Coda Change

Are you ready for this rumble in the urban jungle?? Chris Ho vs Joe Bellezzo in the no holds barred debate about whether ECMO CPR is a step too far? The next cage match from SMACC Chicago. Chris and Joe are the director and vice-director respectively, of Emergency Medicine at Sharp Memorial Hospital in San Diego, California. They are two of the leading experts in ECPR, with Joe being one of the key players behind EDECMO. On a day-to-day basis, they are friends and colleagues, working together in one of the very few centers around the world to deliver ECPR. However in this Cage Match, friends become foe and there are no limitations to how far each will go to prove their side of the debate. On the AFFIRMATIVE side, Chris Ho delivers a convincing argument for why ECPR IS a step too far. From lack of evidence to the cost of “re-animating the dead” and everything in between, Chris Ho delivers a practical approach to the argument and demonstrates without a doubt why we are not ready for this to be the next step in resuscitation. On the NEGATIVE side, Joe Bellezzo delivers an outstanding rebuttal to “Dr Ho’s Nutty Brown Bullshit”. In an inspiring argument filled with anecdotes and occasional facts, Joe Bellezzo makes it impossible to think the ECPR shouldn’t be the next step in our ALS algorithm. Despite strong arguments from either side, as in all debates, there must be a winner. Do you agree with the outcome? If you want to find out whether Chris and Joe were able to kiss and make up, check out the exclusive ICN interview with the two, where they discuss more on ECPR.

Working night shifts is a part of medicine that we have come to accept. We work these shift because generations of people before us had done it. But could working night shifts have negative consequences? Night shifts have been shown to be detrimental to patient safety by increasing errors in medication administration and direct patient care. Working night shifts may negatively affect our health by increasing the risks of substance abuse, obesity, social relationships, and certain malignancies. Finally, working night shifts may lead to career burnout leading to dissatisfaction and early retirement from the profession. Several strategies can be used to combat the negative effects of working night shifts and these include a better awareness of the problem, improved sleep hygiene, strategies for better rest, and alternative staffing techniques. The Casino shift is an alternative approach to scheduling, which has been found to combat several of the problems associated with night shifts. Night shifts will never disappear because hospitals must operate 24 hours a day. We must be aware, however, that there are many potentially negative consequences to this practice as a better understanding of this problem will allow us to develop and research new solutions.

Patients are at risk – from the moment they begin their healthcare journey. They are at risk of bad outcomes (as defined by us) and of bad experience (as can only be defined by them) Patient safety experts like James Reason, and groups like the Institute for Healthcare Improvement (IHI) have prompted us to think about systems and complexity as sources of error – and supported strategies to remove predictable human fallibility as far as possible. This is important to make healthcare safer. Vic Brazil’s talk suggests there is also a human face to patient safety - in the behaviour and attitude of healthcare practitioners and patients themselves...... We think too little of patients. We feel affronted if patient takes a different view of ‘evidence’ or of ‘risk’. …and they think too much of us....! Every day patients allow nurses (and doctors) to inject drugs into their IV line without asking “whats in that syringe”.... This combination of our subconscious paternalism and patients’ blind faith is a heady mix……but ripe for us to make a difference. Vic suggests there are are small, human ways we can involve patients in safer healthcare, of better quality and with an improved patient experience. We can ask them. We often do involve patient advocates at the ‘strategic end’, but when was the last time you invited a real patient to your departmental teaching or consultant meeting (or smacc conference...!) We can connect with advocates for patient experience and ‘personalised medicine’, especially if we are interested in social media. Follow people like @JenWords and @EricTopol Involve patients as another layer of Swiss cheese. Ask them to be on the lookout for mistakes. And maybe Stop ‘looking after’ patients and start ‘partnering with’.

What is the problem?Delivering bad news and having an end of life conversation are core skills for any practitioner who deals with critically ill patients. Current data show that while 22% of deaths in the USA now occur in ICU, 54% of families surveyed have a poor understanding of patient’s diagnosis, treatment plan and prognosis. Dr. Kate Granger found this out first hand while admitted to hospital in the UK and started the #hellomynameis campaign. What is the evidence?While families feel more validated if given longer to speak, doctors speak for 71% of the time in family meetings. -Longer meetings are also associated with greater patient and family member satisfaction. -Patients perceive that doctors spend longer with them if the doctor is sitting down. -Use of a simple mnemonic increases satisfaction and reduced the incidence of PTSD in family members. What do experts do?1. Prepare for the meeting. Decide who will attend, what you will talk about and what your goals are.2. Introduce everyone and explain the agenda.3. Gather everyone’s understanding 4. Listen and don’t interrupt5. Empathise (physicians express no empathy in 1/3 of family meetings)6. Make the patient’s voice heard7. Make your recommendation to go forward8. Reflect on the meeting after it concludes What about the difficult situations? Hope is an issue that comes up often. Many other specialties emphasise the importance of hope, while intensivists are often seen as being nihilistic. But we can still foster a degree of hope in patients and families without being unrealistic. -Techniques for managing conflict are discussed such as identifying discord in the family and avoiding mixed messages from staff. -The importance of spirituality is discussed.

Pain in children is often under treated due to practitioners lacking the knowledge or confidence to be aggressive enough. This is partly due to the lack of structure presented in pain managment and it is frequently made to seem more complex than it is. Almost all acute pain in children can be dealt with by a simple stepwise regime using a small number of common, established and easy to use drugs. Likewise, procedural sedation can be safely and simply performed with simple regimes.

Advances in understanding the cardiopulmonary physiology during CPR, perfusion and reperfusion of the brain, and advancing technologies have made possible directed and customised resuscitation of cardiac arrest. We will present where current CPR fails, and what it may look like in the future.

Phil Hyde vs Greg Kelly - We Should Perform Therapeutic Hypothermia (T32– 34C) for Children After Cardiac Arrest The recent publication of THAPCA-OH filled an important gap in our knowledge. THAPCA does not support cooling children after cardiac arrest which was a common practice until recently in many units. It is illustrative to look at how a practice became routine with no supporting evidence at it raises questions about what questions we ask and how we operate in the absence of good evidence.

Working in a remote hospital often means working without the aid of formal medical imaging or Labs. So does this mean that we must compromise on our patient’s care? No. Bedside Ultrasound has changed the way I diagnose, treat and care for patients in this paradigm.This talk will explore the utility and a practical approach to bedside sonography for range of clinical situations: trauma, fracture management, sepsis diagnosis and resuscitation, Paediatric fever and bowel obstruction – all without X-rays. Ultrasound can allow us to provide faster, more accurate and compassionate care – regardless of where you work.

Preparing your hospital for a disaster Sara Gray Synopsis: This talk will highlight essential components of hospital-based disaster planning. We will discuss tips for planning training exercises, getting funding, and effective debriefing. Preparedness really matters, find out why! Objectives:1.Discuss essential components of a disaster plana.All hazardsb.IMS structures. Should your plan be long or short?2.Talk about training exercisesa.Low fidelity versus high fidelity exercises.Getting funding3.Review why debriefing mattersReferences and Links1.Canada’s national preparedness site, pitched mostly to individuals http://www.getprepared.gc.ca/index-eng.aspx 2.Ontario’s Emergency Management Office site includes some training tools and resources for organizationshttp://www.emergencymanagementontario.ca/english/home.html 3. The CDC Emergency Preparedness Site http://emergency.cdc.gov/hazards-all.asp 4. FEMA’s site has some good resources for organizations. Also has an interesting text message program about hurricanes and other natural disasters, where people can sign up for text updates about local disasters. https://www.fema.gov/ 5. A good site for improving debriefing skills: http://thoughtleaderzone.com/2013/03/11-questions-and-prompts-for-insightful-debriefing-sessions/

Improved patient outcomes as the goal of training. With this philosophy in mind, Bill Hinkley shares his three pillars of training; train yourself, train as a team, train others. Advice from an inspiring educator on how to build a personal learning network, tips on training as a team and how influential passionate educators are to teaching others.