Coda Change

The Role of the Immediate Responder in Mass Casualty Trauma Christina Hernon describes a traumatic experience in gripping detail. In doing so, she shares her deeply personal insights into what it is to be an Immediate Responder. Christina suggests that the medical system must change to support these people. After a major formative experience at a life-threatening mass casualty incident, Christina felt incredibly unprepared despite over two decades of training in emergency and first response. Christina reflects that all the training that students undergo does not prepare them for every scenario. The standard approach to emergency care, is this scene safe? is completely inadequate for those present the very moment an incident occurs. These people are then amidst and surrounded by an unsecured and potentially unsafe scene. After her experience Christina had an acute stress reaction exactly like after rough calls in prehospital Emergency Medical Services. However, Christina wasn't offered the usual support given in these circumstances. She felt somehow betrayed, but unsure who to be mad at. Therefore, Christina tried to understand why she felt so unprepared and overlooked. In deconstructing and reflecting on the experience, she self-identified neither as bystander nor first responder. Instead she was an on scene, immediate responder, victimised rescuer. Realising that she did not fit into any already existing category, she uncovered an undefined time period that we need to give attention to. The Disaster Gap is the time between the moment an incident occurs, through the first call for help, and until the clearheaded First Responders arrives. In this definable time gap, the only available rescuers are people who are on scene when the event happens. These Immediate Responders, who are traumatised by their experience themselves, take immediate action to help another person or make the situation better. They are present at virtually every scene and have been for all of time. However, we know very little about them, their actions, their safety, their impact, and their recovery. By trying to understand the Disaster Gap and Immediate Responders, we can improve training, preparedness, resilience, and recovery. The Role of the Immediate Responder in Mass Casualty Trauma For more like this, head to our podcast page. #CodaPodcast

Natalie May brings the lessons she has learnt from Sydney HEMS training and teaches you how to apply them to your practice. What can hospital specialties learn from teaching and training in prehospital and retrieval medicine? Natalie, a self-described medical education enthusiast, gives you her thoughts on the application of educational theory to the challenges of the prehospital environment. Evidently, Natalie will discuss three domains of medical education – Induction, Competence and Culture. Firstly, Induction How do you welcome new staff to your service? In Sydney HEMS there is a week-long full team training. This teaches new clinicians to contextualise pre-existing knowledge into their new environment. Here, they combine teaching tools including demonstration, simulation, discussion and debriefs. This is often in stark contrast to in-hospital inductions that can consist of a cursory department tour and online modules. Moreover, Natalie discusses the medical education principles that provide the basis of the importance of a well-rounded induction. Inductions are crucial to ensure that new clinicians can safely learn how to operate successfully in their new environment. Secondly, Competence Competence is necessary for good outcomes. Training is essential in the development of competence. Natalie discusses the proven theory of spaced repetition to embed new skills. This involves regularly practicing alongside skilled clinicians – as is done in the HEMS program. Furthermore, In-hospital, simulating cardiac arrest scenarios regularly can dramatically improve junior clinicians’ competencies and highlight deficiencies in competence that can be addressed. Thirdly, Culture Natalie describes the methods of culture building that exists in Sydney HEMS. These include ‘Coffee and Case’ meetings, fortnightly clinical governance days and interactive lectures and journal clubs. These all acknowledge the higher order thinking processes that is involved in the care the services provided. Natalie recommends fostering a culture of learning from practices and providing open non-judgemental clinical governance days in the in-hospital setting. Finally, Natalie wants you to use what you have learned to inspire, teach, and motivate others. For more like this, head to our podcast page. #CodaPodcast

Sara Gray tackles the controversial topic of disaster ethics in critical care. Most hospitals develop a disaster plan, but few jurisdictions develop a plan for triaging or rationing scarce resources when the existing supply is overwhelmed. Rather than leaving individual health care workers to make these decisions, we should work together as a community of experts to develop ethical, practical and appropriate policies for triaging scarce resources during a disaster. Healthcare resources are finite. In the case of large-scale trauma with large numbers of casualties, such as a disaster scenario, how do you decide who gets what? Sara discusses her guiding principles when thinking about disaster triage. First and foremost, avoid having to triage or ration scarce resources. Have a plan and make first part of the plan to be “Never use the plan”. Mitigate all the risks and possibilities that would see the plan being enacted. This involves sharing with partner hospitals, urgently reordering supplies and repurposing what is available. The second guiding principle relates to the ethics. Normal circumstances dictate offering the best for every individual patient. In a disaster, a shift to the utilitarian philosophy – the greatest good for the greatest number – is necessary. This means not everyone is going to get what they need, which is a difficult concept for people. Thirdly, Sara stresses the importance of developing a disaster plan in a public way. This stops a plan being “sprung” on staff, the public and stakeholders. It encourages buy-in and engagement which makes it a smoother process should the plan ever be enacted. Sara next discusses the inclusion and exclusion criteria when dictating who should receive the finite resources of a hospital in a disaster. This, she admits, is the tricky part. She backs her thoughts up with the available data. Sara concludes with some points regarding the implementation of disaster plans. Making these plans is tough, however not having them is tougher. Hospitals and health authorities should have a clear criteria for when a crisis is declared. This needs to come from the hospital level, if not the health region or government. It is not an individual decision. Next a dedicated team should review de-identified patient files to allocate resources according to the inclusion and exclusion criteria. This team needs to be multi-disciplined and received adequate support. This is a tough job. Finally, for more like this, head to our podcast page. #CodaPodcast

Liz Crowe believes that love can revolutionise the way we approach critical care. She wants every doctor to become love ambassadors for their critical care community and share love like nothing is holding them back. Liz believes that work life balance does not exist because we spend most of our time at work. Therefore, it is essential to love and be passionate about the work we do. Liz compares the feeling of being a novice in critical care to first being in love. Initially, there is fear and excitement doing new procedures. However, as days go by, you lose the rhythm. This is how relationships evolve, both in life and in critical care. Relationships with critical care is all about hanging in there and, love. Love helps to sustain it. She discusses the role of love and leadership in critical care. Liz demonstrates that great leaders always lead with love and compassion. Leading with love does not make them weak or indecisive, instead it creates a climate of trust and intimacy that makes individuals and the team feel emotionally and physically safe. This in turn promotes robust conversations and conflict which is beneficial to the patients. By being kind and compassionate, a leader inspires their team to work better and achieve higher standards. According to Liz, a good leader is supportive, genuine, works hard, apologises when they are wrong, has a good sense of humour, creates an environment of trust and acts as a human shield for their team. The most stressful thing in an intensive care is not death but being unappreciated. Being loved and supported leads to increase in brain capacity and the ability to make difficult decisions. Liz strongly recommends having a work spouse because family and friends do not understand what critical care workers go through. The people we work with are our support and community. Love builds innovation and creativity and not the brain. She quotes the example of the three doctors whose passion made the SMACC conference a reality. Liz discusses the role of love in dealing with patients. She believes that beginning a conversation with a patient with love, respect and compassion makes things easier because they will believe that we care about them. She feels it is as important to teach newcomers about love and compassion as it is to teach them about having boundaries. The more we care about patients, the less likely we are to be burnt out. Liz explains the concept of Ikigai which says that you can achieve bliss if you can combine passion, mission, vocation and profession, which according to her most doctors can. Though there are times when this job can leave you heartbroken, it is also quite rewarding and important. For more like this, head to our podcast page. #CodaPodcast

For Ross Fisher there are things that scare him. And he knows there are things that scare you too. Ross discusses the purpose and effect of fear in medicine and surgery. Whoever you are and whatever you do, there are things that you are afraid of. It is not stress, it's fear, it's real and it affects us. Ross wants you to know, it is okay to be afraid. Being afraid is recognising a threat and realising that there is a limitation to your ability, and that you have reached that point. Ross describes three moments in his career that he has felt fear. Real fear, that was different to stress. Moments before operating on a preterm neonate of 29 weeks. Believing he had transected the common iliac artery in a haemorrhaging 9-year-old during a removal of a Wilm’s tumour. And being reported for malpractice by a colleague. In each situation, Ross felt fear. What does fear do to a person? It is different to stress. Stress in critical care medicine is part of the job. In fact, it is necessary to reach a performance state. Fear on the other hand is when an individual is way into the “red zone”. Your hands shake so much that you cannot perform tasks. Your head pounds from tachycardia and hypertension. You breathe so fast it is like you have just finished a run. Your focus is directed at one thing only and you can no longer appreciate your surrounds, nor any inputs from your senses. You cannot think, you cannot remember, you cannot calculate, and you cannot make decisions. That is what it is to be afraid. Fear affects us acutely. However, it also affects those around us. Similar to how a yawn will spread person to person, fear can spread through a group. This is particularly true when the person showing fear is a senior person or leader. The reason things go wrong in stressful situations is not because of a lack of knowledge or training. Rather it is due to poor performance as a result of fear. So, Ross wants us to acknowledge our fear. He wants us to recognise how common it is, and how we can confront our fears and no longer be fearful if we stand together. For more like this, head to our podcast page. #CodaPodcast

Resa Lewiss gives her insights into leadership. Through her experience training and working in Emergency Medicine and Critical Care, Resa has collated a series of pearls, pitfalls, and lessons shared by leaders. For Resa, there are leaders, and there are follows – more often than not, people know good leaders. Resa firmly believes that leaders look like leaders. She affirms that it is neither a male nor a female trait – despite what some may assume. Resa shares her lessons on leadership. 1) There is never a need to publicly embarrass someone Public embarrassment serves a purpose, however this purpose is often misguided and can be better achieved in other ways. Resa has experienced the embarrassment firsthand and knows of its detrimental impact. A good leader will give a person an out and speak to them in private. This is much more effective. 2) Make a decision Being indecisive can be perceived as worse than making the wrong decision. Leaders need to be confident in their decisions. 3) Know your strengths and build on those Also, know your weaknesses. For what you are not good at, reach out and bring people into your circle to complement yourself and your team. 4) “People may forget what you say, they may forget what you do, but they will never forget the way you make them feel.” Maya Angelou Leadership is not about hierarchy. Leaders should make their subordinates feel respected, welcome and part of the team. 5) Ask Leaders need to get over their imposter syndrome. This allows them to advocate for themselves and for their team. Never be afraid to ask for what you need. Resa concludes by sharing ways that everyone can improve their leadership skills. For more like this, head to our podcast page. #CodaPodcast

Medical journals have many possible functions, but the main one for most is publishing science. They are actually better at campaigning and agenda setting, rather like the mass media. Journals are now beset with problems, including failing to include data, publishing lots of poor quality material, being slow to publish, publishing research that is either not reproducible or fraudulent, encouraging waste in the system, failing to be transparent, and exploiting academics. New ways of publishing science are appearing, and a better system would be for the grant proposal, protocol, and full data to be published on a database with the whole process transparent.

Antibiotic Use for Sepsis in Critical Care: Steve McGloughlin Steve McGloughlin presents his thoughts on antibiotics and their use in sepsis and critical care. Steve discusses the ABC of sepsis… the trouble is after A for Antibiotics there is not a whole lot else! In sepsis and severe infection, the goal is to change the trajectory of the patient, away from death and to a more favourable outcome. The tools that are currently on offer in critical care are pretty simple. There are things to support the patient such as fluid and ventilators. In addition, we consider goal directed therapy. In terms of definitive therapy, the list is quite small. Perhaps only antibiotics and source control can be turned to. Antibiotics are a powerful tool. So much so that the number needed to treat is around four. They are also very commonly used. 70-80% of patients in the ICU will get antibiotics – far higher than nearly all other treatments. Steve has some basic advice for the use of antibiotics to enhance their effectiveness. Go early as possible when prescribing and administering. In saying that, he cautions to move beyond simple antibiotic prescribing regimes. Whilst we need early antibiotics, we need the right antibiotics. Why? Alexander Fleming warned against drug resistant bugs when developing penicillin. There has been reports of pandrug resistant organisms (bug against which no known drug is effective) in multiple countries and 214 000 neonatal sepsis deaths per year are attributed to resistant pathogens. Steve concludes with a discussion on what more we need when considering sepsis. We need more than antibiotics. As it stands one definition covers all categories of sepsis. The result is a homogenous treatment protocol. In reality, the source, the bug and the pathology all change the disease and all call for an individualised treatment regime. That is the future. For more like this, head to our podcast page. #CodaPodcast

Per Bredmose discusses the use of inhaled nitric oxide (iNO) in retrieval medicine and critical care. He explains why iNO is useful for retrieval and transport of the critical respiratory failure patient. iNO is not a magic bullet, but rather a bridge that will help you get to where you need to go when treating a patient. Furthermore, it can be useful in both pre-hospital and in hospital care. What is nitric oxide? It is an endothelial derived potent short acting vasodilator mainly found in the pulmonary system. It also exists in other areas of the body. When nitric oxide is delivered via the inhaled route it has local effects only, with no systemic effects. Most people will be familiar with the use of iNO in persistent pulmonary hypertension of the newborn. However, there are other uses which are more “off label”. For instance, take the case of severe ARDS lungs in pre-hospital settings. These patients present challenges in retrieval for several reasons, including the retrieval ventilation systems being inferior when compared to hospital systems. Of course, you could turn straight to ECMO. However, setting up ECMO takes time and is complex. It requires a large amount of equipment, skilled operators, and room. Nitric oxide can act as a bridge. Per stresses, iNO is a tool to get the patient to the right place. Nitric oxide is simple to use. It is an extra gas that goes into the ventilatory circuit. It is accessible, can be used in any vehicle, is easy to transport, and fast to grab and use. Much faster than a big ECMO set up or retrieval. A lot of places have stopped using iNO and it has gained something of a bad reputation. The main reason for deleterious effects appears to be kidney injury. Per posits that this may be due to an increased length of time using the drug. Therefore, he advises caution. Per concludes by explaining other conditions where iNO may be used as an adjunct to standard therapy. These situations include pulmonary hypertension, non-thrombotic pulmonary vasoconstriction, and pulmonary emboli. For more like this, head to our podcast page. #CodaPodcast

In Critical Care we deal with death on a regular basis and although it seems an ‘on or off’ issue where you are either dead or you are not, nothing is more true. Not only physicians but scientists, philosophers, writers and theologians have been debating about the subject for as long as we have become aware of the concept of death. To try to create order from chaos I divide the deceased in 5 categories: The soon to be dead, The reversibly dead, The irreversibly dead The walking dead (although this group I will leave to Hollywood to educate us about) and the most curious group The reversibly, irreversibly dead. They are the patients of whom we think they are irreversibly dead, we stop our resuscitation efforts, and then they have return of spontaneous circulation. This is known as the Lazarus phenomenon and although many case reports have been published about this phenomenon over the years, presumably it’s only the tip of the iceberg. In providing Critical Care we sometimes need to make immediate decisions on who’s dead and who’s not. Yet decisions about whether further treatment of patients is futile or not can only be made when one is aware of the limits of extremes in physiology that are survivable. Although not every patient should be treated up to these physiological limits, knowing these extremes can help in making an informed decision of whether to continue treatment.