Coda Change

Howie shows us the tools in his toolkit: Tourniquets save lives and do not cause limb ischaemia. The aorta is clamped for many hours in cardiac surgery. Data from the battlefield showed that in >800 cases where tourniquets were applied, there were 3 adverse outcomes (loss of sensation in the distal fingertips). Haemorrhage control (Israeli) bandages are tourniquets with a haemostatic agent that can be applied to a bleeding wound QuickClot (haemostatic powder) can be used for abdominal wounds but may draw the ire of surgeons because they cause an exothermic reaction that burns surrounding tissue. Howie emphasises that not all bleeding have to be stopped - if it's not pouring out, it can wait. He teaches us to quantify blood loss in the field - three 335 mL cans of soda worth is when to start worrying. The talk ends with an interesting mini Q&A session as trauma surgeons and paediatricians also weigh into the debate.

Airway management induces stress and fear in the heart of many Critical Care practitioners. In a high pressure situation, it's easy to falter on the see-saw of demand vs. ability. Rich argues that in difficult airway management, we are hindered by: complex algorithms, anecdotal expertise and the negative perception of the task as 'undoable' and the downplaying of our abilities. In crisis, we need simple! Rich discusses the need to redefine the priorities of the airway (away from 'find the vocal cords/cricothyroid membrane'), incrementalisation and consensus of method. Rich also briefly discusses the future of airway management - nasal oxygenation and the need to move past the surgical airway as a failed airway.

Andy Naidech gives a fascinating and powerful short talk on controversies in management of aneurysmal subarachnoid haemorrhage, followed by discussion from the panel of experts and questions from the crowd. This was recorded at the neuro workshop for SMACC Chicago and was a very popular session.

In this hypothetical panel discussion, our protagonists have just started work at the Utopia Trauma Centre – a state of the art facility that is world renowned for its excellence in trauma care, research and teaching … Our panel includes a social worker in intensive care, a senior intensivist and director of training for ICU, an emergency physician and director of 'physician leadership development', a trauma surgeon, an ICU and flight nurse, a consultant high performance coach for the institution, and the director of research and global health programs As we work though a series of clinical cases and events at the hospital we consider performance – highs and lows, including the dark side of high performance/ ambition. We teeter over boundaries and ethics in pursuit of high performance. We consider the impact of diversity in our staff profile. When it all goes wrong we discuss resilience, and dealing with human fallibility - mental health, substance abuse, physical illness, and aging. What does it all mean for our own practice and our critical care communities. Food for thought.

Simon Carley has us asking ourselves some confronting questions about our abilities in his SMACC Chicago talk 'Are You as Good as You Think?'. Carley has us delve into our confidence, competencies and whats makes for a good self learning environment. Initially Carley asks how good we think we are at driving? He then sites studies of Australian and European driver responses stating that 93% of Aussies and 69% europeans rate themselves as above average drivers. In using the example Carley suggests as individuals we are not particularly good at rating ourselves, while inexperienced people tend to rate themselves more highly then experienced people, calling this illusory superiority cognitive bias. Carley asked the question since you can't have awesome without average, how do we measure ourselves?. He then talks us through the following tools and processes to establish better self learning and teaching processes; Reflection Diaries - revisit it (clinically and physically), follow up. Peer reviews: 1:1 feedback doesn't work. It needs to planned with clear goals and objectives such as; Clarify expectations review logistics focus lens plan feedback observe event (i.e teaching) debrief and action Clinical Feedback Follow up - not just the exceptionally sick patients, but follow up with the routine ones. Build Peer Reviews into your practice. Carley finishes by asking us to choose on of the following items and commit to ourselves to making it happen within the month. I am going to … Organise Trainee Feedback Focused 360 Assessment Keep a Patient/Teaching Diary Be Peer Reviewed Reflect Develop Team Feedback Follow up with Patients Something Else Nothing I am already Awesome! What have you committed too?

Cliff Reid unites our passion of Critical Care in his SMACC Chicago talk Advice to Young Resuscitationist - It's up to us to Save the World. Talking us through his advice to his former younger self, Reid sights mistakes, case examples, and essentially provides us with invaluable tips to nudge us along to Resus Mastery. Reid offers the following advice to his former, younger self; Your career and speciality is a journey and you chose your destination: Don't be defied by the expectations of one chosen path. Have an appreciation of what other specialities can add and what you can learn from them. Leave your ego at the door. Have a balance of confidence and competence. When something goes wrong you have to change something: Be it either yourself, your colleagues or the system. Follow up on your hypothesis: You won't know if you got it right or wrong and will not gain or learn from the experience. Preserve comfort and dignity for your patients: 'No one knows how much you know, until they know how much you care' - Greg Henrey. Protect yourselves: Think about the people around you and share your experience with them, chose your colleagues and where you work wisely. Increase team cohesion - it is protective against burnout and compassion fatigue. Be Aware: look after the tools of your trade, your body and mind. Try and maintain good physical health, and train your mind to be more effective under stress. Remember society puts their trust in you - you only fail them when you fail to learn in them. Every patient is a gift/lesson accept it with grace and gratitude. Behave in the way you want to be remembered. Keep perspective and enjoy the ride!

Simon Finfer has spent his career managing patients with traumatic brain injury nad has watched treatment fads come and go. He's also taken part in some of the best and biggest clinical trials in this area which give him a unique perspective on why we do what we do in managing this devastating but common condition. In the contraints of 15 minutes, he'll make you think and hopefully question your own practice!

Imogen Mitchell's SMACC Chicago talk 'Morphing the Recalcitrant Clinician' talks us through the steps to engage the reluctant physician when implementing change. Imogen initally touches on the stages of physician engagement from aversion, to apathy, to engaged and then outlines the steps to morphing the reluctant physician. 1. Seek out a clinical champion 2. Establish a common purpose/vision 3. Standardise what is standardisable 4. Communication, communication, communication 5. Work out barriers and overcome them 6. Deal with the 'Whats in it for me?'WIFM

David Juurlink SMACC Chicago talk 'Drug Interactions That Can Kill (and How to Avoid Them)' takes us on a journey of drug interactions, case studies, and avoidance strategies. Juurlink starts by educating us on the two different drug-drug interactions (DDI) - effects of one drug altered by the use of another . First of which is Pharmacokinetic where by one drug alters the level of another, the second Pharmacodynamic being no change in drug levels, and uses this as a basis for his following case studies. Juurlink speaks of the dreadful literature that is available on the thousands of drug interaction per year, stating that most information comes from case reports and volunteer studies, and suggests that majority of these interaction are avoidable. Juurlink then goes on to discuss the findings of 4 case studies involving the following Drug-Drug Interactions and their effects on the patients. SMX/TMP + sulfonylureas Macrolides + digoxin APAP + warfarin SMX/TMP + ACEI/ARB Juurlink provides us with a short list of trigger drugs that we should be aware of, a list of meds that warrant extra caution and list of possible safer alternatives. He also suggests that it is of the up most importance to have a good pharmacist to turn to as they are given more information on drugs interactions then physicians. And, to utilise resources such as pharmacy times - where you can get information on drug interactions at a push of the button. Juurlink also suggests that an Informed patient is a very useful safety mechanism.

Rick Body's SMACC Chicago talk 'Is compassion a Patients Right?' takes us on a journey of emotions in critical care. Starting with his rendition of john Lennons 'Love'. Body, explains the origin of the word compassion - a move to act based on someone else suffering, a sharing of suffering with. Body, initially focuses on a study conducted within his hospital of 125 patients, who were interviewed when admitted to their emergency department and when they where discharged. From the study it was depicted that, what patients truely wanted was simple human intervention; reassurance, friendliness, explanation, basic care. These responses were then coded into 5 different themes to depict how patients believe their suffering should be addressed; 1. Emotional distress 2. Physical symptoms - including pain (but not restricted to) 3. Information - Included reassurance and explanation 4. Care - Basic care 5. Closure - patients want to put this horrible episode behind them Body notes that patients are telling us that they want something positive from us. They don't want us to focus on what we shouldn't do. They want us to be thinking about what we can do to help… suggesting that if we follow the above 'EPPIC' we could provide more compassionate care. The problem is this is not compassion as compassion is an emotion and needs to be felt. Body then explores whats stopping us (care providers) from showing compassion? Sighting the The Good Smaritian Study: that depicts the more in a rush one is the less likely they are to show compassion. The By Standers Affect: if a large crowd is doing nothing, you are more likely to do nothing. Unclear of Who is Responsible: less likely for anyone to respond and Personal Reasons: the responsibility for other peoples lives, fatigue, tough, resilient to showing emotion, emotion been seen as a weakness and a feeling as doctors we are not meant to show emotions. Body, then shows a picture of a doctor crouched slumped over and inconsolable, shortly after the image was taken the doctor loses a 19 year old patient he was treating and minutes later the he walks back into the emergency room and continues working. This picture went viral on social media and the doctor pictured was seen as admorable. Body sites this example to state that clearing having compassion and showing compassion is right, but is it a right?. And, asks the question 'Would you prefer the surgeon who shaking with emotion as you go into surgery or the surgeon who is composed, objective, calm, tough, resilient, unmovable and efficiently get on with the task in hand?'. Body believes that patients don't have a right to compassion as it is an emotion and means to suffer with but asks for health providers to be emotionally intelligent. Explaining that emotional Intelligence recognises that there is a difference between traditional intelligence, IQ and our ability to form effective forms of interpersonal relationships. Siting the 5 domains of emotions intelligence as; 1. Know your emotions - know what we are feeling 2. Manage your emotions - cool rational and object in the rests room, show emotion with patients and family 3. Motivating ones self 4. Recognising emotions in others - empathy 5. Handling Relationships - interpersonal Skills - relate to other people Body suggest that these are skills that can be developed as ones life goes on and by building skills in emotional intelligence that maybe one can be both a compassionate and effective doctor. Body concludes by asking the question 'How are you going to care more for your patients?'