The Critical Care Commute Podcast

Dr Sandy Widder is a Trauma Surgeon, Intensivist and overall amazing human being. She works as an associate professor in the departments of critical care and surgery at the University of Alberta, and is the Assistant Zone Director on Integrated Quality Management for the Edmonton zone in Alberta, Canada. She is passionate about Quality Improvement/Patient Safety and somehow finds time for Health administration in her busy schedule. We were lucky to get her on our podcast!  Join us as she talks about what the general intensivist needs to know about the trauma patient.  Further reading: ABC assessment: Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)?  Nunez TC, Voskresensky IV, Dossett LA, Dutton WD, Cotton BA.  J. Trauma.  2009.  Feb 66 (2): 346-52. TXA: Effects of transexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant hemorrhage (CRASH-2): a randomized, placebo-controlled trial.  Lancet.  2010.  376: 23-32. Fibrinogen: Reversal of trauma-induced coagulopathy using first-line coagulation factor concentrates or fresh frozen plasma (RETIC): a single-centre, parallel-group, open label, randomized trial.  Innerhofer P, Fries D, Mittermayer M, Innerhofer N, von Langen D, Hell T et al.  Lancet Haematology.  2017.  4 (6): 258-271. Stop the bleed:  www.stopthebleed.org VTE Prophylaxis: Updated guidelines to reduce venous thromboembolism in trauma patients: a Western Trauma Association critical decisions algorithm.  Let EJ, Brown C, Moore E, et al.  The Journal of Trauma and Acute Care Surgery.  2020.  89 (5): 971-981. Geriatric trauma: ACS TQIP Geriatric Trauma Management Guidelines.  HTTPS:\\www.facs.org/media/314or1oq/geriatric_guidelines.pdf Rib fractures: Western Trauma Association Critical Decisions in Trauma: Management of rib fractures.  Brasel KJ, Moore E, Albrecht RA et al.  2017.   Journal of Trauma and Acute Care Surgery.  82 (1): 200 - 203.

Doctor Jarrod Mosier is a bit of a polymath, and we were delighted he could squeeze us into his busy life. His day jobs include Intensive Care Medicine and Emergency medicine in Tucson, where he is a professor (at the other UofA: Arizona).He is an expert in all aspects of airway management, ranging from the physiologically difficult airway, through the importance of first pass success, including how to optimize for intubation, the roles of ultrasound and extracorporeal support, and all the way to safe extubation. This was the focus of our wide-ranging entertaining conversation. When away from work Jarrod throws a mean football, dotes on his two kids, and loves getting up into the mountains to snap superb nature photographs. Further reading: 1. Mosier JM, Sakles JC, Law JA, Brown CA 3rd, Brindley PG. Tracheal Intubation in the Critically Ill. Where We Came from and Where We Should Go. Am J Respir Crit Care Med. 2020;201(7):775-788. doi:10.1164/rccm.201908-1636CI 2. Mosier JM. Physiologically difficult airway in critically ill patients: winning the race between haemoglobin desaturation and tracheal intubation. Br J Anaesth. 2020;125(1):e1-e4. doi:10.1016/j.bja.2019.12.001

As health care providers, we are often called on to manage patients with chronic pain. In the acute setting, how do we manage them well? Join us on this podcast with Dr Saifee Rashiq, as we unravel chronic pain secrets well beyond opioids and other medications. Dr. Saifee Rashiq is an Anesthesiologist and Pain Medicine Specialist at the University of Alberta in Edmonton and a Professor in its Faculty of Medicine and Dentistry. He studied medicine at University of Nottingham, anesthesia training at the University of Alberta, fellowship in Pain Medicine in Seattle, and a Master’s Degree in Clinical Epidemiology from the Harvard School of Public Health. His clinical practice combines anesthesia and treating chronic pain patients in a Multidisciplinary Pain Clinic, where his clinical interest is in medically and psychosocially complex patients and non-organic pain syndromes. He is a loving husband and father of 3 and cycles to work when the weather is fine. Note that this was an earlier recording and the sound quality is not what we are hoping to achieve.  Further Reading: 1. Beyond nociception: the imprecision hypothesis of chronic pain. G. Lorimer Moseleya, Johan W. S. Vlaeyen. Painjournalonline January 2015, Vol 156, Nr 1. http://dx.doi.org/10.1016/j.pain.0000000000000014 2. Injuries of the Nervous System: On Railway and Other Injuries of the Nervous System. London, Walton and Moberly 17-23.4349,1866. 3. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain. The SPACE Randomized Clinical Trial. Erin E. Krebs, MD, MPH; Amy Gravely, MA; Sean Nugent, BA; Agnes C. Jensen, MPH; Beth DeRonne, PharmD; Elizabeth S. Goldsmith, MD, MS; Kurt Kroenke, MD; Matthew J. Bair; Siamak Noorbaloochi, PhD. JAMA. 2018;319(9):872-882. doi:10.1001/jama.2018.0899

In brief, “it’s okay to not feel okay” and “to do well we ought to feel well”. The problem is that many of us don’t feel okay, hence this candid, caring and common-sense podcast. We timed it to coincide with what is- statistically at least- the most depressing day of the year, namely the third Monday of January. Otherwise known as “Blue Monday” it’s a day to take a moment, to reach out, to acknowledge that the job can be tough, and to be reminded that we need to care for the carers. There is nobody better than Dr. Shelly Dev to highlight the importance of burnout, wellness and medical culture. Thank you for your time and for the work you do. Take care of yourself. Dr. Dev has been a Staff Intensivist at Sunnybrook Health Sciences Centre in Toronto since 2006, after completing her Internal Medicine residency and Critical Care Fellowship at The University of Toronto, followed by a Fellowship in Multimedia Education at the New England Journal of Medicine.  She is a Clinician Educator and Associate Professor of Medicine, Director of Education in the Department of Critical Care Medicine at Sunnybrook and lead for Mentorship and Wellness in the Interdepartmental Division of Critical Care Medicine at the University of Toronto. She is an award-winning medical educator of undergraduate, postgraduate and continuing medical education audiences. In addition to nearly 300 lectures given to national and international audiences about healthcare worker mental health, burnout, resilience and medical culture, Dr. Dev has written and spoken extensively on these topics in the wider media. But, if asked, she would say her most significant accomplishment to date is continuing to convince 14-year-old Nathan and 12-year-old Jack that it is beyond cool to be seen with your mother in public.

Join us on this podcast as we discuss Renal Replacement Therapy with Professor Sean Bagshaw from the University of Alberta Hospital, Edmonton, Canada. Dr. Bagshaw is Professor and Chair for the Department of Critical Care Medicine at the University of Alberta in Edmonton, Canada. He completed medical school and residency training at the University of Calgary (Doctor of Medicine – 2000; Internal Medicine – 2003; Critical Care Medicine – 2005; Master of Science in Epidemiology – 2005) prior to completing a Critical Care Nephrology fellowship in the Department of Intensive Care Medicine, at the Austin Hospital in Melbourne, Australia. Dr. Bagshaw works as a full-time staff intensivist in two of the busiest and highest acuity intensive care units in Alberta – the General Systems ICU at the University of Alberta Hospital and the Cardiovascular Surgical ICU at the Mazankowski Alberta Health Institute. Dr. Bagshaw has expertise in acute kidney injury, renal replacement therapy, frailty and vulnerable patients and end-of-life care in ICU settings. He has published over 400 peer-reviewed articles and it was our absolute privilege to have him on the show. In this episode we talk about timing of replacement therapy, data around continuous and intermittent therapy, intensity of dialysis, fluid management, anticoagulation and weaning of renal replacement therapy. Articles of Interest: 1. Timing of Initiation of  Renal-Replacement Therapy in Acute Kidney Injury. New England Journal of  Medicine. 2020 Jul 16;383(3):240–51. 2. Zarbock A, Kellum JA, Schmidt C, van  Aken H, Wempe C, Pavenstädt H, et al. Effect of Early vs Delayed Initiation of  Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute  Kidney Injury. JAMA. 2016 May 24;315(20):2190. 3. Barbar SD, Clere-Jehl R, Bourredjem A,  Hernu R, Montini F, Bruyère R, et al. Timing of Renal-Replacement Therapy in  Patients with Acute Kidney Injury and Sepsis. New England Journal of Medicine.  2018 Oct 11;379(15):1431–42. 4. Gaudry S, Hajage D, Schortgen F,  Martin-Lefevre L, Pons B, Boulet E, et al. Initiation Strategies for  Renal-Replacement Therapy in the Intensive Care Unit. New England Journal of  Medicine. 2016 Jul 14;375(2):122–33. 5. Jaber S, Paugam C, Futier E, Lefrant  JY, Lasocki S, Lescot T, et al. Sodium bicarbonate therapy for patients with  severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a  multicentre, open-label, randomised controlled, phase 3 trial. The Lancet.  2018 Jul;392(10141):31–40. 6. Intensity of Continuous  Renal-Replacement Therapy in Critically Ill Patients. New England Journal of  Medicine. 2009 Oct 22;361(17):1627–38. 7. Intensity of Renal Support in  Critically Ill Patients with Acute Kidney Injury. New England Journal of  Medicine. 2008 Jul 3;359(1):7–20.

This podcast was a little different and, hence, so are the show notes. What follows is the books mentioned during the recording. The list is neither comprehensive nor to suggest we’re especially literate: we’re not. Instead, we’re merely encouraging people to explore books about the wider world of medicine and to bolster your courage when you come to write your own! Feel free to share your favorites, especially those that we missed, via our Twitter or Instagram accounts. Matt Morgan Critical 2019 (history of ICU, personal reflection) One Medicine, 2023 (popular science, comparative physiology) James Maskalyk Life on the Ground Floor, 2017 (emergency medicine in both developed and developing world, personal reflection) Kevin Fong Extreme Medicine, 2014 (popular science, physiology) Rachel Clarke Your Life in My Hands, 2017 (life as a junior doctor, personal reflection) David Nott War Doctor, 2019 (surgery in developing world and war zones), personal reflection) Aoife Abbey Seven Signs of Life, 2019 (ICU physician, personal reflections) Henry Marsh Do no harm, 2014 (neurosurgeon, personal reflections Admissions, 2017 Adam Kay This is Going to Hurt 2017 (obstetrics, personal reflections, diary) Undoctored (2022) Kathryn Mannix With the End in Mind 2017 (end of life, palliative care, insights) Michael Bliss The Discovery of Insulin 1982 (medical history) William Osler: a life in medicine, 1999 Harvey Cushing, 2005 Rose George The Big Necessity, 2008 (the story of human waste) Nine Pints, 2019 (blood and transfusion) Mary Roach Stiff: the curious life of human cadavers, 2021 (self explanatory) Caitlan Doughty Smoke gets in your eyes, 2015 (working in the funeral and cremation business) Sam Keens The tale of the dueling neurosurgeons, 2014 (popular science, neuroanatomy) The Icepick Surgeon, 2021 (the awful things done in the name of medical science) Roy Porter Medicine, a history of healing, 1997 (medical history) The greatest benefit to mankind, 1999 And one we didn’t mention but should have Wendy Moore The Knife Man, 2005 (biography of John Hunter and the history of surgery and Victorian medicine)

Join us as we discuss Neuroprognostication after Cardiac Arrest with Clinician-Scientist, Dr Gord Boyd. Dr Boyd has dual certification in Neurology and Critical Care Medicine and is a Clinician Scientist at Queens University, Kingston, Canada. He works at the Kingston General Hospital as an Intensivist and heads a research program aimed at understanding the relationship between cerebral perfusion, delirium, and long-term neurological outcomes for ICU survivors. He received his undergraduate degree (Psychology) from Lakehead University in his hometown of Thunder Bay, Ontario. That was followed by his PhD in Neuroscience from the University of Alberta, where he studied the role of growth factors in peripheral nerve regeneration. In 2001 he moved to Kingston to do a post-doctoral fellowship in the Queen’s Department of Anatomy and Cell biology, examining the potential of glial cell transplantation to treat spinal cord injury. He stayed in Kingston to do his undergraduate degree in Medicine, which was followed by his residency in Neurology and fellowship in Adult Critical Care. He is an active musician and plays the drums in an all-physician band. In this episode we discuss the importance of admitting uncertainty when it comes to neuroprognostication following cardiac arrest, allowing enough time to pass, some of the best and worst tests for clinical prognostication, usefulness of biomarkers, EEG, seizure treatment and the risk of persistent neurovegetative states. Further Reading: 1. Nakstad ER, Stær-Jensen H, Wimmer H, et al. Late awakening, prognostic factors and long-term outcome in out-of-hospital cardiac arrest - results of the prospective Norwegian Cardio-Respiratory Arrest Study (NORCAST). Resuscitation. 2020;149:170-179. doi:10.1016/j.resuscitation.2019.12.031 https://pubmed.ncbi.nlm.nih.gov/31926258/ 2. Nolan JP, Sandroni C, Böttiger BW, et al. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med. 2021;47(4):369-421. doi:10.1007/s00134-021-06368-4 https://pubmed.ncbi.nlm.nih.gov/33765189/ 3. Sandroni C, D'Arrigo S, Cacciola S, et al. Prediction of good neurological outcome in comatose survivors of cardiac arrest: a systematic review. Intensive Care Med. 2022;48(4):389-413. doi:10.1007/s00134-022-06618-z https://pubmed.ncbi.nlm.nih.gov/35244745/ 4. Beuchat I, Novy J, Barbella G, Oddo M, Rossetti AO. EEG patterns associated with present cortical SSEP after cardiac arrest. Acta Neurol Scand. 2020;142(2):181-185. doi:10.1111/ane.13264 EEG patterns associated with present cortical SSEP after cardiac arrest - PubMed (nih.gov)

Join us on this podcast for a case-based discussion on Human Factors and Patient Safety with Dr Jocelyn Slemko, an Intesivist Internist from Edmonton, Canada and rising star in the area of Human Factors and Patient Safety. Dr Slemko completed medical school in Calgary, followed by Residency in both Internal Medicine and Critical Care Medicine in Edmonton, Canada. She is a published author and recently contributed to a chapter in the Textbook of Acute Trauma Care (2022). She is currently completing a MSc degree in Patient Safety and Clinical Human Factors at the University of Edinburgh and works as an Intensivist in the Edmonton Zone. She is navigating life as a busy mom. Important discussion points from this episode: 1. Introduction of the Safety Engineering Initiative for Patient Safety (SEIPS) model as an alternative to the classic “Swiss Cheese” model as a framework to analyse adverse events. 2. The pillars of team communication. 3. Team leadership, especially in “Flash or Ad Hoc” teams. 4. Equipment design. 5. Situational awareness. Hope you enjoy this one! Further Reading: 1. Brindley, Peter & Slemko, Jocelyn. (2022). Human Factors in Trauma Care: Why the Human Factor Is Always a Factor. 10.1007/978-3-030-83628-3_1. Here 2. Holden RJ, Carayon P  SEIPS 101 and seven simple SEIPS tools  BMJ Quality & Safety 2021;30:901-910. Here

Join us on this episode as we talk to Dr Oleksa Rewa, who along with Professor J Kutsogiannis (Department of Critical Care Medicine, University of Alberta, Canada), were authors on the recently published LOVIT paper. Dr. Oleksa Rewa is an Assistant Professor and an Associate Chair for Research & Innovation in the Department of Critical Care Medicine and has a Masters of Clinical Epidemiology from the University of Alberta. He completed his M.D. and Internal Medicine Residency at Queen’s University followed by his Critical Care Medicine Fellowship at the University of Toronto. Dr. Rewa’s research focuses on Critical Care Nephrology with a specific interest in evaluating the quality of healthcare delivery for critically ill patients. Vitamin C administration in Septic Shock has been a hot topic over the last few years. It’s role as a powerful anti-oxidant and possible therapy to minimize tissue damage in Septic Shock gained traction after the publicized paper by Marik et al (link below). Listen as we tease apart the LOVIT trial and discuss the following learning points: 1. Vitamin C is not associated with any improvement in clinical outcomes in critically ill patients. 2. Death or persistent organ dysfunction seems higher in the Vitamin C group. 3. Translation of scientific data can be accelerated improving knowledge translation where it is needed the most, next to the bedside. Further reading: LOVIT paper: https://www.nejm.org/doi/full/10.1056/NEJMoa2200644 VITAMINS paper: https://jamanetwork.com/journals/jama/fullarticle/2759414 ATESS paper: https://link.springer.com/content/pdf/10.1007/s00134-020-06191-3.pdf Marik paper: http://journal.publications.chestnet.org/article.aspx?articleid=2593508 Meta Analysis on Vitamin C in Septic shock: https://link.springer.com/article/10.1007/s00134-021-06558-0

In this engaging discussion, Dr. Peter Brindley, an Intensive Care Doctor and Professor at the University of Alberta, dives into the nuances of crisis resource management over the phone. He emphasizes the importance of emotional intelligence and clear communication during emergencies, especially in remote medical settings. Dr. Brindley shares insightful strategies for triaging patients with color codes, fostering relationships via telephone, and addressing end-of-life discomfort among healthcare workers. His perspective on conserving bandwidth during calls is both practical and enlightening.