Coda Change

John Myburgh speaks passionately about the use of oxygen in resuscitation, and clinical outcomes in critical care. For the 30 years, clinical understanding of haemodynamic resuscitation has been based on physiological paradigms that focus on convective oxygen delivery. Most of these emphasise the role of cardiac output, haemoglobin and recommend interventions using synthetic agents such as dobutamine, synthetic colloids and blood transfusions. However, markedly influenced by industry, these interventions and strategies hijacked critical thinking creating a belief in the utility of attaining short-term physiological surrogates for resuscitation that have little relevance in improving patient-centred outcomes. This ‘physiological fallacy’ has been demonstrated in high-quality RCTs of fluids, goal-directed therapy and catecholamines, that paradoxically inform the interpretation of new insights in the physiological basis of health and disease. In this talk John presents two halves. In the first half, he discusses oxygen delivery. He begins with the oxygen cascade and applies this to the current thinking by some on oxygen delivery in critical care. He believes the two are incongruous. Measuring and altering oxygen is achieved using expensive toys and is likely not having a great impact on patient outcomes. John questions the whole concept of driving P02 to influence patient outcomes and mortality. In the second half John talks about the ‘physiological fallacy’ – the clinical practice of relying on variables we cannot accurately measure and do not understand. He presents a different approach. Physiology and haemodynamics encompass complex processes under intense neurohormonal vasoregulation. There is no one simple metric to rely on, such as V02 or D02. When considering a patient, the clinician must use their brain. John stresses the importance of focusing on understanding the disease process in its entirety rather than chasing instant gratification by altering a number. Work out where your patient exists on a spectrum. Consider acute versus chronic presentation, as well as compensated versus decompensated patients. This will dictate treatment. The situation usually complex and dynamic… Treat it as such. For more like this, head to https://codachange.org/podcasts/ 

Scott Weingart discusses the scientific aspects of meditation. He believes meditation is to the mind what exercise is to the body. There are two types of meditation: focussed attention meditation or vipassana, and contemplative meditation. Generally, people exist in a default mode network. This happens when we are not focussed on anything in particular and thoughts occur in our brain without us being aware of it. Spending a few minutes every day aware of what thoughts are occurring in our brain is highly beneficial. This helps with stress control, relaxation response control, slowing of telomere degradation, control over emotions and increased concentration. Scott, however, wants us to focus on a single objective benefit of meditation - controlling the stimulus-response gap. Viktor E. Frankl explains - “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” Meditation helps to choose our responses to stimuli, both good and bad. Scott explains how to do mindfulness meditation or vipassana. First, pay attention to your present circumstance by linking it to your breath. Second, be non-judgemental and forgive yourself for the random thoughts that come up while meditating. Finally, watch moment by moment as experiences unfold. A book written by William B. Irvine on Stoics, introduced Scott to contemplative mediation. Stoicism is based on a philosophy of happiness which tries to eliminate negative emotions like hate, envy, anxiety, and fear.  Scott dedicates this podcast to John Hinds by explaining how he appreciated the moments he spent with John due to his practising of mindfulness. Meditation is a way to appreciate every moment that we have in our short life. Exercise is work to live longer, while meditation is work to live better. For more like this head to https://codachange.org/podcasts/ 

Paul Young discusses remote ischaemic preconditioning and along he delves into the pitfalls of clinical research. 2016 was the 30th anniversary of ischaemic preconditioning. Remote ischaemic preconditioning is the magical offspring of ischaemic preconditioning and refers to the phenomenon whereby brief periods of ischaemia in one organ can protect other organs from subsequent prolonged ischaemic insults. Ischaemic preconditioning rose to prominence after a seminal paper in 1986 that demonstrated the protective effects of ischaemic preconditioning in dogs who had coronary ischaemia. This effect had been appreciated in humans. For instance, pre-infarct angina leads to smaller infarcts that in heart attacks without preceding angina. Remote preconditioning is for more magical. Paul takes you through the basics. The idea is simple enough. Blockage to one site leading to ischaemia preconditions another site to subsequent ischaemia. This was first demonstrated by blocking the circumflex artery in the first instance with a series of temporary occlusions. The left anterior descending was then blocked for a prolonged period. This preconditioned the heart to the prolonged ischaemia and decreased deleterious effects. This effect was then repeated with transient renal ischaemia protecting the heart from prolonged cardiac ischaemia. This effect was demonstrated with different organs – with almost any organ being able to protect another organ. The clinical application? Inflate a blood pressure cuff on an arm (to above systolic blood pressure) for five minutes and you will protect the opposite limb… or the heart. Remote ischaemic preconditioning is a reproducible phenomenon. However, as Paul explains, no one knows how it works. In this talk Paul describes his research – a double blind trial on remote ischaemic preconditioning; the first of its kind. He also describes a systematic review and meta-analysis he conducted. He found conflicting results in his trial and heterogeneity across other studies. When considering further research Paul concluded that it nothing was convincing and there were many pitfalls in the papers. What matters? What the patient can do, how they feel, whether they live and to a lesser extent does the intervention save money. In the end it seems that it is the relationship between ischaemia and reperfusion that makes a difference. That is, apply the remote ischaemic preconditioning after the primary ischaemia but before the reperfusion. This has potential clinical implications for the following: 1. Heart surgery with cardiopulmonary bypass 2. Planned percutaneous coronary interventions 3. Acute myocardial infarction 4. CBA being treated with lysis or clot retrieval 5. Carotid endarterectomy surgery 6. Hypoxic ischaemic encephalopathy 7. Organ transplantation 8. abdominal aortic aneurysm surgery While this technique is not yet ready for clinical application, it remains an exciting potential therapeutic modality for the future. Finally, Paul finished with his top tips. Don’t believe single centre studies, consider biological plausibility, be sceptical about secondary endpoints and don’t be misled by surrogate endpoints. For more like this, head to https://codachange.org/podcasts/ 

Marius Rehn examines the difficulties and importance of evidence based medicine in prehospital resuscitation. Notably, combining academic activity with pre- and in-hospital clinical practice is hard work. Being an academic in a flight suit can be quite lonely. Marius wants this to change and is passionate about increasing the quantity and quality of prehospital research. Prehospital research that examines patient pathophysiology should dictate care – as it does in the hospital environment. However, Evidence based practice pertaining to the prehospital environment is minimal. This needs to change. Evidence based medicine in the prehospital setting can dictate care, critically appraise practice and enable improvements in process and cost effectiveness whilst decreasing harms. Evidently, in-hospital evidence is different to the field application. Ultimately, prehospital research is critical, 5.8 million people die from injury every year – around 10% of the world’s deaths. Unfortunately, pre-hospital research is underfunded. So, how can we take interventions from the hospital to the streets? Marius shares three important steps: The research that is needed How to interpret the evidence Why all research is important to consider (from case studies to randomised controlled trials) Moreover, Marius highlights the need to lean on other members of the scientific community when conducting your own research. For example, a statistician is worth their weight in gold in observational studies when fleshing out regression analysis. Finally, Marius discusses the importance of information dissemination across all platforms, including peer reviewed journals and informal FOAMed platforms such as Twitter. They all have their place. For more like this, head to https://codachange.org/podcasts/ 

Anand Swaminathan brings precision emergency medicine and outcomes in critical care into the light. He will convince you to start calling diseases for what they are and as a result start offering the proper treatments and care. All disease exists on a spectrum. You can’t treat one end of the spectrum the same way you treat the other end. This talk is inspired by a case of Anand’s. An older man presented to the ED with acute onset shortness of breath and crackles. He was treated with Lasix. More and more Lasix – even though he wasn’t improving. Anand knew this presentation was more than just an exacerbation of heart failure. This was acute pulmonary oedema and this man needed a different treatment. Disease is on a spectrum with ‘urgent’ on one end and ‘critical’ on the other. The umbrella term that identifies the disease needs to be spread out so that it can be placed on this spectrum by you and others around you. Calling a presentation an exacerbation of CHF when it is in fact acute pulmonary oedema is wrong and leads to harm for the patient. We have the medications and treatments for both end of the spectrum. However, they aren’t always used. Too often disease gets miscategorised on the wrong, milder end of the spectrum. Why? First, more patients exist at this end, and we therefore default back to this presentation of the illness. Secondly, there is an inverse relationship between the severity of disease and the research guiding treatment. Therefore, the temptation is to use this research to guide management all along the spectrum. Finally, time and resources are precious. The sicker a patient is, the more of these commodities they use up so err towards an approach for milder disease. To counteract these points Anand wants you to understand the diseases better. How? First, educate yourself and those around you to assess and treat disease properly. Call the disease the right thing and ensure proper allocation of proper and adequate treatment and resources. Secondly, spend more time at the bedside – especially early in your training. This is how you rapidly identify sick patient, and rapidly determine what needs to be done. After this talk Anand hopes you are inspired and can walk into work tomorrow and make a change. Empower each other to act by calling things what they are! For more like this, head to https://codachange.org/podcasts/ 

Sue Mason gives you her take on Geriatric Emergency Medicine. Sue’s bread and butter is managing the elderly in the Emergency Department. It is not a sexy topic and there are few gizmos and gadgets. Nevertheless, it is very important. How big is the problem? Patients over 65 years represent about a quarter of the patients that attend Sue’s Emergency Department. However, most of these patients arrive by ambulance and the vast majority of visits in this age group are deemed necessary. This culminates with 50% of these patients being admitted. Attendance and admissions in the elderly age group are both going up. What are we doing about it? Advances have been made in prehospital care. In Sue’s region, paramedics have been trained in assessing and managing elderly falls. This found a reduction in ED attendance by 25% and decreased admissions by 6%. Approaching the management of the elderly with a multidisciplinary team has proved to be effective in a ward setting. This has not been replicated in the Emergency Department. Within the ED there is potential for the inclusion of a pharmacist to improve admission rates. However there has not been any other “in department” interventions involving a broader team. The initiation of interventions from the ED to continue in the community has been looked at, although the evidence is mixed. How can we do it better? Sue explores the question of whether all Emergency physicians should be trained in Geriatric Medicine. Or whether there should be sub-specialists in Geriatric Emergency Medicine. She also explores other strategies. Simple things such as not putting elderly patients on beds/trolleys unless clinically indicated and ensuring they have fluids on board. Overriding all decisions should be the question – does this patient need this investigation, treatment, and admission. For more like this, head to https://codachange.org/podcasts/ 

Dr Michelle Johnston talks about dystopian futures and the relevance of emergency medicine in forming such futures. Literature can provide insights into the two types of future we can expect: an optimistic, technologically advanced future as showcased in the movie “Blade Runner” or a dystopian future as envisioned by George Orwell in the novel “1984”. She discusses how different authors have written along similar dystopian themes with government controlling all aspects of human life. Some examples are novels like “Brave New World” by Aldous Huxley and “The Handmaid’s Tale” by Margaret Atwood. Or, “The Hunger Games”, “The Maze Runner”, and movies like “Brazil”. The common theme of these stories is oppression of the individual, non-existence or illusion of freedom, poverty, and police societies. Michelle believes that dystopian literature is based on the tiny fears of individuals and how they react to it, shaping the future. Therefore, she asks the question: what are the things that we do today that might lead to a dystopian future? She begins with discussing technology in emergency medicine that already exists and points towards a bright utopia. This includes augmented reality, smart glasses, shmeat, 3-D printed replacement parts, robots, nano-robots and genome mapping. Michelle next discusses factors in emergency medicine that might lead us to a dystopian future. Over use of broad-spectrum antibiotics combined with uncontrolled use of antibiotics in agriculture, and international travel has led to increased microbial resistance. Unnecessary tests and treatments are another factor contributing to a dystopian future. Economic inequity in emergency medicine. One side of society spend huge amounts on sustaining the last years of a patient’s life. Meanwhile, on the other side, huge populations are deprived of basic needs. Increased waste production by hospitals due to increased usage of disposable tools is contributing to climate change. Administrative bureaucracy is another factor which though necessary, might be restricting creativity and individuality. Michelle concludes by quoting Immanuel Kant: “Even small decisions ought to be made as if we were choosing for all of humanity, not just our paltry self.” Finally, for more like this, head to https://codachange.org/podcasts/ 

Mike Abernethy runs you through the pitfalls and challenges of rural trauma resuscitation and prevention. The farm is a dangerous workplace. Accidents have an unusually high morbidity and mortality not only for the worker, but also his/her family members. The reasons are multi-factorial but are the result of a complex interaction of environment, equipment and human factors. The vast majority of agricultural deaths involve tractors. No other industry uses 70-year-old machinery operated by workers whose age ranges from 10 to 90. How can we prevent such incidents? Mike is a prehospital physician (who is a wannabe farmer & tractor mechanic) and long-time resident of an agricultural community. In this talk, he will examine the details of a life-threatening accident involving one of his neighbours which perfectly illustrates the multifaceted nature of agricultural trauma. He will then discuss agricultural trauma more broadly. The statistics are similar across the globe, from the United States to Australia, Cambodia to Ireland. Fatalities involve heavy machinery (usually tractors) and the farmer or their family. Furthermore, deaths occur between 18-60 years of age in most industries. In farming however, fatalities can occur across the whole life span.  Whilst there are equipment changes that have made things safer, they have a poor uptake amongst farmers. This is due in a large part to interference with productivity and functionality. Mike believes change can only come about through community engagement and education at a meaningful, personal level. Rural and farming communities are faced with inherent risk of injury and death on a daily basis. It is pertinent to be aware of this and to educate these communities when the opportunity presents itself. After all, if it is made of steel, sharp and moving… It will %^&* you up! For more like this, head to https://codachange.org/podcasts/ 

Dr Simon Carley discusses the future of emergency medicine. Simon begins by talking about how things have changed in emergency medicine since he started his career in the 1990s. He wants to shed some light on where we are going with emergency medicine, what is happening to us and what is shaping us. He believes that predictions about the future, as shown in movies like Back to the Future, might not always come true but they certainly provide clues as to what is possible. According to Simon, three major factors influence the future of emergency medicine. The first factor is the people. Population predictions show that life expectancy has gone up, leading to an increase in the number of elderly people. As the age of the population increases, the age of the people dying due to trauma becomes older. This changes the approach of emergency medicine. Moreover, the age of the workforce in medicine is also increasing. Simon believes that the rigid systems must change to encourage the next generation of healthcare workers to enter medicine. Patients, pathologies, and the workforce are changing. The second factor influencing emergency medicine is politics. There is an increased financial constraint on health services which is in part due to increases in technology. Horizontal equity, where everyone gets equal treatment, and vertical equity, where some people get more, must be balanced. This can be achieved by involving emergency physicians in the political decision making. The future points in a direction where emergency medicine divides into different specialties which according to Simon might not be the right path. Furthermore, the third factor affecting emergency medicine is technology. Technology is essentially revision and refinement making things cheaper, easier, and portable. Revolution in technology is what matters. It changes the way we approach emergency medicine in fields like decision support, disease probability models and personal diagnostics turning doctors into probabilistic clinicians. Simon believes that though we cannot actually predict the future, we can definitely get involved in shaping it, making the future of emergency medicine as exciting as the past. Tune in as Dr Simon Carley discusses the future of emergency medicine. Finally, for more like this, head to https://codachange.org/podcasts/ 

A Tribute to Dr John Hinds, Dr Janet Acheson speaks about her life with Dr John Hinds and how unexpected his death was. John Hinds was known as the pioneer of pre-hospital trauma, a master educator and powerful orator. He was “son” to his mother Josephine, “John boy” to his father Dermot and “John” to his friends and family. John Hinds inherited his meticulousness from his mother and sense of adventure from his father. Janet speaks about different lectures given by John Hinds during which he coined the term #ResusWankers and spoke about cricoid pressure and Cricolol.  She speaks about “Johnisms”, thoughts that she and John shared; find your people and acquire memories of life; do not let wankers bring you down, learn from your mistakes and finally, make your intentions honourable - the patient is the centre of everything. She requests the audience to help trend #WhatWouldJohnDo. Dr Fred MacSorley, a good friend of John Hinds, talks about how promising and talented John Hinds was when he entered the field of anaesthesia in 2004. His passion for motorcycling and fierce determination to help those injured, though it helped him in his career, also led to confrontations with peers who had more rigid minds. John, however, overcame these obstacles with passion, humour and risk-taking ability. Fred reminisces about how training sessions with John would stretch on as John was a passionate teacher. He speaks about the call sign Delta 7 assigned to John while being part of the Northern Ireland Ambulance Service. Fred remembers that John always arrived first at an accident scene and worked away quietly. He was polite and had excellent people management skills. He established a relationship with his critically ill patients by talking to them and reassuring them. Fred shares stories of John’s growth to become a flying doctor. He claims that John revolutionised the management of traumatic cardiac arrest. A tribute to a legend, Dr John Hinds. For more like this, head to https://codachange.org/podcasts/