Wellbeing for healthcare providers: 3R'S - Reinvigorate

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Learn how to reinvigorate yourself after nights, a period of downtime, or when you are recovering from compassion fatigue or post critical care exhaustion

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Sepsis is a common presentation in the prehospital and retrieval environment, with most cases having a respiratory, urinary or soft tissue origin. However the best practice for identifying and management sepsis in the prehospital environment remains unclear. Despite sepsis having been a priority for in hospital guidelines and protocols for decades now, relatively little attention has been paid to prehospital sepsis management. Traditional teaching is that early antibiotics in sepsis save lives, however trials examining this are observational and confounded by outdated ICU care. An appropriately sensitive and specific tool for the prehospital identification of sepsis remains elusive. NEWS2 is common and lactate-modified QSOFA emerging (although prehospital lactate measurement remains difficult). The role of prehospital antibiotics, and the most appropriate one are also unclear. Most ambulance services that carry antibiotics use ceftriaxone. The retrieval environment is similar, with sepsis probably being the single commonest reason to call a retrieval service. For more head to our podcast page #CodaPodcast

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A Speech Pathology Perspective with Amy Freeman-Sanderson Sepsis causes organ and tissue dysfunction in response to severe infection, resulting in significant physical and cognitive morbidities. For patients diagnosed with severe sepsis, admission to an intensive care unit and use of an artificial airway are often required. The sequalae of severe sepsis necessitating critical care can result in significant changes to a patient’s swallowing and communication function. These negative changes and impacts to function can occur during and after a diagnosis of sepsis, and ultimately impact a patient’s health and functional status. The nature and long-term recovery of swallowing and communication function is still to be completely understood; however evidence affirms recovery continues well beyond hospital discharge. This presentation will focus on tasks we do daily – eating, drinking and speaking. Specifically, the nature of swallow impairments will be described, and the impact of this new disability will be explored from the perspective of the patient’s body structure, function and activities. Core components of swallowing safety and efficiency will be described, alongside the role of assessment and management within and beyond the ICU. Changes to communication including altered voice, speech and language function will be described. Outcomes of altered communication function over the continuum of care during, and after hospital will be explored. The evidence base and the lived experience of sepsis and patient stories will underpin the content delivered in this presentation. The final aim of the presentation will be to describe and highlight the role of speech pathology, an allied health profession, in the management of swallowing and communication function. Following the workshop attendees will be able to (1) describe the characteristics of swallowing and communication disorders; (2) have knowledge of the impact of these new disabilities; and (3) will be able to describe the role of speech pathology in the healthcare team for the patient with sepsis. For more head to our podcast page #CodaPodcast

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2 weeks: a case from India Ankur Verma opens the podcast by telling his listeners that he’s going to share with them something that happened during the time that Delta was in its dreadful stages in both Australia and India. He goes on to talk about a case that took place during the Delta wave, when minutes matter. He recounts a patient - Mrs P - who had come in gasping and immediately went into cardiac arrest, and notes that – as is often the case – she immediately became part of the ward’s family. After testing positive for Covid, they then gave her a CT scan to see if she had pneumonia and subsequently put her on various experimental medications, including steroids. She got better over the next four or five days and was weaned off the ventilator and over the next couple of days we removed her TPI (trigger point injection) but then her sugars went up. Ankur explains that just when he thought she was becoming much better, she started becoming hypoxic again and he then found out her left lung had collapsed. She then went on to improve – and, understandably – her family were thrilled, especially her son. After a two-week rollercoaster ride, she was discharged, much to the joy of everyone involved. At a time of great distress, Ankur explains that Mrs P reminded him and his co-workers of the power of determination and motivation, and it was through a combination of compassion and great determination and motivation that she survived. He notes that Mrs P gave the hospital staff a ray of hope and a much-needed silver lining during what was an otherwise hellish Covid wave, and notes that he owed her more than she owed him for saving her life. But, continues Ankur, she had other plans. She had been a ray of hope during the dreadful delta in India and the world and sadly, she died. But Ankur says that he and his co-workers didn’t lose sight of the vision and the hope that she gave them and that they continued to support each other. He concludes the podcast with an important lesson learnt: take care of yourself and those around you because when the dark times come, those people will be the ones surrounding you.

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Bec Szabo – an obstetrician, gynaecologist, and medical educator – begins the podcast by asking the audience to go back to Melbourne with her on a journey through the looking glass. She notes that while taking her listeners to Wonderland might be a bit quirky, but that it’s essential for the point of the story. Bec also wants to preface the talk with a trigger warning; and acknowledges that the subject matter of her talk might be triggering – so please do bear in mind that this talk covers Covid, ICU and pregnancy before listening. As per the notion of taking her readers through the looking glass, Bec wants to take listeners back to spring 2021 – a time that Melbourne was looking down the barrel of a sixth lockdown. Known as having had one of the longest – and strictest – lockdowns in the world - people in Melbourne were tired and had done a lot. Many were already vaccinated. Bec then goes on to say that she wants to talk about Covid and pregnancy and, explains to listeners that she wants to paint a picture of inequality and sexism. She runs through a case of what happened shortly after the Delta strain had arrived in Melbourne – it was a time when things were changing rapidly during covid with delta things came thick and fast. A pregnant woman was admitted to hospital; it was her third child, and her two toddlers, partner and parents were all sick with Covid; and despite concerns over a post-partum haemorrhage, a healthy baby was delivered, and the woman went back to the ICU. Except, says Bec, this wasn’t what actually happened; what she described was a simulation, carried out in order to ensure they had everything prepared in the case that something similar happened. She goes on to say that teamwork and communication are everything, but so too is listening to the voice of the patient. And that while we’ve heard that belonging and community and connection are important, having those values and shared goals to keep us doing what we’re doing. Bec closes the podcast by that we need to remember we’re the captains of our soul. And that if we can be human and kind, we can deal with emotionally fraught situations. For more head to our podcast page #CodaPodcast

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Coda Change

In this week’s podcast Liz Crowe – an advanced clinician social worker who has worked in Brisbane’s major children’s hospitals in intensive care, emergency departments and cancer wards - begins the podcast with the question – is all this talk of burn out, actually making us burnt out? In this podcast, Liz goes on to address exactly what the term burn out actually means and discusses how the literature on burnout in healthcare workers is prolific. She discusses how healthcare presents as an occupation of high risk, distress, and despair, with an escalation of risk post pandemic. Yet, she says, burnout is not the whole story even though it is the only story being told. Liz speaks about the extensive research into burnout and what it reveals, and the risk factors for burnout, which include excessive workload, lack of control or recognition, mismatch of values, lack of meaning and emotional contagion. However, she notes that none of these are individual deficits and says that it is concerning that ‘wellbeing’ in healthcare is never discussed in terms of meaning making, purpose, contribution, community, stimulating work or growth and development. Yet, she goes on to say, for many critical care staff these positive factors for wellbeing are found in abundance. Liz also states that her research shows that people want to believe that the bad stuff happens on one side of life; the good on the other, and people want to know how they get to the other side. Whereas, she says, in reality, life is a crappy mess that sits somewhere in the middle. The podcast concludes with Liz stating that purpose and community are everything, that life is messy, but some days - despite how awful we feel - we soar because of the opportunities we have. She encourages listeners to savour life, and to remember that even on the worst day of their working life, their patients are doing it tougher. For more head to our podcast page #CodaPodcast

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"Death is not the enemy but occasionally needs help with timing." Peter Josef Safar (1924 – 2003) 'The Father of Modern CPR' In this week’s episode of the Coda podcast, former flight paramedic Gary Berkowitz – who previously worked in Afghanistan and now works for Queensland Ambulance Service - explores how when death is inevitable, the way of dying matters. To open the discussion, he addresses the fact that out of hospital emergency care practitioners are often faced with time critical decisions. He notes that fortunately, most of these situations often have clear guidelines because – generally speaking - they follow pathways with expected outcomes. When it comes to ethics in healthcare, however, it can be a nuanced topic. For example, the decision to not commence resuscitation, or to withdraw life saving measures in a patient who appears to have no meaningful prospect of recovery, can be a difficult one. Gary goes on to note that in this environment, it’s impossible to design a guideline that could encompass all the elements of such a complex decision. In this talk Gary examines providing care to patients rather than always trying to fight death. By way of example, Gary tells listeners how he was working closely with the various western military forces, when one day they asked a favour – a young Afghani soldier had been badly burnt fighting against the Taliban, and while his treatment had begun in a military hospital, it was decided it shouldn’t be continued there. Gary was asked if he could assist transporting the soldier to a hospital in the city, and he goes on to talk about the fact that he had two options – to take the easy choice, which would have involved giving the soldier enough medication that he wouldn’t have to see him suffer; or the brave choice – which would have been to give him enough medication so he wouldn’t be suffering at all. He discusses the ethics around each alternative – and how he came to sit with his final choice. Gary notes that the decision he made that day has remained with him ever since, and continues to influence his decisions in his everyday practice. For more head to our podcast page #CodaPodcast

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In this podcast, Ed Litton summarises 10 clinical trials in 10 minutes. Ed invites you to choose, based on the title alone, whether the findings were consistent with, or contrary to, the study hypothesis. Ed discusses 10 non-covid clinical trials, all published in 2020. Notably, all of these were published in the New England Journal, JAMA or Lancet and had important findings. The following hypothesises are discussed: 10. Firstly, the impact of resident physician schedules and the affect on patient safety. 9. Early initiation of renal replacement therapy and whether this improved outcomes for Acute Kidney Injury. 8. Does the implementation of early ECMO improve outcomes for patients with refractory VF and out of hospital cardiac arrest? 7. Then, can a machine learning algorithm reduce hypotensive severity? 6. In mechanically ventilated patients, is an approach of non sedation superior to light sedation? 5. Moreover, in patients who are ready for decannulation, does timing based on the suctioning frequency improve outcomes? 4. Does administering high dose tranexamic acid in patients with upper or lower GI bleeds decrease mortality? 3. Next, does a decreased exposure to vasopressors improve outcomes in older critically ill patients? 2. Will starting Dexmedetomidine at the time of cardiac surgery reduce AF and delirium in patients? 1. Also, will being conservative with oxygen in patients with ARDS improve outcomes? Tune in to a talk by Ed Litton as he shares the top 10 papers of 2020 in 10 minutes.

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From CodaZero Live, Alex Rowell reviews the available advanced liver supports for patients with acute liver failure. Artificial supports for the liver are quite complex and difficult. This is largely due to the liver's complex function. Some of the advanced liver supports include CVVHDF, Molecular Adsorbent Recirculating System (MARS), Single Pass Albumin Dialysis (SPAD) and high volume plasma exchange. In this podcast, Alex takes us through the research and evidence for these supports and shares some guidance on when they should be used. CVVHDF is familiar and effective but we need to remember to use it early with acute liver failure patients. Furthermore, Molecular Adsorbent Recirculating System (MARS) is widely studied but unfortunately not available in all places. Single Pass Albumin Dialysis (SPAD) is easily implemented. Although there is less evidence on SPAD, it is generally agreed to be an effective support. Unfortunately, there are no mortality benefits in any of these supports. They are however, useful tools in bridging to transplant. From #CodaZero tune in to a quick, sharp & informative talk by Alex Rowell on Acute Liver Injury.

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Echo in Cardiac Arrest by Behny Samadi From #CodaZero Live, Behny explains the importance of Echo and lists some of the ways in which Echo can help us during a cardiac arrest. It is more than we think! Echo is a quick, easy and simple tool, making it invaluable in many situations including cardiac arrests. It is a bedside test that is non invasive and painless for the patient. It is easily taught to any doctor or nurse and done in real time at the bedside. It can be used to guide and inform management and treatment... so why isn't everyone embracing Echo? Behny challenges us to consider another bedside tool which compares to the effectiveness and usefulness of Echo. Furthermore, in the chaos of cardiac arrests, Echo can help to exclude some of the 4Hs & 4Ts. It can help to check the rhythm, check the quality of compressions and assess for post-resuscitation care. It is an invaluable tool in managing patients suffering from cardiac arrest. Behny suggests that the focused 2D echo is our generations stethoscope. We need to open our minds and embrace the capabilities of Echo and challenge each other to learn how to effectively utilise this tool in times that matter. Tune in to a fascinating podcast by Behny Samadi on the value of Echo in Cardiac Arrest. As a self-confessed Echo enthusiast - Behny is here to share her knowledge on the benefits of Echo. For more like this, head to our podcast page. #CodaPodcast

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The importance of sex and gender in medical research. For many years it was widely assumed that the occurrence and outcome of disease was the same for women and men. Our understanding was that studies involving only men would be equally relevant for women. In the last two decades however, it has been shown that this assumption is highly prejudice and can have a detrimental impact on the health of women. It is, therefore, really important to incorporate a sex and gender research lens in to medical research. First, Kelly makes the important distinction between sex and gender and how this can impact medical diagnosis, treatment and outcomes. Then, she identifies how the incorporation of sex and gender into research has allowed for advancements across healthcare. Improved accuracy, avoiding misinterpretation, reduced unintentional bias and greater social equity to name a few. In this presentation, Kelly Thompson refers to case studies to examine the differences in the interpretation of health data when examining through a sex and gender research lens. The severity of disease, risk factors and treatment effectiveness are just a few of the reasons why this is so important. Kelly encourages researchers to ensure gender diversity in the research team and to explain how sex and gender are accounted for in research applications moving forward. From CodaZero Live, tune into this fascinating discussion on the importance of sex and gender in medical research by Kelly Thompson.

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Coda Change

The aim of having a structured decision matrix in the approach to vascular access is to reduce catheter-associated complications and to increase device longevity. There are over 15,000 central venous catheters placed in Australia annually. The actual insertion process for placing a central line only accounts for a small part of the 'life span' of that line (approximately 1%), but the choices made at the time of insertion have a huge impact on the longevity of the device and the associated complications. In this introductory talk Evan Alexandrou outlines the top ten tips for reducing complications associated with vascular access devices: 1. Always use ultrasound: Never do a blind puncture 2. Ensure with the site chosen for the catheter that it exits the skin on a flat surface. 3. Consider the Axillary vein in preference for the subclavian vein 4. Use micro-puncture techniques 5. Avoid using a scalpel if possible 6. Avoid catheters being inserted all the way to the hub 7. Use impregnated dressings when possible 8. Use sutureless securing techniques 9. Secure the dressing on a flat surface (refer rule 2) 10. Ensure optimal positioning of the catheter tip by utilising ultrasound or intracavitary ECG

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Surgical management of burn injuries by Varun Harish. From #CodaZero Live, Varun Harish provides an overview of the surgical management of burn injuries. He talks us through how surgeons make decisions regarding burn management, including the importance of early assessment and intervention. Burns evolve, what you see at the beginning is going to be very different in 24 hours and different again in three days. Importantly, the management and principles of intervention differ for minor burns compared to severe burns. For smaller burns, the golden rule is two weeks. If there is a good chance that the burn will heal in two weeks, intervention is avoided. If this is not the case, intervention in the way of a skin graft or other surgical procedure is usually the best option. Varun details how the management priorities shift for larger burns. Larger burns significantly increase the chances of infection, making it important to intervene earlier rather than later. Tune in to an interesting talk on the Surgical management of burn injuries by Varun Harish.

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