Bare Knuckle Trauma Debate: There's no denying it - Prehospital doctors add plenty of value in trauma CON
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Ever wondered if prehospital doctors add LITTLE or LOTS of value in trauma? Ever wondered if an Amazonian Warrior Girl can take on a Kangaroo Aussie Military Man? If you are looking for level-1 evidence on either of these topics, you are in the wrong room! But stick around, it will sure be entertaining & enlightening. Show me anyone who doesn't like a full-contact bare knuckle debate. Bring it on!
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Certificate DSATC 2016
The Radboud university medical center declares that T. Timmers participated in and received accreditation for the Definitive Surgical and Anaesthetic Trauma Care Course held from November 29 to December 1, 2016. The course was accredited for 18 points by several Dutch organizations and 24 points by LVO. The certificate was signed by Prof. dr. R.F.J.M. Laan and Drs. D.M.J. van Overbeek on December 14, 2016.
D2 1455-swaminathan 13
This short document discusses the importance of shared decision making between doctors and patients when considering treatment options. It notes that doctors should discuss both the potential benefits and harms of treatments with patients so they can make informed choices about their care. The document advocates for open communication and ensuring patient values and preferences are prioritized in medical decisions.
Scott Weingart - Emergent Intubation Resequenced
Pretty much everything I learned as a resident in terms of the sequencing of airway management in ED has changed over the past 15 years. No longer is there simply RSI or stick a laryngoscope in with nothing and use pure brute force to intubate a patient; we have a host of different options and pathways when approaching airway management in the emergency department.
This lecture discusses some of these updated ways of getting from a sick patient requiring airway management to a tube between the cords…with only minor technical mishaps.
Leisurely Laryngoscopy
In the past two decades, airway management has been revolutionized by the development of video laryngoscopy, hyperangulated blade geometry, optical stylets, laryngeal masks, and a host of advances in airway pharmacology and technique. The core skill of airway management, however, remains laryngoscopy, whether or not the operator uses a blade with a camera at the end. In this presentation, we break down laryngoscopy into its discrete components and describe best practice technique at each step. We will start by describing common mistakes made in patient positioning; proposing a set of parameters the provider can use to guide positioning that is optimal for laryngoscopy, including the configuration of the patient in the bed, the bed height and head elevation, as well as provider stance. We then move into the effect of laryngoscope grip on operator catecholamine management and describe the optimal laryngoscope grip for emergency airway management. We next confront one of the core principles of RSI, the delay between medication administration and commencement of laryngoscopy, and propose an alternative approach that emphasizes early laryngoscopy with deliberate slowness. We turn our attention to the value of the jaw thrust–as performed by an assistant–during airway management, and then move into a step by step analysis of laryngoscopy as the blade moves into the mouth, down the tongue and ultimately to the glottis. We espouse suction as an underutilized device by emergency providers, and describe the two most important intra-laryngoscopy optimization maneuvers: optimization of the position of the head, and optimization of the position of the larynx. We discuss the value of using the gum elastic bougie for both difficult and routine intubations and describe pitfalls encountered when using the bougie (and how to manage them). We conclude by describing the 3-finger tracheal palpation method of endotracheal tube depth confirmation.
OCUS is a Problem - PRO
POCUS is a problem? Really? For who? Maybe a radiologist holding down their turf in a small hospital that has been shielded from the world wide web. Will paint a broad picture of the wide multi-specialty impact POCUS has made in clinical care citing key references and case examples.
Healthcare Capacity Building in Fiji
Dr Anne Creaton talks about the healthcare capacity building in Fiji.
Fiji was struck by Cyclone Winston in 2016. It caused widespread devastation and the impact will be felt for a long time in the future.
The most important thing that Fiji has taught her is faith, patience and persistence.
Anne begins by talking about the three Rs that are essential in trainees who want to work in Fiji or similar situations.
The three Rs being: Realistic, Resilient and Resourceful.
Emotional intelligence is also very important. Most of the people are highly trained, but always in a high resource environment. Dysfunctional systems in places like Fiji, can impact the clinician’s welfare and performance.
Critical care systems are made up of multiple building blocks with doctors playing a small part. Anne compares critical care systems in Fiji to a game of Jenga. This is because multiple blocks that are essential for critical care systems are non-existent.
Anne divides the Jenga blocks of a critical care system into three: a pre-hospital block, a hospital block, and an administration and governance block.
The pre-hospital block consists of scene care, transport care, communication, hazmat, decontamination and retrieval.
The hospital blocks consist of factors like triage, medical assessment, equipment, drugs and patient flow.
The administrative and governance block provides data, audits, leadership and human resource activities such as training, recruitment and retention.
All these blocks put together form the critical care system. This illustrates how when the different blocks in critical care services are removed, it makes it very difficult to successfully treat a patient.
She explains how doctors face multiple difficulties like faulty equipment, untrained staff, lack of timely transport vehicles, inaccessibility to interventional cardiology, lack of risk management and quality improvement. They also lack hazmat, decontamination, personal protective equipment (PPE), proper communication.
Anne then gives an example of using the three Rs technique to reduce VF arrest by early defibrillation.
Realistic: Automatic external defibrillator (AED) for all health facilities.
Resilient: Placed all AEDs in pelican cases.
Resourceful: Acquired the AEDs via Twitter.
Anne ends by saying that life is about expectation management and you need to understand that there will be a gap between the type of care you want to provide and what you will be able to provide in situations like Fiji.
So, are you ready to play critical care Jenga?
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Certificate DSATC 2016
The Radboud university medical center declares that T. Timmers participated in and received accreditation for the Definitive Surgical and Anaesthetic Trauma Care Course held from November 29 to December 1, 2016. The course was accredited for 18 points by several Dutch organizations and 24 points by LVO. The certificate was signed by Prof. dr. R.F.J.M. Laan and Drs. D.M.J. van Overbeek on December 14, 2016.
D2 1455-swaminathan 13
This short document discusses the importance of shared decision making between doctors and patients when considering treatment options. It notes that doctors should discuss both the potential benefits and harms of treatments with patients so they can make informed choices about their care. The document advocates for open communication and ensuring patient values and preferences are prioritized in medical decisions.
Scott Weingart - Emergent Intubation Resequenced
Pretty much everything I learned as a resident in terms of the sequencing of airway management in ED has changed over the past 15 years. No longer is there simply RSI or stick a laryngoscope in with nothing and use pure brute force to intubate a patient; we have a host of different options and pathways when approaching airway management in the emergency department.
This lecture discusses some of these updated ways of getting from a sick patient requiring airway management to a tube between the cords…with only minor technical mishaps.
Leisurely Laryngoscopy
In the past two decades, airway management has been revolutionized by the development of video laryngoscopy, hyperangulated blade geometry, optical stylets, laryngeal masks, and a host of advances in airway pharmacology and technique. The core skill of airway management, however, remains laryngoscopy, whether or not the operator uses a blade with a camera at the end. In this presentation, we break down laryngoscopy into its discrete components and describe best practice technique at each step. We will start by describing common mistakes made in patient positioning; proposing a set of parameters the provider can use to guide positioning that is optimal for laryngoscopy, including the configuration of the patient in the bed, the bed height and head elevation, as well as provider stance. We then move into the effect of laryngoscope grip on operator catecholamine management and describe the optimal laryngoscope grip for emergency airway management. We next confront one of the core principles of RSI, the delay between medication administration and commencement of laryngoscopy, and propose an alternative approach that emphasizes early laryngoscopy with deliberate slowness. We turn our attention to the value of the jaw thrust–as performed by an assistant–during airway management, and then move into a step by step analysis of laryngoscopy as the blade moves into the mouth, down the tongue and ultimately to the glottis. We espouse suction as an underutilized device by emergency providers, and describe the two most important intra-laryngoscopy optimization maneuvers: optimization of the position of the head, and optimization of the position of the larynx. We discuss the value of using the gum elastic bougie for both difficult and routine intubations and describe pitfalls encountered when using the bougie (and how to manage them). We conclude by describing the 3-finger tracheal palpation method of endotracheal tube depth confirmation.
OCUS is a Problem - PRO
POCUS is a problem? Really? For who? Maybe a radiologist holding down their turf in a small hospital that has been shielded from the world wide web. Will paint a broad picture of the wide multi-specialty impact POCUS has made in clinical care citing key references and case examples.
Healthcare Capacity Building in Fiji
Dr Anne Creaton talks about the healthcare capacity building in Fiji.
Fiji was struck by Cyclone Winston in 2016. It caused widespread devastation and the impact will be felt for a long time in the future.
The most important thing that Fiji has taught her is faith, patience and persistence.
Anne begins by talking about the three Rs that are essential in trainees who want to work in Fiji or similar situations.
The three Rs being: Realistic, Resilient and Resourceful.
Emotional intelligence is also very important. Most of the people are highly trained, but always in a high resource environment. Dysfunctional systems in places like Fiji, can impact the clinician’s welfare and performance.
Critical care systems are made up of multiple building blocks with doctors playing a small part. Anne compares critical care systems in Fiji to a game of Jenga. This is because multiple blocks that are essential for critical care systems are non-existent.
Anne divides the Jenga blocks of a critical care system into three: a pre-hospital block, a hospital block, and an administration and governance block.
The pre-hospital block consists of scene care, transport care, communication, hazmat, decontamination and retrieval.
The hospital blocks consist of factors like triage, medical assessment, equipment, drugs and patient flow.
The administrative and governance block provides data, audits, leadership and human resource activities such as training, recruitment and retention.
All these blocks put together form the critical care system. This illustrates how when the different blocks in critical care services are removed, it makes it very difficult to successfully treat a patient.
She explains how doctors face multiple difficulties like faulty equipment, untrained staff, lack of timely transport vehicles, inaccessibility to interventional cardiology, lack of risk management and quality improvement. They also lack hazmat, decontamination, personal protective equipment (PPE), proper communication.
Anne then gives an example of using the three Rs technique to reduce VF arrest by early defibrillation.
Realistic: Automatic external defibrillator (AED) for all health facilities.
Resilient: Placed all AEDs in pelican cases.
Resourceful: Acquired the AEDs via Twitter.
Anne ends by saying that life is about expectation management and you need to understand that there will be a gap between the type of care you want to provide and what you will be able to provide in situations like Fiji.
So, are you ready to play critical care Jenga?
For more like this, head to our podcast page. #CodaPodcast
Why would you do ECPR?
Peter McCanny is part of the LearnECMO team. In this podcast he explains some of the background and history of ECMO CPR, what evidence there is to support its use and where we're heading in the future.
Evidence Based Medicine in Prehospital Resuscitation
Marius Rehn examines the difficulties and importance of evidence based medicine in prehospital resuscitation. Notably, combining academic activity with pre- and in-hospital clinical practice is hard work. Being an academic in a flight suit can be quite lonely.
Marius wants this to change and is passionate about increasing the quantity and quality of prehospital research.
Prehospital research that examines patient pathophysiology should dictate care – as it does in the hospital environment. However, Evidence based practice pertaining to the prehospital environment is minimal. This needs to change.
Evidence based medicine in the prehospital setting can dictate care, critically appraise practice and enable improvements in process and cost effectiveness whilst decreasing harms.
Evidently, in-hospital evidence is different to the field application. Ultimately, prehospital research is critical, 5.8 million people die from injury every year – around 10% of the world’s deaths. Unfortunately, pre-hospital research is underfunded.
So, how can we take interventions from the hospital to the streets?
Marius shares three important steps:
The research that is needed
How to interpret the evidence
Why all research is important to consider (from case studies to randomised controlled trials)
Moreover, Marius highlights the need to lean on other members of the scientific community when conducting your own research. For example, a statistician is worth their weight in gold in observational studies when fleshing out regression analysis.
Finally, Marius discusses the importance of information dissemination across all platforms, including peer reviewed journals and informal FOAMed platforms such as Twitter. They all have their place.
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It's all about function NOT movement re-education!
The document discusses the importance of early rehabilitation after a stroke to maximize recovery. It emphasizes starting rehabilitation as early as possible, within 24 hours of the stroke, and ensuring it is repetitive and intensive. The document also shares an inspiring story of a young woman who survived a severe stroke and defied expectations with her recovery through hard work. It advocates for patients not lowering their expectations and voices the importance of self-belief and peer support. Finally, it proposes potential areas for further stroke rehabilitation research.
Resuscitation in Paediatric Cardiac Patients: Michele Domico
Michele Domico presents a talk on the pitfalls of common paediatric resuscitative manoeuvres in paediatric cardiac patients. Emergency and critical care physicians are all well accustomed to items such as oxygen, bolus adrenaline, intubation and cardioversion. However, as Michele explains, these ‘go to’ interventions may in fact be harmful for the paediatric cardiac patient presenting to the emergency department in extremis. Due to the physiology of certain complex congenital heart diseases, the usual resuscitation manoeuvres may in fact kill the patient instead of helping.
Supplemental oxygen can worsen the pulmonary to systemic blood flow ratio in single ventricle patients and cause them to have rising lactate levels and cardiac arrest from low systemic cardiac output. Intubation and positive pressure ventilation may impede pulmonary blood flow in patients with a Glenn shunt and the patient can become more desaturated. With increasing PEEP and higher respiratory rates, the patients will continue to deteriorate and desaturate. Regular dosing of adrenaline boluses in patients with single ventricle physiology who are nearly arrest, can worsen their systemic output by increasing systemic vascular resistance and promoting pulmonary overcirculation. Cardioversion of a previously healthy paediatric patient might be tempting when you see what looks like a stable ventricular tachycardia. This wide complex rhythm has fooled many people into shocking it. You might in fact be dealing with something else and can make the patient infinitely worse by shocking.
In her talk, Michele highlights the importance of understanding the physiology of your patients. This particularly applies to paediatric cardiac patients. In this population, the change from typical physiology means standard models of care are harmful. Tune in to hear what not to do!
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The Role of the Immediate Responder in Mass Casualty Trauma
The Role of the Immediate Responder in Mass Casualty Trauma
Christina Hernon describes a traumatic experience in gripping detail.
In doing so, she shares her deeply personal insights into what it is to be an Immediate Responder. Christina suggests that the medical system must change to support these people.
After a major formative experience at a life-threatening mass casualty incident, Christina felt incredibly unprepared despite over two decades of training in emergency and first response.
Christina reflects that all the training that students undergo does not prepare them for every scenario. The standard approach to emergency care, is this scene safe? is completely inadequate for those present the very moment an incident occurs. These people are then amidst and surrounded by an unsecured and potentially unsafe scene.
After her experience Christina had an acute stress reaction exactly like after rough calls in prehospital Emergency Medical Services.
However, Christina wasn't offered the usual support given in these circumstances. She felt somehow betrayed, but unsure who to be mad at. Therefore, Christina tried to understand why she felt so unprepared and overlooked.
In deconstructing and reflecting on the experience, she self-identified neither as bystander nor first responder. Instead she was an on scene, immediate responder, victimised rescuer. Realising that she did not fit into any already existing category, she uncovered an undefined time period that we need to give attention to.
The Disaster Gap is the time between the moment an incident occurs, through the first call for help, and until the clearheaded First Responders arrives.
In this definable time gap, the only available rescuers are people who are on scene when the event happens. These Immediate Responders, who are traumatised by their experience themselves, take immediate action to help another person or make the situation better.
They are present at virtually every scene and have been for all of time. However, we know very little about them, their actions, their safety, their impact, and their recovery.
By trying to understand the Disaster Gap and Immediate Responders, we can improve training, preparedness, resilience, and recovery.
The Role of the Immediate Responder in Mass Casualty Trauma
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Interprofessional Communication: Challenges and Opportunities - Walter Eppich
This document discusses interprofessional communication challenges and opportunities. It notes that competent individuals may form incompetent teams, and that communication breakdowns can impair learning and team performance. It emphasizes that a supportive workplace culture with psychological safety is key. When people feel safe speaking up about concerns, mistakes, or asking questions, teams can achieve collective competence through open communication and learning conversations. Specific aids like checklists and frameworks can help facilitate productive discussions. Leaders play an important role in establishing a culture where input is welcomed and people are empowered to solve problems together.
Gadgets and Simulation by Jon Gatward
The Sim revolution. Jon Gatward on the future of simulation in critical care. Strategies for pulling it off, no matter your resources. See smacc.net.au and intensivecarenetwork.com for more.
Chief Medical Informatics Officer- I could do that!
It’s natural that as doctors we fear failure. In Health, never has so much been asked by so many of so few. Every day feels like a battle zone. Engage a Chief Medical Informatics Officer (CMIO) to introduce technology. That will save us. Established with structure, status and enough support to create and translate innovative models of change in the mindsets of clinicians and healthcare politicians alike, this role could work. However reality is so different. So lets understand failing early to succeed sooner, simplifing and standardising the clinical arena for clinician interoperability, and driving clinician inclusion in the business of health.
Zack Shinar - How we do ED– ECMO
ECMO or extracorporeal membrane oxygenation has shown promise in the use of cardiac arrest patients. Zack Shinar and his crew from San Diego have lead the way in emergency physician initiated ECMO for patients in cardiac arrest.
In this lecture he explains briefly how ECMO works, what their outcomes have been and where ECMO is moving. Initially 5 of their first 8 patients were neurologically intact survivors. Their first patient had over an hour of downtime when cardiac bypass was initiated. He walked out of the hospital completely neurologically intact nine days later and now has been featured on the film “Code Black”. Physicians from their hospital, Sharp Memorial, were also recently featured on the television show “Untold Stories in the ER” for a save of a 21 year old female arresting from hyperkalemia. Dr. Shinar also discusses some of the latest physiologic questions as the Australians have pushed for smaller diameter catheters that allow for smaller flow volumes.
He also discusses how in Paris pre-hospital ECMO is being done by physicians in various places like the subway, apartment buildings and even the Louvre.
In the end, Dr. Shinar discusses the biggest question in any novel resuscitation technique: cost. Prolongation of life and particularly after a cardiac arrest is expensive and many people do not survive.
Dr. Shinar uses various pioneers in the world of technology to tell how true genius is not in technologic advancements but in making those advancements available to the masses. He ends with a story about Linus Torvalds. Dr. Shinar shows how this man through the use of the collective minds of computer programmers worldwide created one of the best operating systems ever created: Linux. He asks the medical community to endorse this idea and introduces the concept of “free open access medical innovation”.
It's time to do away with the hard Cervical Collar
The document argues that hard cervical collars should be done away with based on three assumptions that are unsupported or proven false. Hard collars are unlikely to provide benefits to patients and can clearly cause harm. Instead of hard collars, the document recommends using softer "reminder collars" or vacuum mattresses for obtunded patients, and limiting energy deposition by not restricting motion for uncooperative patients. Hard collars are compared to other medical ideas that seemed good initially but were later disproven.
Jim Manning - Selective Aortic Arch Perfusion
Selective Aortic Arch Perfusion -
Summary by: Jim Manning
Selective Aortic Arch Perfusion (SAAP) is an endovascular-extracorporeal perfusion resuscitation technique designed specifically to treat cardiac arrest. SAAP involves the blind insertion of a large-lumen balloon occlusion catheter into the descending thoracic aortic arch via a femoral artery. With the SAAP catheter balloon inflated in the thoracic aorta, the heart and brain are relatively isolated for resuscitative perfusion through the SAAP catheter lumen with an oxygen-carrying fluid (such as blood, hemoglobin-based oxygen carrier or fluorocarbon emulsion). SAAP promotes restoration of spontaneous circulation (ROSC) by the heart while protecting the brain from further ischemic insult. SAAP can be used to treat both hemorrhage-induced traumatic cardiac arrest and medical, non-traumatic cardiac arrest.
In traumatic cardiac arrest, SAAP provides the combination of (1) thoracic aortic balloon occlusion for control of hemorrhage below the diaphragm, (2) rapid volume replacement in hemorrhage-induced hypovolemia to restore normovolemia and (3) perfusion of the heart and brain in an effort to achieve ROSC. SAAP also allows titration of small doses of intra-aortic adrenaline or other medications to achieve ROSC.
In medical cardiac arrest, SAAP catheter balloon occlusion of the thoracic aorta limits the distribution of oxygenated perfusate toward the heart and brain. Since medical cardiac arrest patients are not typically hypovolemic, SAAP with an exogenous oxygen-carrier is a volume loading intervention that can only be used for a short time period (5-10 min). If ROSC is not achieved with the limited volume of exogenous oxygen-carrier, femoral venous access during initial SAAP infusion allows venous blood withdrawal for continued SAAP support to promote ROSC without further volume loading (autologous blood SAAP or, essentially, aortic arch ECMO). Intra-aortic adrenaline and anti-reperfusion agents can also be used. Even if ROSC is not rapidly achieved, SAAP serves as a bridge that limits hypoperfusion until cannulation for full body ECMO can be achieved.
Spinal Trauma: The Legend of the C-Spine Collar - A Case Report
A 27-year old female presented with persistent central intrascapular pain after a high-speed skiing injury in Japan. Imaging revealed fractures at C7, T1 spinous processes, and T7 vertebral body. She was initially managed conservatively with a cervical collar and neuro checks. However, evidence shows cervical collars may do more harm than good and their use is based more on tradition than clinical evidence. Proper history and exam, along with imaging as indicated, are more important for assessing spinal injury and instability than routine hard collar use.
Emergency Care Of Stroke
1. The document discusses pre-hospital and emergency department management of acute stroke. It emphasizes the importance of rapid detection, transport, and treatment to maximize outcomes for stroke patients.
2. Treatment guidelines recommend administering intravenous tissue plasminogen activator (tPA) for ischemic stroke within 3 hours of symptom onset to reduce disability and mortality.
3. In the emergency department, the focus is on quick assessment, diagnosis of hemorrhagic vs ischemic stroke using CT scan, and treatment or referral for definitive care such as thrombolysis within the treatment window.
Debate: Prehospital Doctors add little value in Trauma
Anthony Holley and Marietjie ‘MJ’ Slabbert debate the value of prehospital doctors in trauma.
Anthony argues that doctors in the prehospital setting add little value.
He does so with the upmost respect for prehospital doctors and having worked in this setting himself. He makes the point that across the globe, the employment of doctors in the prehospital setting is a rarity.
Working in this environment is diverse and every situation encountered requires a different skillset. This presents a logistical challenge.
Anthony continues to discuss the evidence, or lack thereof, in this space. He raises the point of competing interests from paramedics, flight nurses and doctors themselves.
This leads to apples being compared to oranges most of the time.
Anthony goes on to suggest all the advanced clinical interventions that are necessary in prehospital situations can be competently undertaken by paramedics.
MJ argues for the negative.
In doing so, she concedes that the evidence base for prehospital medicine is scarce.
This is due to inherent biases, the difficulty of gathering data and the issues with methodology. However, MJ believes that care provided outside of the hospital should be of the same level as care received in hospital.
This provides a seamless patient journey from the prehospital setting into the hospital and improving the chain of survival.
Furthermore, MJ posits that prehospital doctors not only improve care of patients outside of the hospital, but care for those in the hospital and clinics too.
Prehospital physicians add value wherever they practise. They bring leadership, knowledge, additional skills, and training as well as innovation and collaboration.
Tune in as Anthony and MJ debate over the value of prehospital doctors in trauma.
For more like this, head to our podcast page. #CodaPodcast
Formal grand case presentation
This document presents a case study of a 71-year-old female patient who experienced a stroke. It includes sections on the patient's history, including her past medical history of a previous stroke in 2005. Physical assessments were performed and vital signs such as temperature and cardiac rate were monitored daily. The document discusses the pathophysiology of stroke, medical management including medications and diagnostic tests, nursing care, and a discharge plan. The overall goal is to provide a clinical guide for a safe and quality nursing care approach for patients who experience stroke.
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Nikki Black provides an insight into critical care in humanitarian emergencies.
Through her experiences in hunger emergencies, epidemics, natural disasters and conflict zones, Nikki has gained a wealth of wisdom and lessons.
She shares these from the SMACC stage.
Nikki talks about some of the practical things she does when working in resource poor settings. It starts with hospital hygiene to reduce nosocomial infections, and often entails Nikki working alongside the cleaners due to resource limitations.
Hand hygiene is difficult without running water and Nikki champions using the WHO Handrub Formulation.
Other challenges include cold chain storage, blood donations, limited monitoring and food and nutrition.
Nikki also discusses the challenges of working in different environments. Invariable the environment will be too hot… or too cold!
On top of this, working in remote locations often entails living with the other medical professionals you are working alongside. This presents interpersonal challenges.
Moreover, Nikki touches on the personal dangers of working in some of the more politically unstable locations around the world. Training becomes hugely important in resource poor settings when you are dealing with complex medical and surgical cases. Especially with less-than-ideal resources and equipment.
Nikki expands on what is possible with good training, intuition, and a Swiss army knife. If you do not do anything stupid, and you have basic resources backed up by sound training, it is amazing what you can achieve and who you can help.
She concludes by touching the future direction of care in resource poor settings highlight the potential for technology to make huge changes and advances.
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Finally, for more like this, head to our podcast page. #CodaPodcast
ECMO in NZ by McGuinness
This document summarizes New Zealand's national adult ECMO service based in Auckland City Hospital. ECMO uses an extracorporeal circuit to support the lungs and/or heart for extended periods. The national service began in 1993 and established a mobile ECMO retrieval team in 2005 to place and transport patients on ECMO anywhere in New Zealand. The mobile ECMO system was designed to be lightweight and portable to transport patients by road, fixed wing aircraft, or helicopter. During the 2009 H1N1 influenza pandemic, the service experienced a surge in ECMO cases and transports across New Zealand.
Submassive PE should be Thrombolysed
Anand Swaminathan and Iain Beardsell debate the use of thrombolytics in the treatment of submassive pulmonary embolism (PE).
PE is a spectrum of disease. Patients should be treated differently depending on where they are on the spectrum.
Subsegmental PE may need no treatment at all, whereas massive PE is unlikely to improve without thrombolytics.
Anand argues for the use of thrombolytics.
Evidently, time is critical when dealing with patients and Anand posits that thrombolytics gives the physician control over time.
Submassive PE can deteriorate, leading to massive pulmonary embolism. A proportion of these patients will die. The data is not conclusive for the use of thrombolytics in terms of mortality, however long term outcomes do improve.
Finally, Anand concludes by suggesting that the decision to use thrombolytics relies on sound clinical reasoning and decision making, informed by the available data. He argues for nuanced treatments and use of these drugs.
Iain takes a different approach in his reply.
Some of the most difficult topics in medicine attract considerable debate. The use of thrombolysis for submassive PE is one of these.
In this argument Iain attempts to highlight some of the most pertinent evidence against the use of thrombolysis. And he does so through song!
Submassive PE should be Thrombolysed: Anand Swaminathan and Iain Beardsell
For more like this, head to our podcast page. #CodaPodcast
Death by Neurological Criteria and Organ Donation: Bill Knight
Bill Knight explains the concept of death by neurological criteria and the complexities surrounding organ donation in such situations.
Bill discusses the process of dying, the definition of death, how to approach the neurologically dead patient and how to consider organ donation.
Death is a complex topic.
Due to advancements in medical technology and processes, the definition of death is a challenging one.
Bill talks at length about the definition of death by the neurological criteria. Dying is an active process, whereas death is an event.
The acceptance of death by the neurological criteria is often challenging as Bill will highlight. Bill talks about the care of the dying or dead patient.
There is a point at which care will transition from supporting the patient to supporting the organs. This is still good care.
There is an alignment of parallel intentions – first and foremost resuscitation of patients and then failing that, proceeding to considering and actioning organ donation. This is important due to the shortage of viable donor organ worldwide.
The donation process itself is complex. Bill provides his thoughts. He insists that an intensivist be involved as this has been shown to increase the number of viable and healthy organs made available.
The timing is also important. Available evidence does not support the need for immediate procurement after brain death. Taking time to optimise perfusion and allow recovery and cardiac function is appropriate and should be done.
Bill also discusses other treatment options at the time of death such as optimising endocrine function.
Finally, Bill will provide some practical considerations when communicating with the dead patient’s family. This involves being clear on your messaging. You are supporting organs, not life.
To reinforce this point, Bill suggests not examining or talking to the patient. He also recommends using all of the available hospital support services.
Similarly, it is best to not introduce the topic of organ donation to the family yourself as the treating clinician. Utilise the Organ Procurement Organisations (or similar services) and get them involved early to speak with the family.
Join Bill Knight in his talk on the North American perspective on Organ Donation, brain death and management of the brain dead donor prior to organ donation.
For more like this, head to our podcast page. #CodaPodcast
The Wrong Stuff: Prehospital Dogma - Cliff Reid
The Wrong Stuff: Prehospital Dogma
Summary by: Cliff Reid
The master of Dogmalysis himself, Cliff Reid, challenges current practices in prehospital and emergency medicine. Warning listeners to be skeptical, Cliff dissects the dogma of acute crush injuries and spinal immobilization. He also explores the false dichotomy of “scoop and run vs. stay and play”. Cliff reminds us that “not to challenge current practice is intellectually lazy”.
Teaching Airways in Critical care - Jon Gatward
The document discusses teaching airway techniques and provides information on understanding the learner, teaching methods, and evaluation. It includes links to websites related to airway management training resources and simulation tools. Evaluation and understanding the learner are emphasized as important parts of the teaching process.
Best Gynaecologist And Obstetrician in Baraut
Dr. Neeraj Multispeciality Hospital, Our Dedicated, Specialized Facilities For All Ailments And Diseases With An Expert Team Of Doctors And Specialists.
Myo protect
This document is the preface to a book titled "New Solutions for the Heart: An Update in Advanced Perioperative Protection". The preface discusses the motivation for creating the book, which was to provide a comprehensive summary of myocardial protection during cardiac surgery since the topic had not been covered in over 15 years. The editors, Bruno Podesser and David Chambers, recruited leading clinicians and scientists in the field of myocardial protection to contribute chapters on topics ranging from the history of cardioplegia to new technologies and approaches. The preface expresses the hope that the book will stimulate further research in myocardial protection to benefit cardiac surgery patients.
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Evidence Based Medicine in Prehospital Resuscitation
Marius Rehn examines the difficulties and importance of evidence based medicine in prehospital resuscitation. Notably, combining academic activity with pre- and in-hospital clinical practice is hard work. Being an academic in a flight suit can be quite lonely.
Marius wants this to change and is passionate about increasing the quantity and quality of prehospital research.
Prehospital research that examines patient pathophysiology should dictate care – as it does in the hospital environment. However, Evidence based practice pertaining to the prehospital environment is minimal. This needs to change.
Evidence based medicine in the prehospital setting can dictate care, critically appraise practice and enable improvements in process and cost effectiveness whilst decreasing harms.
Evidently, in-hospital evidence is different to the field application. Ultimately, prehospital research is critical, 5.8 million people die from injury every year – around 10% of the world’s deaths. Unfortunately, pre-hospital research is underfunded.
So, how can we take interventions from the hospital to the streets?
Marius shares three important steps:
The research that is needed
How to interpret the evidence
Why all research is important to consider (from case studies to randomised controlled trials)
Moreover, Marius highlights the need to lean on other members of the scientific community when conducting your own research. For example, a statistician is worth their weight in gold in observational studies when fleshing out regression analysis.
Finally, Marius discusses the importance of information dissemination across all platforms, including peer reviewed journals and informal FOAMed platforms such as Twitter. They all have their place.
For more like this, head to our podcast page. #CodaPodcast
It's all about function NOT movement re-education!
The document discusses the importance of early rehabilitation after a stroke to maximize recovery. It emphasizes starting rehabilitation as early as possible, within 24 hours of the stroke, and ensuring it is repetitive and intensive. The document also shares an inspiring story of a young woman who survived a severe stroke and defied expectations with her recovery through hard work. It advocates for patients not lowering their expectations and voices the importance of self-belief and peer support. Finally, it proposes potential areas for further stroke rehabilitation research.
Resuscitation in Paediatric Cardiac Patients: Michele Domico
Michele Domico presents a talk on the pitfalls of common paediatric resuscitative manoeuvres in paediatric cardiac patients. Emergency and critical care physicians are all well accustomed to items such as oxygen, bolus adrenaline, intubation and cardioversion. However, as Michele explains, these ‘go to’ interventions may in fact be harmful for the paediatric cardiac patient presenting to the emergency department in extremis. Due to the physiology of certain complex congenital heart diseases, the usual resuscitation manoeuvres may in fact kill the patient instead of helping.
Supplemental oxygen can worsen the pulmonary to systemic blood flow ratio in single ventricle patients and cause them to have rising lactate levels and cardiac arrest from low systemic cardiac output. Intubation and positive pressure ventilation may impede pulmonary blood flow in patients with a Glenn shunt and the patient can become more desaturated. With increasing PEEP and higher respiratory rates, the patients will continue to deteriorate and desaturate. Regular dosing of adrenaline boluses in patients with single ventricle physiology who are nearly arrest, can worsen their systemic output by increasing systemic vascular resistance and promoting pulmonary overcirculation. Cardioversion of a previously healthy paediatric patient might be tempting when you see what looks like a stable ventricular tachycardia. This wide complex rhythm has fooled many people into shocking it. You might in fact be dealing with something else and can make the patient infinitely worse by shocking.
In her talk, Michele highlights the importance of understanding the physiology of your patients. This particularly applies to paediatric cardiac patients. In this population, the change from typical physiology means standard models of care are harmful. Tune in to hear what not to do!
For more like this, head to our podcast page. #CodaPodcast
The Role of the Immediate Responder in Mass Casualty Trauma
The Role of the Immediate Responder in Mass Casualty Trauma
Christina Hernon describes a traumatic experience in gripping detail.
In doing so, she shares her deeply personal insights into what it is to be an Immediate Responder. Christina suggests that the medical system must change to support these people.
After a major formative experience at a life-threatening mass casualty incident, Christina felt incredibly unprepared despite over two decades of training in emergency and first response.
Christina reflects that all the training that students undergo does not prepare them for every scenario. The standard approach to emergency care, is this scene safe? is completely inadequate for those present the very moment an incident occurs. These people are then amidst and surrounded by an unsecured and potentially unsafe scene.
After her experience Christina had an acute stress reaction exactly like after rough calls in prehospital Emergency Medical Services.
However, Christina wasn't offered the usual support given in these circumstances. She felt somehow betrayed, but unsure who to be mad at. Therefore, Christina tried to understand why she felt so unprepared and overlooked.
In deconstructing and reflecting on the experience, she self-identified neither as bystander nor first responder. Instead she was an on scene, immediate responder, victimised rescuer. Realising that she did not fit into any already existing category, she uncovered an undefined time period that we need to give attention to.
The Disaster Gap is the time between the moment an incident occurs, through the first call for help, and until the clearheaded First Responders arrives.
In this definable time gap, the only available rescuers are people who are on scene when the event happens. These Immediate Responders, who are traumatised by their experience themselves, take immediate action to help another person or make the situation better.
They are present at virtually every scene and have been for all of time. However, we know very little about them, their actions, their safety, their impact, and their recovery.
By trying to understand the Disaster Gap and Immediate Responders, we can improve training, preparedness, resilience, and recovery.
The Role of the Immediate Responder in Mass Casualty Trauma
For more like this, head to our podcast page. #CodaPodcast
Interprofessional Communication: Challenges and Opportunities - Walter Eppich
This document discusses interprofessional communication challenges and opportunities. It notes that competent individuals may form incompetent teams, and that communication breakdowns can impair learning and team performance. It emphasizes that a supportive workplace culture with psychological safety is key. When people feel safe speaking up about concerns, mistakes, or asking questions, teams can achieve collective competence through open communication and learning conversations. Specific aids like checklists and frameworks can help facilitate productive discussions. Leaders play an important role in establishing a culture where input is welcomed and people are empowered to solve problems together.
Gadgets and Simulation by Jon Gatward
The Sim revolution. Jon Gatward on the future of simulation in critical care. Strategies for pulling it off, no matter your resources. See smacc.net.au and intensivecarenetwork.com for more.
Chief Medical Informatics Officer- I could do that!
It’s natural that as doctors we fear failure. In Health, never has so much been asked by so many of so few. Every day feels like a battle zone. Engage a Chief Medical Informatics Officer (CMIO) to introduce technology. That will save us. Established with structure, status and enough support to create and translate innovative models of change in the mindsets of clinicians and healthcare politicians alike, this role could work. However reality is so different. So lets understand failing early to succeed sooner, simplifing and standardising the clinical arena for clinician interoperability, and driving clinician inclusion in the business of health.
Zack Shinar - How we do ED– ECMO
ECMO or extracorporeal membrane oxygenation has shown promise in the use of cardiac arrest patients. Zack Shinar and his crew from San Diego have lead the way in emergency physician initiated ECMO for patients in cardiac arrest.
In this lecture he explains briefly how ECMO works, what their outcomes have been and where ECMO is moving. Initially 5 of their first 8 patients were neurologically intact survivors. Their first patient had over an hour of downtime when cardiac bypass was initiated. He walked out of the hospital completely neurologically intact nine days later and now has been featured on the film “Code Black”. Physicians from their hospital, Sharp Memorial, were also recently featured on the television show “Untold Stories in the ER” for a save of a 21 year old female arresting from hyperkalemia. Dr. Shinar also discusses some of the latest physiologic questions as the Australians have pushed for smaller diameter catheters that allow for smaller flow volumes.
He also discusses how in Paris pre-hospital ECMO is being done by physicians in various places like the subway, apartment buildings and even the Louvre.
In the end, Dr. Shinar discusses the biggest question in any novel resuscitation technique: cost. Prolongation of life and particularly after a cardiac arrest is expensive and many people do not survive.
Dr. Shinar uses various pioneers in the world of technology to tell how true genius is not in technologic advancements but in making those advancements available to the masses. He ends with a story about Linus Torvalds. Dr. Shinar shows how this man through the use of the collective minds of computer programmers worldwide created one of the best operating systems ever created: Linux. He asks the medical community to endorse this idea and introduces the concept of “free open access medical innovation”.
It's time to do away with the hard Cervical Collar
The document argues that hard cervical collars should be done away with based on three assumptions that are unsupported or proven false. Hard collars are unlikely to provide benefits to patients and can clearly cause harm. Instead of hard collars, the document recommends using softer "reminder collars" or vacuum mattresses for obtunded patients, and limiting energy deposition by not restricting motion for uncooperative patients. Hard collars are compared to other medical ideas that seemed good initially but were later disproven.
Jim Manning - Selective Aortic Arch Perfusion
Selective Aortic Arch Perfusion -
Summary by: Jim Manning
Selective Aortic Arch Perfusion (SAAP) is an endovascular-extracorporeal perfusion resuscitation technique designed specifically to treat cardiac arrest. SAAP involves the blind insertion of a large-lumen balloon occlusion catheter into the descending thoracic aortic arch via a femoral artery. With the SAAP catheter balloon inflated in the thoracic aorta, the heart and brain are relatively isolated for resuscitative perfusion through the SAAP catheter lumen with an oxygen-carrying fluid (such as blood, hemoglobin-based oxygen carrier or fluorocarbon emulsion). SAAP promotes restoration of spontaneous circulation (ROSC) by the heart while protecting the brain from further ischemic insult. SAAP can be used to treat both hemorrhage-induced traumatic cardiac arrest and medical, non-traumatic cardiac arrest.
In traumatic cardiac arrest, SAAP provides the combination of (1) thoracic aortic balloon occlusion for control of hemorrhage below the diaphragm, (2) rapid volume replacement in hemorrhage-induced hypovolemia to restore normovolemia and (3) perfusion of the heart and brain in an effort to achieve ROSC. SAAP also allows titration of small doses of intra-aortic adrenaline or other medications to achieve ROSC.
In medical cardiac arrest, SAAP catheter balloon occlusion of the thoracic aorta limits the distribution of oxygenated perfusate toward the heart and brain. Since medical cardiac arrest patients are not typically hypovolemic, SAAP with an exogenous oxygen-carrier is a volume loading intervention that can only be used for a short time period (5-10 min). If ROSC is not achieved with the limited volume of exogenous oxygen-carrier, femoral venous access during initial SAAP infusion allows venous blood withdrawal for continued SAAP support to promote ROSC without further volume loading (autologous blood SAAP or, essentially, aortic arch ECMO). Intra-aortic adrenaline and anti-reperfusion agents can also be used. Even if ROSC is not rapidly achieved, SAAP serves as a bridge that limits hypoperfusion until cannulation for full body ECMO can be achieved.
Spinal Trauma: The Legend of the C-Spine Collar - A Case Report
A 27-year old female presented with persistent central intrascapular pain after a high-speed skiing injury in Japan. Imaging revealed fractures at C7, T1 spinous processes, and T7 vertebral body. She was initially managed conservatively with a cervical collar and neuro checks. However, evidence shows cervical collars may do more harm than good and their use is based more on tradition than clinical evidence. Proper history and exam, along with imaging as indicated, are more important for assessing spinal injury and instability than routine hard collar use.
Emergency Care Of Stroke
1. The document discusses pre-hospital and emergency department management of acute stroke. It emphasizes the importance of rapid detection, transport, and treatment to maximize outcomes for stroke patients.
2. Treatment guidelines recommend administering intravenous tissue plasminogen activator (tPA) for ischemic stroke within 3 hours of symptom onset to reduce disability and mortality.
3. In the emergency department, the focus is on quick assessment, diagnosis of hemorrhagic vs ischemic stroke using CT scan, and treatment or referral for definitive care such as thrombolysis within the treatment window.
Debate: Prehospital Doctors add little value in Trauma
Anthony Holley and Marietjie ‘MJ’ Slabbert debate the value of prehospital doctors in trauma.
Anthony argues that doctors in the prehospital setting add little value.
He does so with the upmost respect for prehospital doctors and having worked in this setting himself. He makes the point that across the globe, the employment of doctors in the prehospital setting is a rarity.
Working in this environment is diverse and every situation encountered requires a different skillset. This presents a logistical challenge.
Anthony continues to discuss the evidence, or lack thereof, in this space. He raises the point of competing interests from paramedics, flight nurses and doctors themselves.
This leads to apples being compared to oranges most of the time.
Anthony goes on to suggest all the advanced clinical interventions that are necessary in prehospital situations can be competently undertaken by paramedics.
MJ argues for the negative.
In doing so, she concedes that the evidence base for prehospital medicine is scarce.
This is due to inherent biases, the difficulty of gathering data and the issues with methodology. However, MJ believes that care provided outside of the hospital should be of the same level as care received in hospital.
This provides a seamless patient journey from the prehospital setting into the hospital and improving the chain of survival.
Furthermore, MJ posits that prehospital doctors not only improve care of patients outside of the hospital, but care for those in the hospital and clinics too.
Prehospital physicians add value wherever they practise. They bring leadership, knowledge, additional skills, and training as well as innovation and collaboration.
Tune in as Anthony and MJ debate over the value of prehospital doctors in trauma.
For more like this, head to our podcast page. #CodaPodcast
Formal grand case presentation
This document presents a case study of a 71-year-old female patient who experienced a stroke. It includes sections on the patient's history, including her past medical history of a previous stroke in 2005. Physical assessments were performed and vital signs such as temperature and cardiac rate were monitored daily. The document discusses the pathophysiology of stroke, medical management including medications and diagnostic tests, nursing care, and a discharge plan. The overall goal is to provide a clinical guide for a safe and quality nursing care approach for patients who experience stroke.
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Nikki Black provides an insight into critical care in humanitarian emergencies.
Through her experiences in hunger emergencies, epidemics, natural disasters and conflict zones, Nikki has gained a wealth of wisdom and lessons.
She shares these from the SMACC stage.
Nikki talks about some of the practical things she does when working in resource poor settings. It starts with hospital hygiene to reduce nosocomial infections, and often entails Nikki working alongside the cleaners due to resource limitations.
Hand hygiene is difficult without running water and Nikki champions using the WHO Handrub Formulation.
Other challenges include cold chain storage, blood donations, limited monitoring and food and nutrition.
Nikki also discusses the challenges of working in different environments. Invariable the environment will be too hot… or too cold!
On top of this, working in remote locations often entails living with the other medical professionals you are working alongside. This presents interpersonal challenges.
Moreover, Nikki touches on the personal dangers of working in some of the more politically unstable locations around the world. Training becomes hugely important in resource poor settings when you are dealing with complex medical and surgical cases. Especially with less-than-ideal resources and equipment.
Nikki expands on what is possible with good training, intuition, and a Swiss army knife. If you do not do anything stupid, and you have basic resources backed up by sound training, it is amazing what you can achieve and who you can help.
She concludes by touching the future direction of care in resource poor settings highlight the potential for technology to make huge changes and advances.
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Finally, for more like this, head to our podcast page. #CodaPodcast
ECMO in NZ by McGuinness
This document summarizes New Zealand's national adult ECMO service based in Auckland City Hospital. ECMO uses an extracorporeal circuit to support the lungs and/or heart for extended periods. The national service began in 1993 and established a mobile ECMO retrieval team in 2005 to place and transport patients on ECMO anywhere in New Zealand. The mobile ECMO system was designed to be lightweight and portable to transport patients by road, fixed wing aircraft, or helicopter. During the 2009 H1N1 influenza pandemic, the service experienced a surge in ECMO cases and transports across New Zealand.
Submassive PE should be Thrombolysed
Anand Swaminathan and Iain Beardsell debate the use of thrombolytics in the treatment of submassive pulmonary embolism (PE).
PE is a spectrum of disease. Patients should be treated differently depending on where they are on the spectrum.
Subsegmental PE may need no treatment at all, whereas massive PE is unlikely to improve without thrombolytics.
Anand argues for the use of thrombolytics.
Evidently, time is critical when dealing with patients and Anand posits that thrombolytics gives the physician control over time.
Submassive PE can deteriorate, leading to massive pulmonary embolism. A proportion of these patients will die. The data is not conclusive for the use of thrombolytics in terms of mortality, however long term outcomes do improve.
Finally, Anand concludes by suggesting that the decision to use thrombolytics relies on sound clinical reasoning and decision making, informed by the available data. He argues for nuanced treatments and use of these drugs.
Iain takes a different approach in his reply.
Some of the most difficult topics in medicine attract considerable debate. The use of thrombolysis for submassive PE is one of these.
In this argument Iain attempts to highlight some of the most pertinent evidence against the use of thrombolysis. And he does so through song!
Submassive PE should be Thrombolysed: Anand Swaminathan and Iain Beardsell
For more like this, head to our podcast page. #CodaPodcast
Death by Neurological Criteria and Organ Donation: Bill Knight
Bill Knight explains the concept of death by neurological criteria and the complexities surrounding organ donation in such situations.
Bill discusses the process of dying, the definition of death, how to approach the neurologically dead patient and how to consider organ donation.
Death is a complex topic.
Due to advancements in medical technology and processes, the definition of death is a challenging one.
Bill talks at length about the definition of death by the neurological criteria. Dying is an active process, whereas death is an event.
The acceptance of death by the neurological criteria is often challenging as Bill will highlight. Bill talks about the care of the dying or dead patient.
There is a point at which care will transition from supporting the patient to supporting the organs. This is still good care.
There is an alignment of parallel intentions – first and foremost resuscitation of patients and then failing that, proceeding to considering and actioning organ donation. This is important due to the shortage of viable donor organ worldwide.
The donation process itself is complex. Bill provides his thoughts. He insists that an intensivist be involved as this has been shown to increase the number of viable and healthy organs made available.
The timing is also important. Available evidence does not support the need for immediate procurement after brain death. Taking time to optimise perfusion and allow recovery and cardiac function is appropriate and should be done.
Bill also discusses other treatment options at the time of death such as optimising endocrine function.
Finally, Bill will provide some practical considerations when communicating with the dead patient’s family. This involves being clear on your messaging. You are supporting organs, not life.
To reinforce this point, Bill suggests not examining or talking to the patient. He also recommends using all of the available hospital support services.
Similarly, it is best to not introduce the topic of organ donation to the family yourself as the treating clinician. Utilise the Organ Procurement Organisations (or similar services) and get them involved early to speak with the family.
Join Bill Knight in his talk on the North American perspective on Organ Donation, brain death and management of the brain dead donor prior to organ donation.
For more like this, head to our podcast page. #CodaPodcast
The Wrong Stuff: Prehospital Dogma - Cliff Reid
The Wrong Stuff: Prehospital Dogma
Summary by: Cliff Reid
The master of Dogmalysis himself, Cliff Reid, challenges current practices in prehospital and emergency medicine. Warning listeners to be skeptical, Cliff dissects the dogma of acute crush injuries and spinal immobilization. He also explores the false dichotomy of “scoop and run vs. stay and play”. Cliff reminds us that “not to challenge current practice is intellectually lazy”.
Teaching Airways in Critical care - Jon Gatward
The document discusses teaching airway techniques and provides information on understanding the learner, teaching methods, and evaluation. It includes links to websites related to airway management training resources and simulation tools. Evaluation and understanding the learner are emphasized as important parts of the teaching process.
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Evidence Based Medicine in Prehospital Resuscitation
Evidence Based Medicine in Prehospital Resuscitation
It's all about function NOT movement re-education!
It's all about function NOT movement re-education!
Resuscitation in Paediatric Cardiac Patients: Michele Domico
Resuscitation in Paediatric Cardiac Patients: Michele Domico
The Role of the Immediate Responder in Mass Casualty Trauma
The Role of the Immediate Responder in Mass Casualty Trauma
Interprofessional Communication: Challenges and Opportunities - Walter Eppich
Interprofessional Communication: Challenges and Opportunities - Walter Eppich
Chief Medical Informatics Officer- I could do that!
Chief Medical Informatics Officer- I could do that!
It's time to do away with the hard Cervical Collar
It's time to do away with the hard Cervical Collar
Spinal Trauma: The Legend of the C-Spine Collar - A Case Report
Spinal Trauma: The Legend of the C-Spine Collar - A Case Report
Debate: Prehospital Doctors add little value in Trauma
Debate: Prehospital Doctors add little value in Trauma
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Critical Care in Humanitarian Emergencies: Nikki Blackwell
Death by Neurological Criteria and Organ Donation: Bill Knight
Death by Neurological Criteria and Organ Donation: Bill Knight
Similar to Bare Knuckle Trauma Debate: There's no denying it - Prehospital doctors add plenty of value in trauma CON
Best Gynaecologist And Obstetrician in Baraut
Dr. Neeraj Multispeciality Hospital, Our Dedicated, Specialized Facilities For All Ailments And Diseases With An Expert Team Of Doctors And Specialists.
Myo protect
This document is the preface to a book titled "New Solutions for the Heart: An Update in Advanced Perioperative Protection". The preface discusses the motivation for creating the book, which was to provide a comprehensive summary of myocardial protection during cardiac surgery since the topic had not been covered in over 15 years. The editors, Bruno Podesser and David Chambers, recruited leading clinicians and scientists in the field of myocardial protection to contribute chapters on topics ranging from the history of cardioplegia to new technologies and approaches. The preface expresses the hope that the book will stimulate further research in myocardial protection to benefit cardiac surgery patients.
Nicola Maffulli - Lesions surgery
Nicola Maffulli
Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Surgery, Salerno, Italy and Queen Mary University of London, Centre for Sports and Exercise Medicine, London, England.
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Surgical indications for muscle injuries
What is Pediatric Cardiac Surgery?
Children who are born with structural heart disease need specialized care. this ppt will help you understand what this field is about.
Ebp mahus
The document provides an introduction to evidence-based medicine (EBM). It defines EBM as an approach to clinical decision-making that integrates the best available research evidence, patient values and clinical expertise. The document outlines the key steps of EBM, including asking clinical questions, acquiring evidence from reliable sources, appraising the quality of the evidence, and applying it to individual patients. EBM aims to improve healthcare quality by minimizing ineffective, unsafe practices and promoting interventions that are supported by scientific evidence.
Instructional design in Surgical Virtual Reality Simulation Training
Scientists Steven Andersen and Ebbe Thinggaard sharing their own research about Surgical Virtual Reality Simulation Training along with some of the key findings and educational design expertise from their team at CAMES - Copenhagen Academy for Medical Education and Simulation in Copenhagen, Denmark.
CAMES is world leading on Surgical Simulation and is integrating Virtual Reality into a lot of their simulations and research.Bear in mind, that Virtual Reality is defined more broadly, than the common public definition of Head Mounted Displays.
Follow the link for more information about CAMES: https://www.regionh.dk/CAMES/Sider/default.aspx
Presentatie Philips 2009
1) The ICU at Reinier de Graaf Hospital in Delft works to ensure patient safety through protocols, guidelines, and an intensivist-led closed format.
2) To further increase safety outside the ICU, the hospital introduced a Medical Emergency Team (MET) in 2004 composed of ICU professionals who provide rapid response to patients experiencing medical emergencies.
3) Evidence on the impact of METs is inconclusive but most studies show benefits to patient outcomes and mortality reduction. The hospital believes early detection and treatment of deteriorating patients can prevent serious adverse events.
Surgeon-Anaesthetist-Intensivist Crosstalk In Abdominal Emergencies (Zsolt Bo...
“One man never made a team.”
Detailed and well-structured handover from operating theatre to ICU is a cornerstone for uncomplicated postoperative care. The constant handover of the information between the members of the perioperative team (surgeon+anaesthetist+intensivist) is a crucial importance. Surgeon and anaesthetist are the key players in the operating room, aiming for a common goal – safety and good outcome for patient. Communication is the glue that holds the team together and is the source of motivation for all and the followings always should been discussed (Reintam et al.):
- exact description of surgical procedure (type of resection, number and placement of drains, timing of drain removal, etc...)
- possible bowel distention and impaired perfusion
- contamination of peritoneal cavity
- location of anastomosis, stoma (small bowel or colon), quality of anastomosis
- risk for bleeding
- type of closure (mesh, fascial, open abdomen, etc...)
- when to start oral diet / enteral feeding
The ed as gatekeeper in transitions of care james hoekstra md 1
This document discusses the role of the emergency department (ED) as a gatekeeper in transitions of care. It covers several key points:
1) The ED plays an important role in determining whether patients are observed, admitted, or discharged. Risk stratification tools help guide these decisions for conditions like chest pain.
2) The ED communicates patient acuity levels and makes recommendations about observation, medical-surgical floors, intensive care, etc. Information on condition, interventions, and risk scores are important to transmit.
3) Protocol-driven care that begins in the ED can continue on hospital floors, improving outcomes. Guidelines help with conditions like heart attacks and pneumonia.
4) The ED can help
Copie de at the work place
The document provides information about different medical professions in a hospital. It lists professions like surgeon, midwife, paramedic, pharmacist, and their roles. It also discusses the simple present and present continuous tenses, providing examples of when to use each. An activity asks students to match professions with their numbers and complete sentences using hospital professions and specified verbs. Another activity asks students to identify hospital staff based on brief descriptions. The document aims to help students learn about hospital roles and differentiate between the simple present and present continuous verb tenses.
Surgical excellence
This document discusses the triad of Head, Heart, and Hand that was coined by Dr. Harvey Cushing as essential qualities of a surgeon. Head refers to using sound clinical judgement and understanding of science. Heart represents compassion for patients. Hand symbolizes surgical skill and teamwork. The document emphasizes the importance of these qualities, as well as continuous learning, humility, and prioritizing patient care over personal or financial gain. Technology is discussed as both enhancing the field of orthopedics but also potentially being misused if not guided by clinical benefit for patients.
Hysteroscopy newsletter vol2 issue 4 english
A new number of this Newsletter about Hysteroscopy. Interview with Stefano Bettocchi to know more about the vaginoscopic approach. Endometrial Polyps, Should they always be removed?. Do you know what's an amniotic sheet?. Techniques for in-office myomectomy, Hydrosalpinx before IVF and some information about the global congress on hysteroscopy. Enjoy this latest issue!!!
Introduction to anesthesia
This document discusses the field of anesthesiology. It provides information on what anesthesiologists do, including administering medications to alter physiology, being rapid problem solvers, and leading medical teams in complex environments like operating rooms. The document highlights some of the skills involved in the specialty like airway management, pharmacology, resuscitation, and regional anesthesia. It also outlines some of the tools used in anesthesiology like inhaled anesthetics, muscle relaxants, and opioids. The field has advanced greatly in recent decades to improve patient safety during medical procedures.
Colin dayan commercial research in cardiovascular disease
This document discusses establishing Cardiff University and surrounding NHS hospitals as a commercial research "hub" for cardiovascular clinical trials. It outlines why cardiovascular disease is a priority area for commercial drug development. Developing a strong reputation with industry would require accelerating trial set-up times, incentivizing staff to refer eligible patients, and providing high-quality principal investigators. The needs of clinicians include protected time, regulatory support, and infrastructure for trial delivery. The document proposes a coordination group called Cardiovascular Research Group - Cymru to facilitate collaborative translational research and multi-center trials across institutions. Establishing clear points of contact and minimizing delays could help deliver studies effectively. An example trial mentioned is the ODYSSEY trial of a P
The implication of the 'covenant'' of care - are we on the same page? by A.Pr...
This document discusses differences in perspectives between surgeons and intensivists regarding care of critically ill surgical patients. It notes that while surgeons and intensivists both care for the same patient, they often have different training, cultures, and approaches to decision making. This can lead to a lack of being "on the same page" and mixed messages. The document explores concepts like the "surgical covenant" where surgeons feel a strong responsibility for patients' outcomes, which can conflict with goals of care discussions. It recommends improving communication through early and regular interdisciplinary meetings to resolve contradictions and align on realistic treatment plans and expectations. The goal is for different specialties to work as a coordinated "choir" rather than "parallel universes
4-Dr.Kaleem_Rajput.pptx
This document outlines an agenda and content for a cupping therapy training session. The session will discuss moving the practice of cupping therapy towards a more standardized, evidence-based, and professionally regulated approach. Speakers will address the current inconsistent practices in cupping therapy and the need to establish standardized protocols for patient safety. They will introduce the British Cupping Society's approach, which focuses on practitioners obtaining proper clinical knowledge and skills, managing treatments appropriately, and engaging in ongoing professional development. The document provides example cases and questions to illustrate key discussion points around professionalization, treatment management, and developing cupping therapy as a safe, effective treatment approach.
The Top 10 Resuscitation Headlines and Controversies: And How To Read Past Th...
We’ve all heard controversies about cardiac resuscitation. “Use the right medications.”, “Medications don’t matter.”, “Airway first!”, “Don’t worry about the airway!” It is confusing for EMS professionals to sort out exactly what they’re supposed to do. Taking a look at the Top Ten Headlines for cardiac resuscitation, this program evaluates the strength of the science behind each recommendation as well as how they might be implemented in different EMS systems. Getting past the “Headlines,” attendees will return home well-equipped to open up discussions about optimizing EMS cardiac arrest resuscitation in their systems beyond “I read this study once” or “This is what the algorithms say now.”
Palliative care
Palliative care focuses on reducing the intensity and severity of symptoms from disease to improve quality of life. It is provided by an interdisciplinary team and addresses physical, emotional, and spiritual needs through pain and symptom management. Palliative care can be provided alongside curative treatment from the time of diagnosis for diseases like cancer, organ failure, Alzheimer's, and AIDS. Radiotherapy can help manage bone metastases, spinal cord compression, and other symptoms in palliative care.
Life as a Nurse
The last of this series for nursing students is Life as a Nurse. Life as a Nurse is one of the most commendable careers you can select. You are held up to a higher standard, and are frequently regarding with the trust, respect, and admiration of not just your patients and their families, but to these same traits in nurses are the same around the world. Being a nurse is not just another job, it is a solemn responsibilty NEVER to be taken lightly or for granted. Congratulations on making a life changing, challenging, exhaustive, and absolutely the BEST choice you could make.
You are about to change the world.
Similar to Bare Knuckle Trauma Debate: There's no denying it - Prehospital doctors add plenty of value in trauma CON (19)
Instructional design in Surgical Virtual Reality Simulation Training
Instructional design in Surgical Virtual Reality Simulation Training
Surgeon-Anaesthetist-Intensivist Crosstalk In Abdominal Emergencies (Zsolt Bo...
Surgeon-Anaesthetist-Intensivist Crosstalk In Abdominal Emergencies (Zsolt Bo...
The ed as gatekeeper in transitions of care james hoekstra md 1
The ed as gatekeeper in transitions of care james hoekstra md 1
Colin dayan commercial research in cardiovascular disease
Colin dayan commercial research in cardiovascular disease
The implication of the 'covenant'' of care - are we on the same page? by A.Pr...
The implication of the 'covenant'' of care - are we on the same page? by A.Pr...
The Top 10 Resuscitation Headlines and Controversies: And How To Read Past Th...
The Top 10 Resuscitation Headlines and Controversies: And How To Read Past Th...
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Precision Medicine in Acute Brain Injury
Systematic review of 26 studies with 55,792 patients found that dedicated neurocritical care (NCC) was associated with decreased risk of mortality (17% relative risk reduction) and decreased risk of poor functional outcomes (17% relative risk reduction) in critically ill brain-injured adults. A survey of Australian ICUs found limited availability of NCC, with only 4 centers specializing in it and 9 employing an intensivist subspecializing in NCC. Continuous EEG monitoring was found to have higher sensitivity for detecting nonconvulsive seizures than routine EEG monitoring, and was associated with reduced in-hospital mortality, though barriers to its universal use include infrastructure and personnel requirements.
CSD by Jeffcote Coda 22.pdf
CORTICAL SPREADING DEPOLARISATION IN NEUROLOGICAL DISEASE – AN INTRODUCTION
By Toby Jeffcote
Cortical spreading depolarization (CSD) is a spreading loss of ion homeostasis, altered vascular response, change in synaptic architecture, and subsequent depression in electrical activity following an inciting neurological injury.
It was first described by Leão in 1944, a disturbance in neuronal electrophysiology has since been demonstrated in a number of animal studies, and recently a few human studies that examine the occurrence of this depolarizing phenomenon in the setting of a variety of pathological states, including migraines, cerebrovascular accidents, epilepsy, intracranial hemorrhages, and traumatic brain injuries. The onset of CSD has been demonstrated experimentally following a disruption in the neuronal environment leading to glutamate-induced toxicity. This initial event leads to pathological changes in the activity of ion channels that maintain membrane potential. Recovery mechanisms such as sodium-potassium pumps that aim to restore homeostasis fail, leading to osmolar shifts of fluid, swelling of the neuron, and ultimately a measurable depression in cortical activity that spreads in the order of millimeters per minute. Equally important is the resulting change in vascular response. In healthy tissue, increased electrical activity is coupled with release of vasodilatory factors such as nitric oxide and arachidonic acid metabolites that increase local blood flow to meet increased energy expenditure. In damaged tissue, not only is the restorative vascular response lacking but a vasoconstrictive response is promoted and the ischemia that follows adds to the severity of the initial injury. Tissue threatened by this ischemic response is then at elevated risk for CSD propagation and falls into a vicious cycle of electrical and hemodynamic disturbance. Efforts have been made to halt this spreading cortical depression using N-methyl-D-aspartate receptor antagonists and other ion channel blockers to minimize the damaging effects of CSD that can persist long after the triggering insult.
Subdural Haemorrhage and MMA embolisation
Celia Bradford takes us through the latest on the management of subdural haemorrhage (SDH). She covers acute SDH, chronic SDH and middle meningeal artery embolisation, a novel treatment for chronic SDH management in certain circumstances.
Andy Neill - More neuroanatomy pearls for neurocritical care
Andy Neill shares some more neuroanatomy wisdom that's highly practical for anyone working with neuro emergencies. This time he covers brain herniation syndromes, hydrocephalus, extradural vs subdural haematomas, cervical spinal imaging, vertebral artery dissection and "things you read on CT reports but don't know what they mean"!
The BONANZA Trial and PbTO2 Monitoring
Andrew Udy talks about Brain Tissue Oxygen Monitoring:
It’s Not What You’ve Got It’s What You Do With It
The BONANZA Trial
Andrew Udy talks about the ongoing BONANZA Trial which is assessing whether an algorithm that incorporates both ICP and brain tissue oxygen (PbTO2) can improve outcomes after traumatic brain injury (TBI). Like with all monitoring, how the PbTO2 is interpreted and managed is critical and the devil is in the detail!
More on BONANZA here
More on BOOST3 here
Dilating the Dogma of Vasospasm
R. Loch Macdonald, M.D., Ph.D.
Community Neurosciences Institute
Fresno, California, USA
Angiographic vasospasm and more accurately, delayed cerebral ischemia, continue to contribute to morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). It is known that angiographic vasospasm is common after SAH, occurring in two-thirds of patients. Cerebral infarctions that developed days after the SAH have been attributed to angiographic vasospasm, occuring in about a third of patients, although this has always been controversial. Angiographic vasospasm theoretically can only damage the brain by restricting blood flow but there is no easy, accurate, widely available method to measure cerebral blood flow and this is not the measurement we need. Blood flow depends on metabolic demand so what we need to know to determine if angiographic vasospasm is causing ischemia is oxygen extraction fraction in the brain tissue supplied the the spastic artery. Without this measurement, the attribution of ischemia to vasospasm is subjective. Since angiographic vasospasm is essentially the only detectable delayed phenomenon after SAH, we focus on it and apply tremendous resources to preventing or reversing the vasospasm. Undoubtedly angiographic vasospasm can cause cerebral infarctions, but it has to be severe and flow limiting. But SAH is a complex disease. There are many other causes for cerebral infarctions after SAH, the most common being due to the aneurysm repair procedure. And a given degree of vasospasm may cause infarction in a volume-depleted patient with poor collateral blood supply but not in a patient without these things. There also are hypodense brain lesions after SAH that are due to intracerebral hemorrhages. There can be hypodensities in the brain directly under usually thick SAH where the brain dies. This observation in particular supports a role for cortical spreading depolarizations/ischemia as a cause of infarction after SAH. Other macromolecular processes that are hypothesized to cause brain damage after SAH include microthromboembolism, changes in the microcirculation, delayed brain cell apoptosis and capillary transit time heterogeneity. Determining the importance of these things is hindered by the lack of an easy way to detect them in patients. It is also known that poor grade patients, who presumably have more early brain injury and ischemia than good grade patients, are more prone to delayed cerebral ischemia, suggesting increased sensitivity to secondary insults of the already injured brain. We also assume delayed neurological deterioration when attributed to vasospasm or delayed cerebral ischemia, is purely due to ischemia. While knowledge about what happens pathophysiologically after SAH is increasing, management of delayed cerebral ischemia still focuses on detecting angiographic vasospasm and then augmenting the blood pressure to improve cerebral blood flow or dilating the spastic arteries with balloons or drugs.
EVD Tips and Tricks
By Catherine Bell and Andrew Udy
Catherine Bell takes us through how to troubleshoot problems commonly encountered when looking after patients who have an external ventricular drain (EVD) in situ. Issues with using brain tissue oxygen monitors are also discussed. A highly practical session aimed at bedside clinicians.
There is no such thing as mild, moderate and severe TBI - by Andrew Udy
Part 2 of a debate over the classification of TBI. Andrew Udy then argues that this classification is fundamentally flawed. He discusses the issues with the Glasgow Coma Scale, and therefore the follow-on issues in TBI classification, including all the confounders to the GCS, the issues with timing of the score as well as GCS not taking baseline function or specifics subtypes of TBI into account. He makes teh argument that biomarkers may better categorise the diffuse entity we call TBI.
TBI Debate - Mild, moderate and severe categories work
Andrew Chow, Intensivist with a neurosurgical background, argues that the current categorisation system for traumatic brain injury (TBI) works, and makes sense! He tackles us through the history of this system, and why it’s important to differentiate different types of TBI. The arguments in favour of this categorisation include the consistency and benefits of a universal language, the implications for triage and management, and the fact that this system has been endorsed by all major organisations
TBI: when to stop and when to give time
Dr Nick Little is an experienced Neurosurgeon who's looked after patients with traumatic brain injury for his whole career. Here he discusses the difficulties of prognostication following traumatic brain injury (TBI). He talks about the statistics of outcomes following mild, moderate and severe TBI and then goes on to tackle the harder topic of how we try to work out what an individual would want if they knew the spectrum of outcomes that they may face. The issues with the clinical examination findings we use to prognosticate are covered, as well as which imaging findings he finds most helpful. He also mentions the difficulties with current prognostic calculators.
Ketamine in Brain Injury by Toby Jeffcote
Historically, when it came to brain injury, ketamine had a bad rap. Much of that dogma was dispelled in the last decade, and ketamine is now frequently used as an induction agent in acute brain injury, especially traumatic brain injury, due to it’s favorable effects on haemodynamics.
However a new application of ketamine is now being explored - whether ketamine may be able to reduce secondary brain injury.
Managing Complications of Chronic SCI by Bonne Lee
20 million people around the world are living with a spinal cord injury (SCI). The medical issues they develop over the years differ to any other patient cohort.
These complications include autonomic dysreflexia, management of pressure areas, specific infections, nuanced peri-operative care and highly specific issues such as baclofen pump management and syringomyelia
Do look at the NeuroResus section on this and listen to Spinal Rehab Specialist Bonne Lee talk about this side of SCI care.
Keywords
SCI, spinal, spinal cord injury, autonomic dysreflexia, pressure areas, infection, peri-operative care, baclofen pump, syringomyelia, chronic SCI, spinal trauma, spinal rehab, incomplete SCI
EEG and Status Eplilepticus by Tania Farrar
Tania is a neurologist and epileptologist with expertise in continuous EEG (cEEG) and status epilepticus (SE). This talk covers what a seizure is, what status is, including focal and generalised status epilepticus.
So why do we do cEEGs for patients with suspected SE?
To confirm the diagnosis
To see if patient just post ictal or still seizing
To establish that the clinical and electric seizures have stopped
To see if burst suppression is achieved
To exclude other differential diagnoses
She makes a good argument for why cEEG is such an important tool in managing SE.
In the questions after the talk, the issue of availability of cEEG in the Australian setting was discussed. Limited montage EEGs are discussed including their pros and cons.
Browne Neuro symposium.pptx
Stuart Browne is a Neuro Rehab specialist from Sydney. These slides accompany a talk he gave at the Brian Symposium in 2023. He discusses what "severe disability" really means.
Severe disability is more common than many realise - about 6% of the Australian population.
Stuart discusses how health is more than simply physical recovery and how it is a multidimensional construct. He covers how permanent disability doesn't necessarily equate to a poor quality of life. He also discusses the long timespan of recovery, which is often much longer than appreciated.
He specifically discusses "Locked-in Syndrome" and how the survivors have surprisingly positive self-reported health-related quality of life and well-being.
Stuart also covers how severely disabled people face various forms of discrimination.
Paediatric Stroke by Shree Basu
Shree Basu is a Paediatirc Intensivist in Sydney. These slides from the Brain Symposium 2023 accompany the talk she gave. She discusses how Paediatric stroke presents, what neuroimaging is required and what interventions are available, including thrombolysis and the role of endovascular thrombectomy.
Hypertensing Spinal Cord Injury - gold standard or wacky?
This document discusses the concept of maintaining higher blood pressure levels, known as hypertension, after a spinal cord injury to improve spinal cord perfusion pressure and reduce secondary injury. It notes that while animal studies and some human trials have shown improved neurological outcomes, the evidence is still limited. It calls for larger randomized controlled trials in humans that also incorporate multi-modal monitoring and standardized outcome measures to further evaluate if inducing hypertension after spinal cord injury should be considered the gold standard of care.
Optimal Cerebral Perfusion Pressure
Mark Weedon takes us through the increasingly utilised concept of an optimal cerebral perfusion pressure (CPPopt) for each unique patient. He discusses the background to CPPopt, including intrcranial pressure (ICP), the Monroe Kelly hypothesis, neurovascular coupling, and cerebral autoregulation in health and following brain injury. He shows how intracranial pressure is affected by intracranial compliance and how this affects ICP waveforms. Cerebral perfusion pressure in relation to the Brain Trauma Foundation guidelines is covered including management of elevated ICP (EICP). The currently recommended tiered approach to managing cerebral perfusion pressure and EICP is mentioned citing recent guidelines. He uses a clinical case of a TBI to illustrate how the CPPopt can be ascertained and used to guide therapy, including the easy to perform “MAP Challenge”. Mark also describes the Pressure Reactivity Index (PRx) and how it can be used as a target for therapy. Finally, he covers the exciting results of the preliminary COGiTATE pilot study.
The Power of Words - Death and Language.ppt
Social Worker Victoria Whitfield and Bereavement councilor Louise Sayers discuss the power of words when health professionals are communicating topics around of death and serious injury with relatives and patients in critical care. They use role plays to bring theories to life.
Sepsis and Antimicrobial Stewardship - Two Sides of the Same Coin
Undertreatment of sepsis can lead to mortality, while overdiagnosis and overtreatment can increase future risk of antimicrobial resistance. Antimicrobial stewardship aims to balance these risks by prioritizing patient safety and appropriate antimicrobial use. Data shows variability in appropriateness of antimicrobial prescribing between different types of hospitals. Embedding antimicrobial stewardship principles throughout sepsis diagnosis and treatment, from initial microbiology testing to post-treatment review, can help standardize care and optimize outcomes.
Brain injury outcomes and predictors
Being able to prognosticate in the aftermath of a traumatic brain injury (TBI) is important as it assists with counselling patients and families. Moreover, it helps rationally allocate healthcare resources.
However, due to the heterogenous nature of TBI and variable pre brain injury patient factors and post brain injury course, this has proven to be a difficult task.
Large cohort studies have enabled improved accuracy in the prediction of 6 month mortality and unfavourable outcome.
Furthermore, many of the factors that contribute to long-term outcome have also emerged. However, it is not yet possible to use them in prediction algorithms or mathematical models.
There is emerging evidence that pre injury psychosocial and demographic factors may be of more relevance than injury severity. Moreover, that 'outcome' becomes increasingly subjective and complex as the post injury duration increases.
We end with three brief vignettes which highlight the fraught nature of long term outcome prediction.
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According to research conducted by the National Family Health Survey of India, diabetic cases show a projection which might increase to 10.4% by 2030.
Cell Therapy Expansion and Challenges in Autoimmune Disease
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
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Bare Knuckle Trauma Debate: There's no denying it - Prehospital doctors add plenty of value in trauma CON
- 1. Bare knuckle knock out Prehospital doctors add little value in trauma??
- 3. Lets face it… (most) (current) prehostpial EBM is B.S. - Bias - Notoriously difficult - Methodologically flawed… *Bit Scanty…. Brilliantly subjective....
- 4. Reality is: We want (our patients deserve) Same level + standard of care as IN hospital
- 5. Reality is: We want (our patients deserve) Seamless patient journey
- 6. The beginning (or the end) of the trauma chain of survival…
- 7. Prehospital doctors in the field
- 9. Prehospital doctor as Trauma Team leaders
- 10. Prehospital doctor(s) in the trauma bay
- 16. LEADERSHIP
- 17. KNOWLEDGE
- 19. DECISION MAKING
- 21. INNOVATION
- 22. COLLABORATION
- 23. VISION
- 25. Hospital teams
- 26. Research teams
- 27. Simulation teams
- 28. unpublished ‘truth’ EVERY DAY ALL OVER THE GLOBE PREHOSPITAL DOCTORS ARE HELPING TO SAVE LIVES
- 29. Don’t take my word for it…
- 30. Legion of extraordinary gentlemen and gentle-ladies
- 90. …we ARE many ...we CARE a lot
- 91. You dare say we add little….? Really? REALLY? No, I say, “a HELL of a LOT”doesn’t even cover it
- 92. “Honourable intentions” “Meaningful interventions” Dr. John Hinds (1980- 2015)
Editor's Notes
- I am a prehospital doctor…. .... But so is my opponent....
- B.S = brilliantly subjective
- Roadside to rehab