Coda Change

Andrew Healey takes us on an exploration of the early phases of donor management in ICU and Emergency Medicine in his heart felt SMACC Chicago talk Optimizing the Care of the Organ Donation Patient. Which focuses on the processes of managing donor patients and their families, while they ride their ICU/ ED journey through to organ donor. Healey summarises his talk into four main points: 1. Set families up to make the right decisions - be it with end of life care or organ donation. 2. Preserve the opportunity for donation - understand that this is often the last decisions a family will have to make about a loved one and they may need time. 3. Never Say No - never say no to an organ donation, ask the specialist. The only people who can decide if a person is not ideal for organ donation are those people who intimately know the recipient. Healey sights some interesting stats that are worth thinking about such as; 1 out of every 4 people who are on the heart transplant list in Canada die. While, the risk of contracting HIV or Hepatitis from a transplant heart is 1 in 4000 (HIV) and 1 in 245 (hepatitis). With these in mind the elevated risk donor can look less risky. 4. Remember Organ Donation is never merely a mention - It's up to physicians and critical care providers to guide families to make the right decisions.

Jeremy Cohen took us on an Adrenal Function journey at SMACC Chicago with his talk Raging Hormones in Critical Care. Cohen explores the natural roll of cortisol in the human body, various schools of thought and recent research in the areas of sepsis and cortisol resistance.

Trauma is Risky Business Deborah Stein SMACC Chicago talk Trauma is Risky Business - delves into the risk patients and physicians undergo when treating or being treated for Trauma. Stein's speaks of the Risk Benefit Determination that physicians make daily and how this is used to best answer on going questions such as; can a patient have?, how do we care for this patient? and how do we best make all the these decisions?. Stein's suggests a thorough Risk Benefit Determination will include: # Analysis of best available data # Use of best available judgement # Gathering of different opinions # An understanding that you won't always make the right decision # To document the 'crap' out of it! # And, to remember you'll never know what you prevented from not occurring. Stein's also focuses on the risk to patients due to missed injuries, stating that 1.3-39% of injuries in trauma are missed (a majority of which present as orthopaedic cases). And, touching on the processes designed to prevent missed injuries such as; Territory Trauma Survey, Roles of Clinical Decision Rules, to scan the living 'crap' out of them - whole body CT scans (can decrease mortality but comes attached with its own risks). Stein's then delves into the risks trauma providers (physicians) face on a daily bases. Stating that in the USA trauma providers are one of the highest categories of physicians to be sued, have higher indemnity payment awarded against them and achieve a higher risk score in studies for being sued. While, lawsuits are more likely to increase the chance of physician burnout, career burnout, depression and are emotionally and physically exhausting. Steins sights recent studies that suggest the more open, honest and forthright a physician is with their error with their peers and their hospital, the likelihood of being sued reduces. Stein's also notes that needle stick injuries in most departments have decreased in recent years due to universal precautions, yet have increased in trauma care due to the nature of the ER environment and proper precautions not being taken. Violence is of risk to attending ER nurses, physicians and paramedics, sighting an Australian study that 79% of triage nurses have experienced physical violence from patients. And, the emotional harm the trauma environment can have on trauma providers. Steins suggests that trauma providers must be aware and learn how to manage risk better to ensure patient and provider safety.

Walter Eppich engages us on the topic of Interprofessional Communication: Challenges and Opportunities. Eppich describes communication as the engine of learning - providing it is coming from a psychologically 'safe' environment free from humiliation and punishment. Eppich characterises a psychologically safe environment being; an environment where people can speak up with idea, questions and mistakes without being fearful of being wrong and stresses when communication breaks down, patient safety breaks down and learning breakdown. It takes a team to do patient care.

Summary by: Rosy Wang Lactate has been viewed as a byproduct of anaerobic metabolism and an indicator of tissue hypoperfusion since the 1900s. This theory is still widely believed. Paul busts the myths surrounding lactic acidosis, anaerobic metabolism, tissue hypoxia and the role of lactate in sepsis. Key take-away facts include: - The production of lactate actually consumes hydrogen ions. Lactic acidosis is really lactic alkalosis. - Lactate is produced physiologically and is a precursor for gluconeogenesis. - During exercise, skeletal muscle exports lactate as the primary fuel for the heart and brain. - At VO2max, intracellular oxygen stays the same. Anaerobic metabolism in cells only occur as a pre-terminal event. The exception is in complete arterial occlusion. - Adrenaline promotes lactate production - Lactate infusion has been shown to increase cardiac output in septic and cardiogenic shock - Lactate is a survival advantage!

Summary By: Rosy wang You don't have to be Bear Grylls to stay alive in the wild. Remember the rule of three - you can live 3 minutes without air, 3 hours without shelter, 3 days without water and 3 weeks without food. The two biggest killers in the wild are cold and heat. Justin discusses the physiology of our body's responses to cold and heat and the pathophysiology of hypo- and hyperthermia. He also talks about the simple of ways of preventing cold and heat injury, including staying dry, adding layers, drink any water you can get your hands on - just not sea water. Lastly - don't panic.

Kath Maitland takes the perspective that we should be cautious with how we give IV fluids. She argues that the underlying physiological evidence supporting the benefits of giving fluids is not there. The findings of the FEAST study are clear. Kath describes how during FEAST, the administration of fluids made the children look better, and improved the recorded physiological parameters. However these surrogate outcomes did not translate to a mortality benefit - fluid boluses were associated with increased mortality. Nick, a paeds intensivist, retaliates with how it's really about understanding physiology. He defends the position we take at the moment and discusses the issues with the parameters used to assess fluid responsiveness, but urges that we shouldn't change everything we do at the moment until we understand the physiology better. He also has nice description of the glycocalyx - "the pubic hair of the blood vessels, only more useful".

The Mystery of MODS Summary By: Oli Flowers Mervyn Singer entertains the SMACC crowd with tales of MODS (Multi Organ Dysfunction Syndrome). With videos of Raquel Welch, stories from the Battle of Trafalgar and lessons from evolution, he makes us think about the important physiology underlying critical illness. This lecture precedes the latest SIRS definition and really puts them into context and leads on to the promise of precision medicine.

Scott Weingart's lecture at SMACC-Chicago was on OODA loops and the supremacy of System I for resuscitation. Check more here

How to Diagnose Dying A patient's death maybe certain but the timing isn't. Ashley Shreves talk is on the difficult subject of dying, and how best to understand and help diagnose when the battle is lost. Shreves discusses the correlating patterns present in the functional decline in end of life patients, with particular reference to the type of disease a patient is suffering from. Shreves suggests, that understanding these patterns is paramount to understanding the care and medical intervention require, at certain points of a patients disease lifecycle.