A Research Perspective with Simon Finfer
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As with everything else, ICU management of sepsis should ideally the evidence based. Evidence based practice combines the best scientific knowledge (evidence) with patient preferences and clinical assessment and judgement. While the pursuit of specific pharmaceutical agents to treat Sepsis has resulted in the expenditure of billions of dollars without producing a single effective agent, much of what we do in the treatment of patience with Sepsis can be evidence based. Clinicians make literally hundreds of decisions day on the management of an individual patient in the ICU, often these decisions are made routinely without a great deal of thought about the reasoning behind them. Every decision made about the treatment of a critically ill patient should be based on evidence or the belief that the action resulting from that decision will improve a patient centred outcome for that particular patient. A patient centred outcome is an outcome that affects how the patient feels, functions or survives meaning we should question every decision we make to ask whether it is going to improve one of those outcomes. The best evidence on which to base of such decisions comes from large robust randomised controlled trials conducted by unbiased investigators. The last 20 years has seen the emergence and maturing of regional and national clinical trials groups who conduct such studies and increasingly collaborate with each other. (2) Such collaboration is often essential to perform studies large enough to provide evidence to guide clinical practice such collaboration is often essential to perform studies large enough to provide evidence to guide clinical practice. As someone who designs and contacts clinical trials I am well aware that they provide evidence on a population basis. Each trial result is the net of harm and benefit resulting from the treatment being studied and even when a treatment is proven to have a net benefit there may be some patients who are harmed by the use of that treatment. A graphic example of this is someone who suffers a massive intracranial haemorrhage when treated with thrombolysis. Causing visible harm to a patient may shake a clinician's faith in an effective treatment making it important that we accept such tragic events without changing our practice to deny that effective treatment to future patients. Research, like clinical practice, has inherent imperfections. Researchers, like clinicians, need to recognise this and be prepared to put their hand up and admit when they have been wrong. Conducting robust studies of appropriate size in an effective collaborative research group is the best way to avoid being wrong too often! For more head to our podcast page #CodaPodcast
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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
Delivering change now
Healthcare Saves!
Healthcare Pollutes!
Healthcare is responsible for 7% of Australia's carbon emissions, consumes 10% of Australia's GDP, and has numerous other adverse environmental effects.
This talk introduces healthcare's polluting ways, and how clinicians can mitigate their own carbon footprint. Action is the Antidote to Anxiety!
For more head to our podcast page #CodaPodcast
2 weeks: a case from India
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.
1420 Rebecca Szabo.pptx
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
Is Burnout Burning Us Out?
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
4 Seconds: A Case from Afghanistan
"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
Prehospital resuscitation of TBI
In this podcast, Marty Nichols talks us through managing patients with TBI in a prehospital environment. This involves avoiding hypoxia and hypotension, ensuring a safe transportation and getting to the right treatment centre the first time.
Top 10 Critical Care Papers of 2020
- A cluster crossover RCT of 6 US PICUs found that limiting duration of patient care shifts to <16 hours (versus >24 hours) increased serious medical errors and unintended consequences from increased workload.
- An RCT of 168 ICUs across 15 countries found no difference in mortality or RRT dependence between an accelerated versus standard strategy for initiating RRT in patients with AKI, but the intervention group had more hypotension and adverse events.
- An RCT of early ECMO versus standard ACLS in 30 patients with refractory VF found lower hospital mortality in the intervention group, but the study was conducted at a single highly invested center and may not be generalizable.
Advanced support of Acute Liver Injury
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.
Surgical considerations in the injured spine patient
This document discusses the surgical management of a patient with injuries to the spine and chest from a traumatic accident. The patient had a burst fracture at L2 with fragments in the spinal canal, as well as transverse process fractures from L1-L3 and injuries to the right chest including broken ribs and lung damage. The surgical procedures performed included fixing the broken ribs in the chest, removing the bone fragments in the spinal canal from L1-L2, fusing the spine from T11 to L4 with internal fixation, and placing an expandable interbody cage at L2. The patient had a lengthy recovery but was eventually able to walk with a stick after six months.
Echo in Cardiac Arrest
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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- 2. What do I want you to take home? • Decision making in ICU is largely based on flawed reasoning • Every decision you make should have one goal – to improve a patient centered outcome • Large randomised controlled trials are generally needed to detect the small incremental improvements we can reasonably expect • All other research methods are substandard (but may be useful) • Do not repeat anything I have said in an exam
- 3. Let’s unpick that …… • Decision making in ICU is largely based on flawed reasoning • • • •
- 4. Let’s unpick that …… • • Every decision you make should have one goal – to improve a patient centered outcome • • •
- 5. Let’s unpick that …… • • • Large randomised controlled trials are generally needed to detect the small incremental improvements we can reasonably expect • •
- 6. Let’s unpick that …… • • • • All other research methods are substandard (but may be useful) •
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