Coda Change

John Greenwood, an expert in pulmonary hypertension and heart-lung interactions, explores the devastating impact of pulmonary hypertension on cardiac function. He discusses the clinical heart-lung interactions, identifies high-risk patients, and shares critical management strategies. The podcast covers the causes and exacerbation of acute pulmonary hypertension, the often-overlooked right ventricle, and the effects of mechanical ventilation. It also delves into the differences between the left and right ventricles, the impact on coronary blood flow, and the use of pulmonary artery catheters.

Michele Domico presents a talk on the pitfalls of common paediatric resuscitative manoeuvres in paediatric cardiac patients. Emergency and critical care physicians are all well accustomed to items such as oxygen, bolus adrenaline, intubation and cardioversion. However, as Michele explains, these ‘go to’ interventions may in fact be harmful for the paediatric cardiac patient presenting to the emergency department in extremis. Due to the physiology of certain complex congenital heart diseases, the usual resuscitation manoeuvres may in fact kill the patient instead of helping. Supplemental oxygen can worsen the pulmonary to systemic blood flow ratio in single ventricle patients and cause them to have rising lactate levels and cardiac arrest from low systemic cardiac output. Intubation and positive pressure ventilation may impede pulmonary blood flow in patients with a Glenn shunt and the patient can become more desaturated. With increasing PEEP and higher respiratory rates, the patients will continue to deteriorate and desaturate. Regular dosing of adrenaline boluses in patients with single ventricle physiology who are nearly arrest, can worsen their systemic output by increasing systemic vascular resistance and promoting pulmonary overcirculation. Cardioversion of a previously healthy paediatric patient might be tempting when you see what looks like a stable ventricular tachycardia. This wide complex rhythm has fooled many people into shocking it. You might in fact be dealing with something else and can make the patient infinitely worse by shocking. In her talk, Michele highlights the importance of understanding the physiology of your patients. This particularly applies to paediatric cardiac patients. In this population, the change from typical physiology means standard models of care are harmful. Tune in to hear what not to do! For more like this, head to https://codachange.org/podcasts/ 

Deirdre Murphy presents everything that can go wrong in cardiac surgery. Deirdre will impress on you that cardiac surgery is by no means a safe procedure! Murphy’s Law stipulates everything that can go wrong, will go wrong. Subsequently, Finagle’s corollary will tell us, it will be at the worst possible moment. In this talk Deirdre attempts to prove these theories in the world of cardiac surgery. Cardiac surgery can vary from being routine elective surgery to time-critical emergency surgery. The term encompasses a broad range of procedures carried out on patients from neonates to nonagenarians. In the 63 years since the first open heart surgery was performed using cardiopulmonary bypass enormous advances have been made in the field such that an average person presenting for coronary bypass grafting in 2016 can expect a very low chance of peri-operative morbidity or mortality. When things go wrong however, they can go badly wrong and at the worst possible moment. The list of problems that occur is extensive. Deidre steps through some of the more common issues that arise post cardiac surgery. She describes pneumonia, mediastinitis, haemorrhage, ischaemia, and neurological issues, amongst others. Along the way she provides clinical pearls as to what to look for, what not to miss and what to do about it. Through her extensive experience, Deidre has seen more than her fair share of post-cardiac surgery complications. She provides a number of clinical scenarios she has encountered, and in doing so gives useful insights to be aware of. Her top tips are to prevent complications if possible. If not possible, recognise the complications early and finally train for ‘avalanches’ – those critical and scary situations that will put your patients at immediate risk of demise. For more like this, head to https://codachange.org/podcasts/ 

Peter Brindley explains how burnout affects us all. It affects the cost, quality of care, organisational culture, performance and patient outcomes. Burnout is fatigue, loss of ideals, purposelessness, presentism and the sense of being under-appreciated. It is not tiredness, exhaustion, boredom, mid-life crisis, depression, PTSD, perfectionism or narcissism. Moreover, burnout involves the 4 C's: cutting corners, cynicism, callousness, and contempt. Peter explains when and why, and to whom a burnout occurs. A major reason for burnout is the difference between expectations and reality. This drives the thought, “this is not what I signed up for.” Furthermore, he presents the 12 steps which lead to a burnout. It begins by the need to prove yourself by working harder, neglecting your needs, avoiding issues, and losing friends or hobbies. This leads to denial, withdrawal, behavioural changes, depersonalisation, inner emptiness, depression and finally burnout. Peter suggests a few things that we can do to prevent burnout. He recommends purposeful imbalance and dividing career into thirds: learning, earning, and returning. Evidently, burnout is a chronic condition, and although it cannot be cured, it is manageable. It might take years to manifest and hence, we must always be on the lookout for the signs. Finally, for more like this head to our podcast page. #CodaPodcast

Francesca Rubulotta talks about disproportionate care in ICU. Disproportionate care is disproportionate in relation to the expected prognosis. Moreover, this can lead to moral distress among clinicians who think they are offering inappropriate care. There is mounting research and evidence pointing to the existence of disproportionate care. Furthermore, stress and burnout cause increased miscommunication and lead to low performance and concentration. Stress leads to absenteeism or in many cases, presenteeism. Presenteeism is when someone just shows up for work but does the bare minimum. Francesca shows the financial burden caused by absenteeism across various countries. Francesca points out that only 14% of employees feel engaged in their jobs. Moreover, data shows that companies which keep their employees engaged have higher rates of performance. Such companies have managers who are more engaged and approachable. Francesca discusses various studies that look at the appropriateness of care in ICU. She talks about the CONFLICUS, APPROPRICUS and DISPROPICUS studies, all of which point to the moral stress experienced when clinicians are forced to give inappropriate care. We must ask whether inappropriate care occurred and why. The three major factors influencing the perception of inappropriate care are client related situations, work characteristics and personal characteristics. 27% of healthcare providers (HCP) report at least one of their patients are mismanaged per day. Furthermore, 63% say that inappropriate care happens all the time. There are multiple reasons for disproportionate care taking place. Studies show that nurses associated inappropriate care to interpersonal factors while physicians ascribed it to prognostic uncertainty. Francesca discusses the methods used and results obtained in the DISPROPICUS study and self-awareness and individual development in ICU. According to her, these future studies will help to find solutions to the problems regarding disproportionate care. Evidently, authentic leaders, who can inspire others, are the need of the hour. For more like this, head to https://codachange.org/podcasts/ 

Karin Amrein highlights the importance of bone health in ICU. Karin asks – do fractures matter? If the presentation is a hip fracture for elderly patients, then the answer is obviously, yes! However, Karin will describe why this answer should be a resounding yes for all patients who are admitted to the ICU. Critical illness affects bone. It is not a stretch to conceptualise this. However, Karin wants to impress on you that bone affects critical illness also! Bone is an endocrine organ, the largest endocrine organ. Fragility fractures are associated with substantially increased mortality and morbidity. One year post hip fracture, 50% of the patients are either dead or in a nursing home. Prevention is crucial! After an ICU stay, patients have a largely elevated risk of fractures – up to 65%. However, this risk factor is not recognised in the literature. If you survive critical illness and get home, you have done well. If you then sustain a fracture, you are almost back to square one! Karin attempts to explain this association. The ICU population is getting older, and the very nature of an ICU admission means they are predominantly sedentary – that much is true. However, there is likely more factors at play. Inflammation, endocrine alterations, increased osteoclastic activity, hypercatabolism leading to muscle breakdown (and in turn bone breakdown), malnutrition and drugs are all likely implicated in the increased risk. Karin takes you through each factor in turn in detail. So, what can be done about the increased risk of fractures in ICU patients post discharge. Addressing each factor in turn is difficult, however Karin shows some viable options to consider in this patient population. Karin demonstrates how poor bone health, leading to fractures, produces poor outcomes. In turn, she discusses how treating the bone health, and reducing the fracture rate, leads to improved morbidity and mortality! Karin concludes with some recommendations for ICU patients providing some tangible and practical takeaways. For more like this, head to https://codachange.org/podcasts/ 

Natalie May gives you the break down of paediatric trauma. Paediatric trauma is relatively rare but terrifying. However, there are many ways we can think about paediatric trauma to make these challenging situations easier to face. Children are inherently portable. This means that they often turn up at peripheral, non-paediatric centres that are not major trauma centres. This highlights the importance of all physicians knowing how to deal with these cases. Anatomy and physiology of children is different to adults. Their ability to compensate is remarkable. This means the index of suspicion of serious injury should be higher. For instance, their ribs are a lot more pliable than those of adults, meaning hollow viscous organ injuries are more common following trauma. Similarly, their vital signs can be more confounding. Tachycardia could simply mean fear or pain. On the other hand, it could indicate a major internal bleed. This leads to children being under and over triaged at a high rate. Teenagers also present challenges. Does the surly, teenage girl with limited verbal responses have a serious head injury..? Or is she being a stereotypical teenage girl? The mechanism of children trauma differs from that of adults. Polytrauma is rare in children without adult involvement, such as a motor vehicle accident. However, as children develop through adolescence, the mechanisms of injury begin to resemble those of adults. Quad bike accidents, stabbings and even shootings become more common. Isolated thoracic injuries become the second most common cause of trauma in adolescents 16 years and older. Toddlers by comparison get isolated limb injuries more commonly. They are mobile, curious and have no sense of danger. Their height to the ground is less, making head trauma less common, and less serious. Under one’s however are more often carried by adults and lack protective reflexes making skull fractures more common. Polytrauma in this age group should also raise suspicion of non-accidental injury. External factors often need to be involved for more serious polytrauma. Natalie suggests being suspicious of horse-riding children! Once a child is in your department, the assessment differs slightly to that of an adult. Specifically, scanning protocols are different with less use of pan scanning and more focussed scanning. CT for heads and penetrating chest trauma and abdomen, and plain films for C-spine, limbs, pelvis, and blunt trauma to the chest. Natalie concludes by discussing the differences in management of injuries, comparing children and adult interventions. She also discusses the outcomes of children with major trauma and the vast implications on the child, the family and society. For more like this, head to our podcast page. #CodaPodcast

Confined Space Airway Management in Emergency and Critical Care by Ross Hofmeyr Ross Hofmeyr discusses the ins and outs of managing an airway in a confined space. He details the challenges, the potential solutions and his top tips when faced with an airway in a less than ideal setting. Ross defines confined space airway management as airway management in an environment where access to the patient, normal positioning, and use of airway equipment is limited by physical constraints. Ultimately, these situations are endless. An icy crevasse or on a mountain top. Inside a cave. Motor vehicle crash scenes. War zones with bullets flying overhead. The inside of a helicopter or the back of an ambulance. Even inside tight Emergency Departments, cath labs or operating rooms that are full of advanced equipment. These are all scenarios in which one may find themselves faced with confined space airway management. Ross contends that all airway clinicians have the possibility to have to handle these situations. In this presentation, Ross addresses the locations and difficulties which can be anticipated, and then discusses the options, techniques, and evidence available for managing airways in constrained places. Learning to cope (and then excel) in abnormal fashions and positions makes us better at managing airways in both emergency and routine situations. Ross discusses the specific techniques, equipment and alternatives that can assist a clinician in tight situations. He backs up his thoughts with literature which demonstrates which techniques may be considered. Moreover, his primary piece of advice to managing an airway in a confined space is, don’t do it! His first tip – get the patient out of the confined situation! Evidently, this may not always be possible. If that is the case, Ross recommends a Supraglottic device. Otherwise, a channel laryngoscope is his next go too. Failing that, Ross stresses that a clinician must be prepared, mentally and physically, to proceed with a surgical airway. The more skills, knowledge, and flexibility the clinician has means the better they will be able to cope with confined airway management. Confined Space Airway Management in Emergency and Critical Care Finally, for more like this, head to our podcast page. #CodaPodcast