The Critical Care Commute Podcast

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.

Join us as we discuss early burns resuscitation with Dr. Dennis Djogovic.  Dennis Djogovic is an emergency physician, trauma team leader and intensivist at the University of Alberta Hospital in Edmonton Alberta. He is the medical director for the HOPE organ donation organization, medical director for the Garner King General Systems Intensive Care Unit, and medical director for the Biggs and Allen Neurosciences Intensive Care Unit. The Garner King GSICU also incorporates the Edmonton Firefighters Burn Treatment unit, an American Burn Association verified burn centre and is a major burn referral centre in Western Canada, where Dennis is an instructor and course director for the Advanced Burn Life Support course. The following make up the major learning points in this episode: 1. Ignore the burn. Burns patients are trauma patients with thermal traumas. Primary survey first! 2. Early on, only note extent as more than, or less than 20% BSA.  3. Airway decompensation is usually slow. Outward appearance may not indicate the presence of an airway injury, if in doubt, intubate.   4. If you are unsure of the exact extent of burns, start with Ringers Lactate at 500cc per hour for all patients who have more than 20% BSA burns and who are older than 14 years of age. If you are sure of extent, use the ABLS formula in place of the traditional (and old) Parkland formula, which is 2cc/kg/BSA divided by 2 and then by 8 for the first hour's starting rate. Changes to fluid administration rate then gets made in accordance to urine output and hemodynamic parameters.  5. Hypotension in the burns patient, especially early on, is usually not due to the burn. Seek other etiologies to explain hypotension early on.  6. Referral criteria include: More than 10% BSA involvement, involvement of special areas like hand, genitals and face, all pediatric burns, burns involving the joints and patients with major comorbidities.  Further reading: State of the Art: An Update on Adult Burn Resuscitation. Causbie, J.M.; Sattler, L.A.; Basel, A.P.; Britton, G.W.; Cancio, L.C. . Eur. Burn J. 2021, 2, 152–167. https://doi.org/10.3390/ ebj2030012. Here Nebulized heparin for inhalation injury in burn patients: a systematic review and meta-analysis Xiaodong Lan1, Zhiyong Huang, Ziming Tan, Zhenjia Huang1, Dehuai Wang, and Yuesheng Huang. Here The Physiologic Basis of Burn Shock and the Need for Aggressive Fluid Resuscitation Lisa Rae, Philip Fidler, Nicole Gibran. Here