, the previous two points are null and void if it does not change practice. The key element to act is to plan! This involves having a clear action plan for the intubation of the patient and failing that, clear points at which Plan B, C and D will be initiated. He encourages his theatre staff to alert him when a cut off Sp02 is reached so he can move to the next course of action. He comes prepared - for example, by having the cricothyroid membrane marked out. Furthermore, it is important to consider putting the patient to sleep and waking them up. As Ben puts it – pay attention to the take off as well as the landing! Lastly, the post-operative care is significantly important. Remember patient positioning in bed (not slumped) and encourage early mobilisation. These patients need to be up and moving, as well as having the appropriate DVT prophylaxis in place. The obese patient presents unique challenges to the anaesthetist.  For more like this, head to https://codachange.org/podcasts/ 

John Carlisle asks the big question – what is the risk of surgery? It is a big question that holds implications for everyone involved in caring for patients. Like John, patients want to live a long and happy life. They would like to know whether the chances of living a long and happy life are enhanced by having surgery or not. They do not generally care whether they will be alive in 30 days or not. John explored whether or not we can accurately answer the question – what are the risks of a given surgery? Prognostic models based on a single surgical cohort are very vulnerable to chance and variation. This is even the case with large cohorts. The reason is that mortality is not that common. Therefore, the range of uncertainty in any one model is big. John explores this concept in the context of surgical intervention for abdominal aortic aneurysms. He highlights the perils prognosticating by describing the trials that influences the treatment guidelines for abdominal aortic aneurysms. John describes the current data, and the flaws in the recommendations currently being offered. John then describes a tool he has developed relating to this particular question. The tool also explains how one piece of research has been misunderstood, a misunderstanding that has resulted in two general mistakes: surgeons operating on aneurysms when they should not; surgeons not operating on aneurysms when they should. For more like this, head to https://codachange.org/podcasts/ 

Karim Brohi gives an insight into his mindset as a trauma surgeon, drawing on lessons from Zen philosophy. During this talk he discusses how we can develop the self confidence that helps us cope with stressful clinical situations. The word confidence is often talked about in a negative context, in terms of overconfidence or arrogance. Karim however uses this talk to highlight the importance of self-confidence. Self-confidence is important for you, your team, your department, and your healthcare system. Karim will teach you how to use this confidence to handle whatever is thrown at you. Zen philosophy draws on the notion of water. Water, mind like water, heart like water and core like water. How do you adopt a heart, mind and core that is like water? Water takes the shape of whatever environment it is in. In a glass, a vase or a lake, the water fills the space. It mimics its environment. Extending this analogy, water in its resting state is calm and still. However, throw a stone into the water and you create ripples and waves. Thereafter, the stone disappears, and the water once again becomes calm. Karim draws parallels between the properties of water and one’s mindset. At a trauma scene, panic and confusion can spread rapidly amongst all present without that panic or confusion every being named. However, if a calm and reassured team leader arrives, everything else stills around them. Like water they react to a challenge, an external stimulus, accept it, deal with it, and then return to a resting state. A trauma surgeon or team leader reacts appropriately to its environment, and then becomes calm again. This, Karim posits, is how a trauma surgeon, or team leader, should behaviour. The notion of the Zen Garden is another useful analogy from which to draw inspiration. Zen gardens are defined by their attention to detail. This extends to medical practice. Attention to detail enables you to be prepared and deal with anything that comes through the door. Again, it allows you to foster confidence. Compounding this, is the quality of the gardens that enhances the minimal. They are perfect not when there is no more to add, rather, when there is no more to take away. In a medial sense, Karim draws comparisons to medical imaging. What is important? What is unnecessary? The gardens are meticulously planned. Karim highlights the importance of planning is his practice that has helped him instil confidence in himself and his team to deal with all scenarios. Using the art of Zen you can be ready for anything and teach the mind to deal with change with confidence. For more like this, head to our podcast page. #CodaPodcast

Haney Mallemat discusses the treatment for PEA cardiac arrest. Patients who present with pulseless electrical activity (PEA) arrest have a high mortality. The treatment of PEA requires finding and reversing the underlying cause; therefore a simple and rapid approach is required. Traditionally we were taught to use the H’s and the T’s, but this diagnostic tool is cumbersome and of questionable utility overall. Haney discusses the problems with the traditional H’s and T’s as well as focusing on newer approaches to PEA arrest. Haney makes the point that PEA is not a diagnosis, but a ‘waste basket term’ for a lot of possible diagnoses. Rather than assisting a clinician in the assessment and treatment of a patient, it acts on to lead to pontification. To that end, Haney wants us to do away with the H’s and T’s. The problem with the algorithm of diagnosing a PEA, as Haney explains, is the reliance on feeling a pulse. It lacks sensitivity and specificity, largely linked to using fingers. They should not be used in resuscitation scenarios – as the guidelines say we should. Haney makes the point that despite all the advances in medicine, resuscitation has stayed essentially the same for decades. He describes two ways in which he thinks we can advance our care. The first involves the QRS complex. Ask the question – is the QRS complex narrow or wide. Narrow (< 0.12 seconds) leads you to consider mechanical problems, such as tension pneumothorax or tamponade. If it is wide (> 0.12 seconds), then consider metabolic problems such as hypokalaemia. If the QRS is narrow, and you are thinking a mechanical problem then there is electrical activity, and the heart is still beating underneath. The step should be to use ultrasound immediately to find the focused cause. If it is wide, and you are considering metabolic causes, this is more aligned with a true PEA. Calcium bicarbonate should be considered in the first instance. Haney describes the limitations with the algorithm that includes the trauma patient or those with underlying cardiac conditions. Next Haney describes a second algorithm - PREM (pulseless with rhythm and echo motion) and PRES (pulseless with a rhythm and echo standstill). The use of ultrasound is central to this pathway. In PREM the left ventricle is not strong enough to produce a pulse. Does this patient get adrenaline or chest compressions? Haney discusses the options. In PRES there is electrical activity, but the heart is not squeezing. Maybe these people should get adrenaline and compressions! The ECG should still play a part in this algorithm. Haney puts it all together for you and takes you through the algorithm he uses when faced with a patient with PEA. He includes some tips for using the ultrasound probe during cardiac arrest resuscitation scenarios. A Revised Algorithm for PEA Cardiac Arrest: Haney Mallemat For more like this, head to our podcast page. #CodaPodcast