Leadership is a Trait of an Individual - Resa E. Lewiss

•

1 like•2,002 views

SMACC Conference

In this talk I will summarize the pearls, pitfalls, and lessons shared by leaders in my own life, both inside and outside of medicine. In my experience, leadership is not a particularly male or female quality. It is a trait of an individual. Individuals tend to dichotomize into leaders and into followers. And people know good leaders “You know the way you know about a good melon” When Harry Met Sally I will share with the audience my lessons and personal examples on leadership. Some of these include 1. There is never a need to publicly embarrass someone. Always give the person an out and speak in private. 2. Make a decision. Being indecisive is perceived worse than making a wrong choice. 3. Know your strengths and build on those. Know your weaknesses and identify people for whom those are strengths and bring them onto your team 4. “People may forget what you say, they may forget what you do, but they will never forget the way you make them feel.” Maya Angelou 5. Leaders must be comfortable with solitude 6. Leaders are not afraid to ask for what they need.

Health & Medicine

“Great minds discuss ideas;
average minds discuss events;
small minds discuss people.”

#ILookLikeALeader

Leadership

There is never a
need to publicly
embarrass
someone.
Always give the
person an out.
Speak privately.

Make a
decision. Being
indecisive is
perceived worse
than making a
wrong choice.

Know your
strengths and
build on those.
Know your
weaknesses and
identify people
for whom those
are strengths.
Bring them on
your team.

“… people will
forget what you
said, people will
forget what you
did, but people
will never forget
how you made
them feel.”

Ask

What
can we
do?

Mentor and Sponsor

Identify your
unconscious bias

Jamieson J et al. Gender equality in emergency medicine:
Ignorance isn’t bliss. Emergency Medicine Australasia 2016

“Nobody can make you feel
inferior without your consent.”

#ILookLikeALeader

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Professor Stephen Bernard is an Intensive Care Physician at The Alfred Hospital and Medical Advisor to Ambulance Victoria. His research interests include the use of therapeutic hypothermia for the treatment of neurological injury after resuscitation from out-of hospital cardiac arrest. Here he provides a presentation on recent advances in the management of refractory cardiac arrest in the out of hospital setting.

$Bernard - Refractory Cardiac Arrest$ $Bernard - Refractory Cardiac Arrest$

Bernard - Refractory Cardiac Arrest

Intensive Care Network Victoria

Francesca Rubulotta talks about disproportionate care in ICU. Disproportionate care is disproportionate in relation to the expected prognosis. Moreover, this can lead to moral distress among clinicians who think they are offering inappropriate care. There is mounting research and evidence pointing to the existence of disproportionate care. Furthermore, stress and burnout cause increased miscommunication and lead to low performance and concentration. Stress leads to absenteeism or in many cases, presenteeism. Presenteeism is when someone just shows up for work but does the bare minimum. Francesca shows the financial burden caused by absenteeism across various countries. Francesca points out that only 14% of employees feel engaged in their jobs. Moreover, data shows that companies which keep their employees engaged have higher rates of performance. Such companies have managers who are more engaged and approachable. Francesca discusses various studies that look at the appropriateness of care in ICU. She talks about the CONFLICUS, APPROPRICUS and DISPROPICUS studies, all of which point to the moral stress experienced when clinicians are forced to give inappropriate care. We must ask whether inappropriate care occurred and why. The three major factors influencing the perception of inappropriate care are client related situations, work characteristics and personal characteristics. 27% of healthcare providers (HCP) report at least one of their patients are mismanaged per day. Furthermore, 63% say that inappropriate care happens all the time. There are multiple reasons for disproportionate care taking place. Studies show that nurses associated inappropriate care to interpersonal factors while physicians ascribed it to prognostic uncertainty. Francesca discusses the methods used and results obtained in the DISPROPICUS study and self-awareness and individual development in ICU. According to her, these future studies will help to find solutions to the problems regarding disproportionate care. Evidently, authentic leaders, who can inspire others, are the need of the hour. For more like this, head to our podcast page. #CodaPodcast

The Problem of Disproportionate Critical Care

The Problem of Disproportionate Critical Care

The Problem of Disproportionate Critical Care

SMACC Conference

In this entertaining talk, Ronan O’Leary discusses conflict in critical care. Ronan explains how to make a team decision about whether or not to perform a decompressive craniectomy. Undertaking a decompressive craniectomy is perhaps one of the most challenging decisions we face within critical care. Ronan contends that we do not know if we should do the operation. As he explains, even if we think we should do it, we don’t know when, or even how. Perhaps more importantly, intensivists do not perform the operation, the neurosurgeons do. However, we frequently put them in the position of doing the operation when we are at our wits end. Alternatively, they do the operation without asking us when we still feel we have space to play. Ronan poses the question - how can we resolve this, in a workplace environment which is already fraught with competing interests, beliefs, values and approaches? Evidence based medicine is not going to provide an answer soon and it is unlikely that a superficial approach to improving teamwork will either. An important component will be the future structure of clinical training. Our current systems reflect the way hospitals worked decades ago and the specialties we now have exist almost independently of the training which leads to consultant posts. Ronan posits that training should involve exposure to collegiate decision making and consensus building. However, this will be difficult to achieve within our current nationally co-ordinated training schemes. For more like this, head to our podcast page. #CodaPodcast

How to manage conflict in Critical Care: Ronan O’Leary

How to manage conflict in Critical Care: Ronan O’Leary

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SMACC Conference

Ah, but you don't look like a professor! A recent statement from a (female) patient says it all, doesn't it? Since the first women were admitted to medical schools – quite a while ago in most countries, the participation of women in clinical and academic medicine has increased steadily. Overall, women represent the majority of health care workers and also medical students in most countries of the world today. SMACC audience is almost 50% female. However, only few women make it to the top, and with each step up the career ladder, the proportion of women decreases substantially, a phenomenon called the “glass ceiling” or the „leaky pipeline“. This is particularly true for some medical specialties such as critical care or trauma surgery, as opposed to specialties like endocrinology, pediatrics or gynecology. Although often subtle, gender discrimination against women continues to be a problem – for instance, it has been shown that a ficticious student named “John” would receive a higher salary and find a mentor easier than “Jennifer”. A manuscript written by “John” is judged more favourably than one that is authored by “Joan”, and female grant applicants with the same scientific productivity are given substantially lower scores than male applicants by reviewers (men and women). Sheryl Sandberg’s statements are as true in clinical and academic medicine as in other areas. This talk will definitely raise your awareness for the topic.

Critical Care: No place for a woman?

Critical Care: No place for a woman?

Critical Care: No place for a woman?

SMACC Conference

Sara Gray tackles the controversial topic of disaster ethics in critical care. Most hospitals develop a disaster plan, but few jurisdictions develop a plan for triaging or rationing scarce resources when the existing supply is overwhelmed. Rather than leaving individual health care workers to make these decisions, we should work together as a community of experts to develop ethical, practical and appropriate policies for triaging scarce resources during a disaster. Healthcare resources are finite. In the case of large-scale trauma with large numbers of casualties, such as a disaster scenario, how do you decide who gets what? Sara discusses her guiding principles when thinking about disaster triage. First and foremost, avoid having to triage or ration scarce resources. Have a plan and make first part of the plan to be “Never use the plan”. Mitigate all the risks and possibilities that would see the plan being enacted. This involves sharing with partner hospitals, urgently reordering supplies and repurposing what is available. The second guiding principle relates to the ethics. Normal circumstances dictate offering the best for every individual patient. In a disaster, a shift to the utilitarian philosophy – the greatest good for the greatest number – is necessary. This means not everyone is going to get what they need, which is a difficult concept for people. Thirdly, Sara stresses the importance of developing a disaster plan in a public way. This stops a plan being “sprung” on staff, the public and stakeholders. It encourages buy-in and engagement which makes it a smoother process should the plan ever be enacted. Sara next discusses the inclusion and exclusion criteria when dictating who should receive the finite resources of a hospital in a disaster. This, she admits, is the tricky part. She backs her thoughts up with the available data. Sara concludes with some points regarding the implementation of disaster plans. Making these plans is tough, however not having them is tougher. Hospitals and health authorities should have a clear criteria for when a crisis is declared. This needs to come from the hospital level, if not the health region or government. It is not an individual decision. Next a dedicated team should review de-identified patient files to allocate resources according to the inclusion and exclusion criteria. This team needs to be multi-disciplined and received adequate support. This is a tough job. Finally, for more like this, head to our podcast page. #CodaPodcast

Disaster Ethics in Critical Care: Sara Gray

Disaster Ethics in Critical Care: Sara Gray

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SMACC Conference

The use of adrenaline in cardiac arrest resuscitation has been advocated since the 1960s. Laboratory studies and anecdotal experience showed improved rates of return of spontaneous circulation (ROSC) with the use of adrenaline at a dosage of approximately 0.01 mg/kg. This led to the widespread adoption of adrenaline administration during cardiac arrest into every resuscitation guideline for decades to come. Extensive laboratory studies characterized the beneficial physiological effects of adrenaline during cardiac arrest and closed-chest cardiopulmonary resuscitation (CC-CPR). Adrenaline administered during CC-CPR results in peripheral arterial vasoconstriction that raises the aortic pressure, particularly during the relaxation phase of CC-CPR. This increase in aortic pressure results in an increased aortic to right atrial pressure gradient that drives blood flow to the myocardium during CC-CPR. This pressure gradient is known as the coronary perfusion pressure (CPP) and has been shown to correlate with ROSC in both laboratory investigations and clinical studies. During the 1990s, the use of “high-dose” adrenaline showed increased rates of ROSC compared to “standard-dose” adrenaline. However, it was subsequently recognized that larger doses of adrenaline did not result in improved survival. Furthermore, questions have been raised as to whether or not “standard-dose” adrenaline improves survival from cardiac arrest. Recent meta-analyses have raised serious questions about the value of adrenaline, showing a benefit for achieving ROSC but no clear evidence of improved long-term survival. Controlled clinical trials to address this question are now underway. However, there is another important issue that needs to be addressed: the “route” of administration. With the growing interest in endovascular resuscitation, the use of intra-aortic adrenaline titration offers a means of rapidly and effectively delivering adrenaline to peripheral arterial effector sites while providing arterial pressure and CPP monitoring to guide titration of adrenaline doses to achieve an optimal hemodynamic effects while avoiding excessive adrenaline doses. To enable screen reader support, press shortcut Ctrl+Alt+Z. To learn about keyboard shortcuts, press shortcut Ctrl+slash.

Rethinking Adrenaline in Cardiac Arrest

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SMACC Conference

Critically ill patients frequently have activation of inflammatory and clotting pathways. These are likely adaptive responses in the human. When they run riot or the fine balance between pro- and anti-inflammatory states is shifted however there can be significant morbidity and mortality. This acronym-busting talk will focus on some acquired haematological disorders in critically ill patients. Disseminated Intravascular Coagulation (DIC) is a clinical and laboratory diagnosis that affects about 1% of hospitalised patients. At the most severe end it is associated with bleeding and/or thrombotic complications. Disorders such as thrombotic thrombocytopenia purpura (TTP) and other forms of micro-angiopathic hemolytic anemia (MAHA) will also be described including the role of ADAMST13. HIT is an uncommon but important conditions which is difficult to diagnose in a critically ill patient. An approach to HIT is discussed. Have you always wondered about NETs (neutrophil extracellular traps) and their importance? If so this whistle-stop tour of non-malignant hematology in the ICU is for you!

Bad Blood

SMACC Conference

Stephen Bernard shares his thoughts and the current evidence for using oxygen for cardiac arrest patients. Oxygen is ubiquitous in society! You can buy it in bottles and there are even oxygen cafes. This is especially true in hospitals where oxygen is used frequently and often without much thought. Oxygen is a natural substance. So surely, a short time on 100% oxygen can’t be harmful, right? Stephen wants to challenge that idea. In this talk he presents the data on why oxygen might be harmful to your patients, particularly following a cardiac arrest. Out-of-hospital cardiac arrest (OHCA) is common and carries a high mortality rate. In Victoria, Australia, approximately 50% of patients with an initial cardiac rhythm of VF achieve a return of spontaneous circulation (ROSC) and 30% overall survive to hospital discharge. The outcome for patients is improving. This is due mainly to faster ambulance response times and increased rates of bystander CPR. What is done in the hospital has altered the patient’s outcomes in the same way. Currently, OHCA patients who have achieved ROSC but who remain unconscious routinely receive 100% oxygen for several hours in the ambulance, ED, cardiac catheterisation laboratory until admission to ICU. However, there is now evidence from laboratory studies and preliminary observational clinical studies that the administration of 100% oxygen during the first few hours following resuscitation may increase both cardiac and neurological injury. Clinical trials are underway to test whether titrated oxygen to a target oxygen saturation of 90-94% in the immediate hours after ROSC results in improved outcomes compared with 100% oxygen. Join Stephen as he makes you think twice about blindly using oxygen for patients following a cardiac arrest.

Cardiac Arrest and Oxygen: Stephen Bernard

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SMACC Conference

How do you diagnose death? In Critical Care we deal with death on a regular basis and although it seems black and white, that is often far from the truth. Patricia Gerritsen discusses what it means to be dead and how that knowledge can aid you in stopping a resuscitation effort. Patricia presents the degrees of death in her eyes as: Soon to be dead Reversibly dead Irreversibly dead Reversibly, irreversibly dead Changes occur following death that can be proof of death. But not always. Pallor mortis, algor mortis, rigor mortis, livor mortis and decomposition can all indicate someone has died. There are other clues that can indicate a person is either dead or will soon be dead – with minimal chance of any life saving intervention. The varying ways death presents itself poses a challenge for the clinician. This is especially true when deciding when to stop a resuscitation effort. Consider the reversibly, irreversibly dead – also known as the Lazarus phenomenon. These patients achieve return of spontaneous circulation AFTER the resuscitation effort has been stopped. There are over 50 cases in the literature, with a wide and unpredictable array of clinical situations. Therefore, the question becomes - what are the limits that can be survived? Patricia suggests that we must know the extreme limits in order to make an educated decision about resuscitation. Patricia details some of the most extreme stories of survival in the literature. Submersion has been survived after 66 minutes in a child. An individual survived being in an ice stream after 40 minutes, with a recorded temperature of 13.7 degrees. A man with a potassium of 14 mmol/L made a good recovery. There is a case of someone with a pH of 6.33 recovery fully and someone surviving a CO2 level of 375mmHg. Patricia highlights these extreme examples to show what is possible whilst acknowledging the decision to stop resuscitation is a difficult and nuanced one. When to Stop Resuscitation in Critical Care: Patricia Gerritsen For more like this, head to our podcast page. #CodaPodcast

When to Stop Resuscitation in Critical Care: Patricia Gerritsen

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When to Stop Resuscitation in Critical Care: Patricia Gerritsen

SMACC Conference

The application of ‘CPR-for-all’ is the ultimate evidence drift. A treatment that is completely appropriate for dropping dead whilst running a marathon has almost no place in acute healthcare facilities where chronic irreversible complex co-morbidities abound. 90% of doctors would not choose CPR for themselves, yet 100% are trained in how to administer it to patients. Defaulting to ‘CPR-for-all’ removes a patients’ ability to provide informed consent for assault whilst they die from another disease. Remember - 2 weeks in ICU can spare you 5 minutes of difficult conversation. vs. Across the globe, patients are assumed to be full code to allow for prompt resuscitation, until code status can be discussed and clarified. There are numerous excellent reasons for this. Can you imagine if our systems decreed that DNR was the default? “Let’s not shock that VF, until we can clarify his code status.” Or, “let’s not resuscitate that child, after all, DNR is the default and her mother isn’t here yet!” Making DNR the default is not a good solution to ICU or hospital over-crowding. Let’s not mandate DNR, let’s mandate having reasonable code discussions early and often.

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DNR Should Be The Default - PRO: Alex Psirides, CON: Sara Gray

SMACC Conference

ICU year in review - Paul Young and Flavia Machado

ICU year in review - Paul Young and Flavia Machado

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SMACC Conference

Scott Weingart discusses post-intubation sedation – a topic that tends to aggrieve him on a regular basis. Scott explains in simple terms why he is bemused at the lack of understanding surrounding intubated patients who become agitated or aggressive. How would you like a piece of plastic placed down your throat? The problem, as Scott explains, is that sedation does not blunt pain. Sedation without analgesia leads to delirium. In simple terms delirium leads to poor outcomes and death. Moreover, concerningly, the early sedation strategy of intubated patients has long term and far-reaching outcomes during their course of critical illness. So, what can be done? Scott explains that we need patients properly sedated, however not too deeply sedated. The goal needs to be a patient who is oriented, safe and with a normal sleep-wake cycle. Paralysis is not the answer. What is the answer? Scott walks you through A1 sedation – meaning analgesia first. Once pain is controlled, then sedation comes in to play. Scott stresses with analgesia first, the sedation needed is less. He explains how he achieves this in practice in detail. He then provides some clinical examples and how he would approach them including which specific medications he uses in practice. Scott’s main points are simple. Control the pain and very few patients will need a lot of sedation. In addition, if you adequately control the pain, very few patients will have delirium in the Emergency Department. Join Scott as he passionately discusses post-intubation sedation. For more like this, head to our podcast page. #CodaPodcast

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SMACC Conference

Myths in ICU: BUSTED by Team Thomas

Myths in ICU: BUSTED by Team Thomas

Myths in ICU: BUSTED by Team Thomas

SMACC Conference

Trish Woods guides you through some clinical pearls in the intensive care management of neonates. The complex physiology of the transitioning required in the journey from foetal life to neonatal presents many challenges and scary moments. Trish helps you to navigate these challenges and to unlock the key to providing quality neonatal intensive care. Many things can go wrong in the neonatal period as babies transition to life in the real world. Trish highlights her thoughts on the use of positive end expiratory pressure (PEEP), how deep to intubate, when to clamp the cord and the use of ultrasound. When babies arrive early their lungs can be full of meconium or fluid. Due to this, Trish recommends using PEEP – without which there is distal airway collapse and fluid accumulation. Aeration of the lungs is vital. To this end, how deep should intubation be aimed? The depth may not be overly important. This is because regional lung aeration triggers widespread, global increase in pulmonary blood flow. There is little definitive evidence to guide clinicians on when to clamp the cord – early or late. Trish recommends considering the physiology of clamping the cord. After clamping the cord there is a massive drop in cardiac output. Ventilatory support will turn this around – something to remember. In a compromised baby, perhaps we should aim to clamp the cord sooner and then initiate ventilation. Finally, Trish highlights the utility of ultrasound. Viewing the heart and lungs provides crucial information for the clinician. Furthermore, Trish discusses actively looking for aeration, collapse, consolidation and pneumothorax in the lungs and thorax. Overall, don’t forget the essentials. Trish reminds you to keep life sweet, warm, and tempting and help neonates to transition into the big world. Neonatal Intensive Care: Trish Woods For more like this, head to our podcast page. #CodaPodcast

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SMACC Conference

Arrested Developments - Natalie May

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$Bernard - Refractory Cardiac Arrest$ $Bernard - Refractory Cardiac Arrest$

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Critical Care: No place for a woman?

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DNR Should Be The Default - PRO: Alex Psirides, CON: Sara Gray

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ICU year in review - Paul Young and Flavia Machado

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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

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SMACC Conference

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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.

EEG and Status Eplilepticus by Tania Farrar

EEG and Status Eplilepticus by Tania Farrar

EEG and Status Eplilepticus by Tania Farrar

SMACC Conference

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.

Browne Neuro symposium.pptx

Browne Neuro symposium.pptx

Browne Neuro symposium.pptx

SMACC Conference

Paediatric Stroke by Shree Basu

Paediatric Stroke by Shree Basu

Paediatric Stroke by Shree Basu

SMACC Conference

After spinal cord injury (SCI), there aren’t many interventions we have available that actually make a difference. Augmenting blood pressure to increase spinal cord perfusion pressure is an attractive concept that may improve neurological outcomes following SCI. We know that hypotension can make SCI worse. Clinical studies looking at blood pressure augmentation are mostly old, retrospective and flawed in various ways. Aiming for a MAP of > 85 for 5-7 days is recommended by guidelines but why this pressure and duration are good questions. Hypertensive therapy is relatively safe and easy to implement but not without risk. Tessa discusses the pros and cons, how this is managed practically and what the future may hold in this area.

Hypertensing Spinal Cord Injury - gold standard or wacky?

Hypertensing Spinal Cord Injury - gold standard or wacky?

Hypertensing Spinal Cord Injury - gold standard or wacky?

SMACC Conference

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.

Optimal Cerebral Perfusion Pressure

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SMACC Conference

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SMACC Conference

Appropriate use of antimicrobials is primarily a patient safety issue, and is the key aim of an effective antimicrobial stewardship program. We discuss the challenges in the management of a patient with sepsis, and how decision-making is usually done in the absence of effective diagnostics. Time dependent protocols and the knowledge that undertreatment of a patient with sepsis will lead to poor outcomes will lead to prescribing that may be driven by fear. Antimicrobial resistance is associated with over-use of antimicrobials but is usually not the immediate concern. Antimicrobial stewardship programs should work closely with sepsis teams to ensure that sepsis pathways are implemented across the whole hospital, and that key principles of judicious use are embedded within the clinical pathway.

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SMACC Conference

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.

Brain injury outcomes and predictors

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SMACC Conference

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Andy Neill - More neuroanatomy pearls for neurocritical care

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There is no such thing as mild, moderate and severe TBI - by Andrew Udy

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Ketamine in Brain Injury by Toby Jeffcote

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Thoracotomy is the surgical procedure with an incision made to access the pleural space and the contents of the thoracic cavity. Given the structures to be accessed with in the cavity, different incisions have been established to easy the procedure and these incisions qualify the types of thoracotomies to be studied hereunder. PRE OP OPTIMIZATION FOR SPECIFIC FACTORS The outcome of surgical procedures is not measured only by clinical end points but also shorter stays and lower costs. Patients’ discharge is delayed commonly due to inadequate pain relief, infection, arrhythmias, prolonged air leak and debility. Many complications that occur from thoracic operations can be anticipated. An aggressive preoperative work up mitigates morbidity and shortens convalescence. APPROACH CONSIDERATIONS There are about three principles that can guides the choice of the thoracotomy incision to be used I. Adequate exposure must be achieved. The choice of incision is aided by a thorough understanding of the surface anatomy and a comprehensive review of the radiographic images that are obtained preoperatively. II. Chest-wall function and appearance should be preserved to the extent possible. This principle include non-spreading video-assisted thoracoscopic surgery (VATS) procedures, muscle-sparing techniques, avoidance of excessive rib retraction, and rib preservation when possible. III. The third principle is that closure must be meticulous and appropriate. Strict layered closure is the rule for thoracic surgical incisions. Every effort should be made to approximate the individual divided chest-wall muscles in appropriate layers; otherwise, a significant delay in the recovery of range of motion (ROM) may result. Care must be taken to avoid over approximating the ribs and to prevent an override; this will help minimize postoperative pain. POST-OPERATIVE CARE AND MONITORING

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Diuretics also known as water pills increases the excretion of water and electrolytes (Na+) in urine. Natriuresis – large amount of sodium excreted in urine due to the action of kidneys. Promoted by – ventricular and atrial natriuretic as well as calcitonin. Inhibited by chemicals such as aldosterone. The drugs which increases sodium excretion are known as natriuretic. Diuresis – increased or excessive production of urine. The drugs which enhances the excretion of water without loss of electrolyte is called as aquaretic.

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Learning Objectives: Contrast the neural and local control of circulations through special regions. Compare the physiological significance of variation in circulations through special regions. Content Overview: This lecture provides a comprehensive exploration of circulation in specialized regions of the body, including coronary, cerebral, splanchnic, cutaneous, fetal, skeletal muscle, and pulmonary circulations. The physiological and anatomical considerations, regulation mechanisms, and unique features of each type of circulation are discussed. Key concepts such as autoregulation, local metabolic factors, and neural influences are covered in detail. Key Topics: Coronary Circulation: Anatomy and physiology of coronary blood supply. Phasic changes in blood flow during systole and diastole. Regulation by autonomic nervous system and local metabolic factors (hypoxia, adenosine). Cerebral Circulation: Control by local metabolic factors (CO2, H+). Autoregulation and hyperemia. Anatomy of cerebral blood supply and special features of cerebral blood vessels. Splanchnic Circulation: Anatomy and regulation of blood flow to the gastrointestinal organs. Role of sympathetic and parasympathetic nervous systems. Chemical factors and the concept of autoregulatory escape. Cutaneous Circulation: Thermoregulatory function and dense nervous innervation. Mechanisms of vasodilation and vasoconstriction. Blood reservoir function and responses to mechanical stimuli. Fetal Circulation: Unique aspects of fetal blood flow including umbilical vessels, ductus venosus, foramen ovale, and ductus arteriosus. Changes in circulation at birth and the stimuli for these changes. Skeletal Muscle Circulation: Regulation during rest and exercise. Role of nervous and local metabolic control. Circulatory adjustments during physical activity. Pulmonary Circulation: Characteristics and regulation of pulmonary blood flow. Zones of blood flow in the lungs and the effect of gravity. Response to hypoxia and other factors influencing pulmonary vascular resistance

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Leadership is a Trait of an Individual - Resa E. Lewiss

1. “Great minds discuss ideas; average minds discuss events; small minds discuss people.”

2. #ILookLikeALeader

5. There is never a need to publicly embarrass someone. Always give the person an out. Speak privately.

7. Make a decision. Being indecisive is perceived worse than making a wrong choice.

9. Know your strengths and build on those. Know your weaknesses and identify people for whom those are strengths. Bring them on your team.

10. 4

11. “… people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”

12. 5

14.

15. What can we do?

16. Mentor and Sponsor

17. Identify your unconscious bias

18. Jamieson J et al. Gender equality in emergency medicine: Ignorance isn’t bliss. Emergency Medicine Australasia 2016

19. “Nobody can make you feel inferior without your consent.”

20. #ILookLikeALeader