Coda Change

A demonstration in the ECMO-CPR process and then going back to basics, to understand the need for such a process and how to design and develop it from scratch using simulation to cut lead time and highlight and remove issues prior to rolling out on the patients. Making E-CPR both possible and safer.

Sara Gray presents an incredible case highlighting the importance of resuscitative hysterotomy. The story is full of drama, moments that went well and moments that went poorly. It demonstrates the key points when considering this emergency lifesaving procedure. The case is a woman who is eight months pregnant and has an out of hospital cardiac arrest. The call comes in advising of an imminent arrival. This is where the preparation for a perinatal resuscitation and resuscitative hysterotomy begins. The first thing to consider is a Code OB – a maternal cardiac arrest code. This will bring neonatal doctors, obstetricians, specialist nurses, airway specialists and all the specific equipment required to the department. A Code OB can be a life saver – if you do not have this, Sara implores you to implement it. Next, you must consider which room will be used for the resuscitation. The room should have two beds and lots of space. As you are organising this, mental preparation should begin. The uncommon and serious nature of a resuscitative hysterotomy makes it a highly stressful situation. This leads to hesitation. Moreover, mental preparation in this situation is tremendously valuable. This is because it makes hesitation less likely, and appropriate action more likely. That appropriate action is the resuscitative hysterotomy which is lifesaving for three reasons. Firstly, it relieves aorto-caval compression allowing better venous return for the mother. Secondly, it improves pulmonary mechanics by allowing free and unobstructed movement of the diaphragm. Lastly, it reduces maternal oxygen demand once the baby and placenta are delivered. This leads to a maternal survival benefit of 32% and a neonatal survival benefit of 50%. Furthermore, in relation to timing, the well promoted 4-minute rule is a myth. Recent data shows maternal survival out to 15 minutes and neonatal survival out to 30 minutes. Mean time for resuscitative hysterotomy is 16 minutes. This does not mean that time is not of the essence, it absolutely is. However, it does mean that 4 minutes is not the cut-off. The aim should be to do it as soon as possible. The procedure itself is not complicated, aside from the fact that a resuscitation is still ongoing concurrently. Sara talks you through the procedure and the required equipment. This talk is a dramatic and fascinating 101 on the resuscitative hysterotomy. Sara wants to let you know – you can do this! For more like this, head to https://codachange.org/podcasts/ 

David Halliwell presents the science of cardiopulmonary resuscitation. Resuscitation means lots of things to different people – compression, CPR, mouth to mouth, ventilation, return to normal and reanimation all come to mind. But how and why does resuscitation really work – let David explain. This talk uses a case study approach to discuss why resuscitation practitioners should focus upon technical accuracy when resuscitating, focussing on all the facets of a resuscitation, compression, decompression, trans-thoracic impedance. Two points David would like you to take away: 1) Blood flows from high to low pressure even when the heart stops beating and 2) Blood doesn’t flow through the heart during systole. David talks about the two big theories of cardiopulmonary resuscitation. The first is the heart squeeze theory – that being chest compressions will pump blood out of the heart and around the body. This is as opposed to the thoracic pump theory which states blood flows due to a pressure gradient and by changing the pressure in the thoracic cavity you enable the blood to continue to move. This is enabled by the papillary muscles and valves failing to work in an arrested heart. The truth is probably that both theories hold merit and a combination of both enables a successful resuscitation. David calls this the lung pump theory. After discussing theory, David moves on to the more practical aspects of CPR. Firstly, compression – compressions clear the heart out. Without compressions, the right ventricle fills with blood (due to the pressure gradient) that cannot move through. This splints the right heart against the collapsed left heart. Secondly, ventilation. David warns of the complications caused by improper and inappropriate ventilation which will decrease venous return and make your compressions futile. Finally, defibrillation. There are a few important points here. The critical mass is the left ventricle, so get the pads as close to this as possible. Prepare the skin (which involves knowing how to use the razors in the defibrillator kit) and place the pads appropriately. David concludes with some technical issues that need to be remembered, performed correctly, and watched out for. These include chest compression depth, compression rate, hand placement and consistency. For more like this, head to https://codachange.org/podcasts/ 

The child with the reduced conscious level presents a unique challenge to the Emergency provider - how can we recognise normal sleepiness versus pathology? Natalie May reminds us that, even if it's after bedtime, we have to take the time to wake children up fully as part of our routine assessment. She then explores the common pathologies - 5MF! - we need to consider in children with a reduced conscious level and how we can figure out which one is in front of us.

Pierre Carli expands on the prehospital and critical care responses to terrorist attacks. For retrieval medicine specialists and prehospital care providers, terrorist attacks are a new and unique threat. As Pierre impresses on you, terrorist attacks are not accidents. They are a targeted human activity whose purpose is to kill, injure, and inflict the maximum amount of human casualty as possible. They do this with the intention of disrupting society, spreading feelings of fear and panic and inflicting feelings of insecurity in the population. Terrorism is not blind. Terrorist attacks involve organised strategy that is much more complex than any natural or technological disaster. To oppose an aggressive strategy a static plan is not enough. Pierre highlights the need for a counter strategy, comprehensive and adaptable enough to counteract this and deal with a multitude of scenarios. This begins with effective leadership, combining the expertise of the Police, Rescue and Emergency. Prior preparation will allow the best possible emergency response. Terrorist attacks raise the possibility of multi-site, multimodal attacks. To face such complex situations requires a coordinated response. Pierre discusses improvements of prehospital and in hospital organisation and protocolisation for massive casualties. Alert shared by all services, close coordination between Rescue Police and Emergency care, backup on a regional basis is crucial. Similarly, strategic allocation of resources and keeping reserve for the next attack are some of the options that may be extremely helpful. Next, there needs to be consideration toward improvements of care for injuries related to military weapons. Injuries that are common in terrorist scenarios are major penetrating trauma and major haemorrhage. These are the results of powerful bombings and assaults riffles. Management of these victims is very different of the care of a multiple trauma patients after traffic accidents. Pierre also discusses adaptations of the principles of the military “damage control” to civilian practice. From the scene to the operating room and the critical care unit, all actions must be coordinated to prevent the death triad - hypothermia, coagulopathy and acidosis. Finally, Pierre talks about resilience. The action of Health Care Services is not limited to medical care, it is also the first step of resilience. By maintaining the quality and the organisation of care despite surprise, violence and aggression you oppose directly the objectives of terrorism. For more like this, head to https://codachange.org/podcasts/ 

Ciaran McKenna discusses 3D printing of high fidelity simulation equipment. Simulation training is useful, but it is often a costly exercise. However, according to Ciaran McKenna, it doesn't have to be.  Ciaran shares his experience of using 3D printing to create simulation equipment. According to Ciaran, anyone with basic computer skills is capable of making their own 3D solutions for simulation training. For example, he demonstrates how to design and print a basic mackintosh blade using 3D modelling. Training for rare procedures can be very costly using the traditional simulation methods. However, training for such procedures shouldn't be avoided. Therefore, creating low cost, high fidelity SIM equipment is key.  Furthermore, Ciaran explains how 3D scanners can be attached to iPads to take accurate facial contours of a person. Ciaran demonstrates how to make a mould of a person’s neck and then 3D print it. This mould is re-usable and cost effective. Ciaran discusses the benefits of 3D printing and how it is an excellent alternative to expensive simulation equipment that is often out of reach for many facilities. Ultimately, 3D printing of high fidelity simulation equipment is a good option. Ciaran is hopeful that more people will reap the benefits of 3D printing in the future.  For more head to: codachange.org/podcasts/

Diana Badcock begins the talk by discussing her decision to take up the role of Chief Medical Informatics Officer (CMIO). Diana was optimistic about taking this job. However, she left the job after a year. Though she failed in the job, Diana thinks she learnt a lot about failing with fortitude. Diana next talks about the death of her father who was very healthy throughout his life. Three months before his death, he went for a check-up as he was not feeling well. However, he was reassured by the doctor that everything was fine without conducting any tests. Diana, therefore, feels that both she and the system failed her father. Doctors today are overwhelmed with the volume of patients who are older and have more complex conditions, morbidities and mortalities. Many feel that technology is the solution to the problem. However, the amount of money spent in health IT does not reflect the value of the product. This happens because the design of the technology does not match the user experience. Therefore the role of CMIO, CNIO or CCIO is very crucial because the end user has to be there when the technology is being developed. However, Diana feels that CMIO does not get any support either from their colleagues or the organisation. While her peers expected her to help them with their daily IT tasks like opening emails or changing passwords, the organisation treated her like a child or a mere token. This is because a clinician is naïve in the ways of governance, politics and project management. The solution is to involve clinicians in the planning, delivery, improvement and evaluation of clinical ICT systems. Clinicians should be responsible for clinical documentation, single sign on and medication management while the project manager should only manage the project and not the people. Technology should be the enabler, not the driver for health IT. Diana thinks clinicians should focus on bringing about clinical intra-operability to have a simple, standardised way of managing common conditions. Roles like Chief Medical Informatics Officer, Ideas Officer, Innovation Officer, Improvement Officer will be coming up in the future and clinicians should take up these posts to improve the system from within. In conclusion, we need to learn to respond and respect the other silo business of health so that we can work together to analyse, dissect and transform healthcare. Medical Informatics improving healthcare outcomes For more like this, head to our podcast page. #CodaPodcast

Resa Lewiss tells you how ultrasound improves resuscitation outcomes in critical care. Ultrasound helps you make more accurate diagnoses. It allows you to perform procedures with fewer complications, and ultrasound enables you to be more time and cost efficient. However, there may be more to ultrasound - Resa enlightens you. The ultrasound allows the clinician to interact with their patients. Further, Ultrasound enables patients to be integrated into their own care and it allows for an element of creativity. Moreover, Resa explores the idea of reciprocal illumination – the process of exchange and education between clinician and patient. It is the dialogue that occurs between the two and allows for different and deep thinking.  Evidently, what underpins these thoughts is the idea of creativity. Resa asks you to consider how you are creative with your hands. It may be gardening, knitting, playing a musical instrument, writing, or even washing the dishes. Working with your hands is the gateway to creativity. Working with your hands in an intentional and purposeful way, on a regular basis elevates your mood and decreases stress and anxiety. The science supports this. Furthermore, a hand-brain interaction is stimulated, fostering creativity. In bringing these ideas back to the Emergency Room, Resa explains that by using your hands through ultrasound, you are enabling creativity and open communication with your patients. Moreover, Reciprocal illumination – enhancing both care and outcomes. Resa describes the evidence behind this idea. Patient’s overwhelming welcome ultrasound at the bedside in the Emergency Department. They agree that it improves patient care and increases efficiency of their treatment.  Finally, Resa concludes by pondering the idea that ultrasound may also lead to great benefits for the clinicians themselves. For more like this, head to https://codachange.org/podcasts/ 

'"Think of the danger while things are going smoothly." Chicago's own Lisa McQueen picks apart the challenges of identifying those children who genuinely need sepsis resucitation in the "pre-shock phase" and explores the pathophysiology and treatment of shock in children.

Two simulations for prehospital care - tactical and motorcycle pit crew with a panel discussion debrief following. Demonstration and discussion of the medical response to these incidents.