Coda Change

Haney Mallemat informs you how technology is improving healthcare. Haney’s talk is grounded in a patient experience. Jim is a gentleman from a small farm in a rural area of United States. His farm is everything to him and his wife and daughter. When Jim got seriously sick, he had to have an extended stay in a major tertiary hospital. As a result, he and his family lost their farm, which was their world. Could Jim have been treated locally with the utilisation of technology? Haney thinks technology may be the way of the future in medicine. Through the utilisation of technology which already exists, patients such as Jim can stay in their communities and have more holistic outcomes. There are three areas Haney discusses. Telemedicine Defined as medical information exchanged though electronic telecommunications to improve a patient’s outcomes. Traditionally telemedicine is big, bulky, and complicated. This brings with it resistance to use. However, with the advent of lighter and faster computers, telemedicine becomes more and more possible. It is also being compacted into our smartphones making the possibilities endless. Patients are not opposed to telemedicine – surveys show the opposite. They would prefer to not wait endlessly in clinics and travel unnecessarily. Robotic surgery This technology is truly remarkable. Fine movements are possible with precise control. This translates to improved patient outcomes. These include smaller incisions and shorter recovery times. Compounding these benefits, surgery can be performed from another continent. The possibilities for under resourced areas are endless. Mobilisation of products and services Drones are becoming ubiquitous. They have medical applications when thinking about the fast and efficient delivery of supplies, vaccines, and medications. This provides great benefits for hard to access areas, whether that is in developing countries, or across city in peak hour traffic. On top of this, ‘paramedic drones’ have been developed, delivery equipment and telecommunication hook-ups to medical professionals rapidly to accident scenes. Let Haney Mallemat educate you on the future of technology in medicine! For more like this, head to https://codachange.org/podcasts/ 

Flavia Machado gives you the ins and outs of a day in the life of an ICU doctor working in Brazil. She addresses healthcare inequality, ethics, and the challenges she faces in a developing country. By sharing a blow-by-blow account of a day at work, Flavia demonstrates the challenges and inequality that exists. And whilst poverty is shocking, Flavia believes inequality is worse. Flavia’s day begins in the morning with a ward round. Critical bed shortages mean that the clinicians have to make impossible decisions – which patients will get allocated one of the scarce beds? At 07:00am every morning, Flavia and her colleagues in the ICU have to play God. Inequality is plain to see. It is graphically depicted when looking at a map of the distribution of ICU beds across Brazil. In the north, an area of greater disadvantage, there are far less ICU beds per capita. Flavia continues her day, but the challenges do not stop. She checks WhatsApp later in the morning and is inundated with issues pertaining to medication shortages and equipment supply issues. The issue of a broken defibrillating is upsetting, but not unexpected – to the point of her staff using humour to cope with the desperation of the situation. Later in the day Flavia has clinical decisions to make. However, she cannot rely solely on her clinical reasoning and skill as a doctor. There are external pressures that exist – from judges, from industry, from scientist and researchers – and she feels all of them. Sometimes, Flavia feels the strain of operating in these challenging conditions in a middle-income country. Sometimes she feels the futility of it all, like pushing a stone up a mountain, or filling the impossible to fill vessel. That being said, Flavia can see the progress that is made and at the end of the day, she and her team remain happy in doing what they do! For more like this, head to https://codachange.org/podcasts/ 

Dr Anne Creaton talks about the healthcare capacity building in Fiji. Fiji was struck by Cyclone Winston in 2016. It caused widespread devastation and the impact will be felt for a long time in the future. The most important thing that Fiji has taught her is faith, patience and persistence. Anne begins by talking about the three Rs that are essential in trainees who want to work in Fiji or similar situations. The three Rs being: Realistic, Resilient and Resourceful. Emotional intelligence is also very important. Most of the people are highly trained, but always in a high resource environment. Dysfunctional systems in places like Fiji, can impact the clinician’s welfare and performance. Critical care systems are made up of multiple building blocks with doctors playing a small part. Anne compares critical care systems in Fiji to a game of Jenga. This is because multiple blocks that are essential for critical care systems are non-existent.  Anne divides the Jenga blocks of a critical care system into three: a pre-hospital block, a hospital block, and an administration and governance block. The pre-hospital block consists of scene care, transport care, communication, hazmat, decontamination and retrieval. The hospital blocks consist of factors like triage, medical assessment, equipment, drugs and patient flow. The administrative and governance block provides data, audits, leadership and human resource activities such as training, recruitment and retention. All these blocks put together form the critical care system. This illustrates how when the different blocks in critical care services are removed, it makes it very difficult to successfully treat a patient. She explains how doctors face multiple difficulties like faulty equipment, untrained staff, lack of timely transport vehicles, inaccessibility to interventional cardiology, lack of risk management and quality improvement. They also lack hazmat, decontamination, personal protective equipment (PPE), proper communication. Anne then gives an example of using the three Rs technique to reduce VF arrest by early defibrillation. Realistic: Automatic external defibrillator (AED) for all health facilities. Resilient: Placed all AEDs in pelican cases. Resourceful: Acquired the AEDs via Twitter. Anne ends by saying that life is about expectation management and you need to understand that there will be a gap between the type of care you want to provide and what you will be able to provide in situations like Fiji. So, are you ready to play critical care Jenga? For more like this, head to codachange.org/podcasts/ 

The paediatric airway terrifies many of us: at the smaccMINI paediatric critical care workshop, Fran Lockie explores some real-life examples of airway challenges and considerations. He takes us through the concept of the "airway bundle" and how teamworking and communication is key to improving paediatric airway care, emphasising the concepts we can borrow from adult practice to offload some of our cognitive burden and outlining the key components of first-class post-intubation care, with pitfalls and pearls of wisdom from his experiences as a prehospital clinician. Phil Hyde follows on with the nuance of assessing paediatric ventilation, starting with simple interventions and exploring the factors that make big differences for children in respiratory distress.

Andrew Chow gives a rapid breakdown of malignant cerebral artery (MCA) infarction and the utility of decompressive craniectomy. An MCA infarction is an ischaemic stroke, affecting the total or subtotal area of the MCA. It involves the basal ganglia (at least partially) and may involve the adjacent territories. The incidence is 10-20 per 100 000 and there is a high mortality rate of up to 80%. Early clinical symptoms of MCA infarction are contralateral hemiparesis, gaze deviation and hemisensory neglect. A malignant infarction will then progress to severe headache, nausea and vomiting, papilloedema and reduced consciousness. The pathophysiology underlying these clinical signs is complex and involves a failure of sodium pumps, leading to cellular swelling, metabolic failure, tissue necrosis and breakdown of serum products. So, how do you predict who progresses to a malignant MCA infarction? Andrew will guide you through the three domains to consider: Radiological, clinical and pathological. From there, the management. Medical management is grounded in methods to reduce the intracranial pressure. This includes admissions to a stroke unit, high dependency unit or intensive care unit. Elevating the head to greater than 30 degrees and maintenance of normal clinical variables are other considerations. Surgical management involves decompressive craniectomy. This procedure first described in 1935. It is not a benign treatment and there are a number of complications. Andrew discusses the risks, and the preferred methods of the procedure to enhance outcome. He also describes the risk benefit analysis that should be undertaken before recommending this treatment to a patient with a malignant MCA infarction. In doing so, Andrew takes you through the landmark trials looking at the use of decompressive craniectomy. For more like this, head to https://codachange.org/podcasts/ 

Natalie Thrutle educates on the critical issue of lead poisoning in developing countries. Critical care means different things to different people. In the context of lead poisoning, you may or may not think of developing countries such as Nigeria. The response to the Zamfara state, lead poisoning outbreak, in Northern Nigeria, is unprecedented and requires a nuanced interpretation of ‘critical care’. In 2010, 400 children died from lead encephalopathy in the largest lead poisoning outbreak ever recorded, affecting more than 5000 children in Zamfara. The outbreak is ongoing. Children were presenting with intractable seizure and coma, not responsive to treatment for malaria and meningitis. 50% of these children were dying. Environmental poisoning was considered early on, due to the high levels of artisanal gold mining in the area. This increase in mining was a major economic boom to a remote and rural population much in need. MSF had never dealt with a lead poisoning outbreak before… neither had the Nigerian government. No one had ever dealt with a lead poisoning outbreak in the world before. It had never been seen. Initially there were three main aims. Chelation, remediation, and safer mining practices. Whilst chelation worked, it would have been futile without an effort to clean the environment (remediation). This in turn was futile without considering safer mining practices. The solution to the problem required by in and input from all parties. Herein lay the challenge.  Parallels with the Ebola outbreak in Guinea can be drawn. In this instance there were attacks on both healthcare workers and quarantine facilities. Zamfara did not see such extreme reactions although there was certainly a feeling of animosity and resistance coming from the mining community. In this talk, Natalie highlights the successes and the ongoing challenges of facing this issue head on. Progress has been made, and challenges still exist. For more like this, head to https://codachange.org/podcasts/ 

Nikki Blackwell tells her story of the emergency response to the Ebola outbreak in Nzerekore, Guinea. She chronicles the enormous challenges of providing care to some of the most vulnerable people in the world, in one of the most under resourced and challenging environments. The Ebola virus was first isolated in 1976. Between then and 2013 there were twenty outbreaks of Ebola. However, the outbreaks, although vicious, were relatively small and in isolated areas. This outbreak was by far the most complex, with a mortality rate of up to 40%. The fruit bat is the natural host and reservoir of Ebola. They transmit it to other animals, and ultimately humans. Human to human transmission occurs from body fluids, mucous membranes, and sexual contacts. Nzerekore, Guinea has a terrible health service and infrastructure stemming from a long period of conflict. This is further exacerbated by the scarce number of doctors. Further, what compounded the problem even more was the delayed recognition and action from the international community. Eventually, Nikki and the Médecins Sans Frontières (MSF) had funding to launch a project, providing care to the region that was dealing with a devastating epidemic. What followed was an eye-opening experience for Nikki and her team. Nikki highlights the endless challenges she faced in delivery care in her role as Medical Director on the project. These include hot, dusty conditions with the constant stench of chlorine. Heavy, thick biohazard suits that take 30 minutes to get into and can only be worn for one hour due to the extreme nature of the dehydration and exhaustion they cause. Lastly Nikki describes the technical and emotional difficulties of providing care to this population of people with grave illness, constantly surrounded by death, all heightened by the real fear of the staff falling ill. Finally, Join Nikki as she tells her incredible tale of the Ebola outbreak in Nzerekore, Guinea as Medical Director for the MSF. For more like this, head to https://codachange.org/podcasts/ 

In this podcast, Mervyn Singer talks about the link between stress and multiple organ failure. Often, the organs involved in multi-organ failure show no signs of structural damage or cell damage that would indicate these organs might be under stress. Stress might cause functional damage rather than structural damage. Stress is a normal coping mechanism which helps to deal with the various stressors we encounter. These mechanisms include changes in behaviour, as well as autonomic and hormonal modulation of various systems. These include inflammatory, immune, cardiovascular, respiratory and metabolic systems. Human bodies are not designed to cope with the stresses of prolonged life. These stresses include old age, co-morbidities, prolonged critical illness, modern lifesaving drugs, and organ support. Mervyn discusses the evolution of various theories associated with stress. Walter Cannon discovered acute stress response in 1915 when he noticed the manifestation of nervous exhaustion as physical illness in soldiers of World War I. Furthermore, Hans Seyle described the general adaptation syndrome in 1936, stating that when in distress, the physiological systems are functionally compromised. Moreover, Takotsubo identified cardiomyopathy in the early 90s in Japan – in this condition heart failure occurs due to emotional stress. Ultimately, Sterling and Eyer defined Allostasis in 1988 as "staying the same by being different." The body goes into allostatic overload when exposed to extreme stress conditions. Type 1 allostatic overload of stress causes the organism to switch off in order to regain energy balance. Hibernation, estivation, anoxia, and dormancy are all example of allostatic response to stress. Myocardial hibernation is an example of an allostatic response in humans. Multiple markers identify poor prognosis in stressed patients. Energy and metabolism are directly proportional to each other and a reduced level of either or both can be seen in critically stressed patients.  An ICU patient is under multiple stressors. These include physiological, pharmacological, environmental, and psychological stress, all of which lead to chronic critical illnesses. Thus, multiple organ failure may be an allostatic response to the prolonged stress faced by an ICU patient. Mervyn ends the podcast by suggesting multiple pharmacological and non-pharmacological methods to de-stress the patients.   For more like this, head to https://codachange.org/podcasts/ 

Jon McCormack gives you what you need to know in the case of paediatric blunt traumatic cardiac arrest. This is a rare but deadly occurrence. Data shows that the population incidence for paediatric blunt traumatic arrest is 1 in 100 000. Of these, most are male, and most are involved in vehicle traffic accidents, along with falls and non-accidental injuries. The median age is 7 years old. The injuries are severe, and the survival numbers make for grim reading… around 1%. So, the numbers are low in both incidence and survival. However, the cases can be deeply personal and effect the clinician and bystanders for a long time. With that being the case, coupled with the enormous upside both socially and economically, surely emergency care should “go all in”. Jon explains why this is the wrong approach. He discusses the reality of the presentation of a paediatric blunt traumatic cardiac arrest. He advises to limit unnecessary treatments and risks to yourself and team. There are potential survivors. Children who maintain a detectable cardiac rhythm and show signs of life have better survival prognostics. Children in asystole or without signs of life will not survive. Objectively assessing signs of life may be important so Jon recommends being well versed in roadside echocardiograms. However, given the fact that the vast majority of children will be in excellent health at the time of injury, if they are showing no signs of life or cardiac activity, they have likely exhausted their enormous physiologic reserve. In this instance, they are in a decompensated which will lead to death. Finally, Jon concludes with some advice. In a paediatric blunt trauma cardiac arrest, initiate CPR and basic life support early, do not resort to a thoracotomy, and organise rapid triage and transport to a trauma centre if there are signs of life. If not, be prepared to stop futile treatments. For more like this, head to https://codachange.org/podcasts/ 

Stephen Bernard shares his thoughts and the current evidence for using oxygen for cardiac arrest patients. Oxygen is ubiquitous in society! You can buy it in bottles and there are even oxygen cafes. This is especially true in hospitals where oxygen is used frequently and often without much thought. Oxygen is a natural substance. So surely, a short time on 100% oxygen can’t be harmful, right? Stephen wants to challenge that idea. In this talk he presents the data on why oxygen might be harmful to your patients, particularly following a cardiac arrest. Out-of-hospital cardiac arrest (OHCA) is common and carries a high mortality rate. In Victoria, Australia, approximately 50% of patients with an initial cardiac rhythm of VF achieve a return of spontaneous circulation (ROSC) and 30% overall survive to hospital discharge. The outcome for patients is improving. This is due mainly to faster ambulance response times and increased rates of bystander CPR. What is done in the hospital has altered the patient’s outcomes in the same way. Currently, OHCA patients who have achieved ROSC but who remain unconscious routinely receive 100% oxygen for several hours in the ambulance, ED, cardiac catheterisation laboratory until admission to ICU. However, there is now evidence from laboratory studies and preliminary observational clinical studies that the administration of 100% oxygen during the first few hours following resuscitation may increase both cardiac and neurological injury. Clinical trials are underway to test whether titrated oxygen to a target oxygen saturation of 90-94% in the immediate hours after ROSC results in improved outcomes compared with 100% oxygen. Join Stephen as he makes you think twice about blindly using oxygen for patients following a cardiac arrest. For more like this, head to https://codachange.org/podcasts/