Simon Carley - Are You as Good as You Think?
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Are You as Good as You Think? Simon Carley has us asking ourselves some confronting questions about our abilities in his SMACC Chicago talk ‘Are You as Good as You Think?’. Carley has us delve into our confidence, competencies and whats makes for a good self learning environment. Initially Carley asks us how good we think we are at driving? He then sites studies of Australian and European driver responses, of which 93% of Aussies and 69% europeans rated themselves as above average drivers. Carley uses this example to suggests that, as individuals we are not particlarly good at rating ourselves, and inexperienced people tend to rate themselves more highly than experienced one - Illusory Superiority Cognitive Bias. Carley asks since you can’t have awesome without average... How do we measure ourselves?. He offers us the following tools and processes to establish better self learning and teaching processes, such as; Reflection Diaries - revisit it (clinically and physically), follow up. Peer reviews: 1:1 feedback doesn’t work. It needs to planned with clear goals and objectives such as; Clarify expectations review logistics focus lens plan feedback observe event (i.e teaching) debrief and action Clinical Feedback Follow up - not just the exceptionally sick patients, but follow up with the routine ones. Build Peer Reviews into your practice. Carley finishes by asking us to choose on of the items below and commit ourselves to making happen within the month. I am going to … Organise Trainee Feedback Focused 360 Assessment Keep a Patient/Teaching Diary Be Peer Reviewed Reflect Develop Team Feedback Follow up with Patients Something Else Nothing I am already Awesome! What have you committed too?
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Firstly, Adrian shares an anecdote regarding how the initiative begun. He sent a letter to the CEO of a hospital appreciating one of the doctors who treated him for cancer. The doctor unfortunately never received it. This caused Adrian to ask - is appreciation and gratitude undervalued?
Evidently, noticing excellence will lead to two things: learning new insights and increasing staff morale.
Adrian raises the question, why we do we not focus on the good things? We spend all our time improving safety and quality even though accidents and disasters are only a small percentage of what we do.
Moreover, Adrian claims that people inherently have negative biases. This is evident in healthcare, so how can we combat this?
The solution is to focus on excellent care. This led to the formation of a reporting system called Learning from Excellence (LfE), where people answer two questions: Who did something excellent? What did they do?
LfE is a formal system for reporting and providing positive feedback and appreciation to the healthcare workers. It is a beneficial and constructive way of learning from excellence.
Finally, Adrian explains, “Saying ‘thank you’ or ‘well done’ is the easiest quality improvement intervention of all.”
Learning from excellence in critical care by Adrian Plunkett
For more like this head to our podcast page. #CodaPodcast
Pellegrino - ECMO CPR - Getting it Right
Associate Professor Vincent Pellegrino is a Senior Intensive Care Specialist at The Alfred Hospital and head of the ECMO Clinical Service. He has had a lead role in the development of ECMO services at The Alfred since 2003. From the ECMO CPR ICN Victoria meeting he discusses how to get patient selection and outcomes right for eCPR.
Tom Bleck - Subarachnoid Hemorrhage: What Matters?
Tom Bleck - Subarachnoid haemorrhage: what matters?
Tom Bleck gives an overview of the pertinent facts regarding the complications and management of aneurysmal subarachnoid haemorrhage (SAH).
The complications of aneurysmal SAH can be divided into immediate, early and late. The risk of re-bleeding is maximal on the first day, it is fatal in 75% of patients and the best management is to secure the aneurysm by coiling or clipping. Blood pressure control is utilised widely but parameters are arbitrary and the data is scarce.
Early complications (days 1 - 3) include early brain injury in its various forms, stress cardiomyopathy, neurogenic pulmonary oedema and cerebral salt wasting. The most important late complication (day 4 onwards) is vasospasm.
Tom briefly discusses the mechanisms and manifestations of SAH-associated brain injury including ischaemia, blood brain barrier breakdown, sustained depolarisation, hydrocephalus, vasospasm, seizures, hyperglycaemia and fever. He goes on to discuss in more detail the management of vasospasm, the associated evidence and the importance of distinguishing between clinically detectable and subclinical vasospasm.
The Uncertainty of Medical Evidence in Critical Care: Jeff Drazen
Jeff Drazen delivers a powerful message on the use of medical evidence in critical care. Medicine is powered by knowledge, but how do we know what is true and what is not? How do we deal with uncertainty in a setting where outcomes are not closely related to known variables?
For example, although there are a few people who have survived jumping or falling from an airplane at high altitude, it is a rare event. Thus, a test to determine how to prevent death from such a disaster would only take a small number of participants to see if a particular method works.
In contrast, when considering a medical condition where a large fraction of people might seemingly “recover” without treatment, such as tuberculosis, how does one determine if a treatment is effective?
In this talk Jeff discusses the trials surrounding blood glucose control in the Intensive Care Unit (ICU). The way we have dealt with increased blood sugar levels in critical care has changed over time. Whereas once upon a time there was little thought given to high blood sugar levels, this changed in the 90s.
One single centre paper was the catalyst for a move toward tighter glucose control for patients in ICU. Due to the novel question and well-designed study, this paper was published in a prestigious journal – even if there were questions surrounding its validity.
Larger, multi-centred papers were not published until many years later due to normal logistical and financial constraints. In the interim, the initial data had informed policy. Therein lies the problem.
Join Jeff as he highlights the benefits and potential pitfalls in medical research by telling the story of tight blood glucose control in the ICU.
For more like this, head to our podcast page. #CodaPodcast
Ashley Shreves - How to Diagnose Dying
A patient's death maybe certain but the timing isn’t.
Ashley Shreves discusses the difficult subject of dying and how best to understand and help diagnose when the battle is lost.
Shreves explores the correlating patterns present in the functional decline in end of life patients, with particular reference to the type of disease a patient is suffering from. Understanding these patterns is paramount to understanding the care and medical intervention require, at certain points of a patients disease lifecycle.
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.
Rob Mac Sweeney vs Paul Marik - Predicting Fluid Responsiveness is a Waste of...
Rob Mac Sweeney and Paul Marik battle it out at SMACCForce in Chicago. Pro and Con is Predicting Fluid Responsiveness a waste of time?
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.
When to Transfuse in Acute Brain Injury: Oli Flower & Simon Finfer
Simon Finfer argues that the transfusion threshold should be 70 g/L. Simon first raises the Choosing Wisely Guidelines for Critical Care.
These state that one should not transfuse red blood cells in haemodynamically stable patients with a haemoglobin concentration of greater than 70g/L.
He continues to discuss the application of this specifically to patients with an acute brain injury. In doing so he will talk about evidence generally and how one must approach the use of evidence in specific patient subgroups.
Simon continues by raising further research to justify his position.
Oli Flower on the other hand will take the position that the transfusion trigger should be 90g/L. He makes the point that this is the easy position to take. Essentially, he is just explaining why the critical care community does what it does!
As Oli explains, haemoglobin plays a pivotal role in providing oxygen to tissue. In the case of a brain injury, to prevent further injury, one must ensure continued supply of oxygen to said tissue.
Oli will lean on animal studies, human studies as well as trial data to support his position. The transfusion trigger is remarkable heterogeneous around the world and even within individual institutions and this drives critical care professionals mad.
So surely there must be a “right” number. Unfortunately, there is not, which is where understanding all the relevant aspects to the argument becomes important.
Join Oli and Simon as they debate on this important issue.
When to Transfuse in Acute Brain Injury: Oli Flower & Simon Finfer
For more like this, head to our podcast page. #CodaPodcast
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.
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
Andrew Naidech - Intracerebral Hemorrhage: Down, Not Out
Intracerebral hemorrhage (ICH) can lead to disability and complications that drive patients away from neurology. While some patients may have a "good outcome" of modified Rankin scale score of 3 or less, their applied cognition and physical function may be impaired in different ways. New strategies are being developed and tested to minimize hematoma growth, evacuate blood clots, prevent complications, and better assess outcomes in order to improve prognosis for patients with ICH.
Mike Winters - Don’t Forget A and B!
Don't Forget A & B!
Over 500,000 patients per year suffer sudden cardiac arrest. Despite advances in our understanding and management of cardiac arrest, less than 15% of patients survive to hospital discharge with meaningful neurologic survival. In recent years, the focus of cardiac arrest resuscitation has been the delivery of high-quality chest compressions and early defibrillation for those with a shockable rhythm. As a result, airway interventions and ventilation now follow attempts to optimize circulation in cardiac arrest patients. Though high-quality CPR and early defibrillation are essential in the initial stages of resuscitation, advanced airway placement and appropriate ventilation are critical to overall patient survival.
Dr. Winters' discusses the current literature on the timing of advanced airway placement, oxygenation, and ventilation for the cardiac arrest patient. In addition, he discusses optimal targets for oxygenation and ventilation in the patient with return of spontaneous circulation from sudden cardiac arrest.
10 Things you Need to Know about TBI by Knight
This document discusses traumatic brain injury (TBI) and strategies for treatment. It provides the following key points:
1. TBI is a major public health problem in the US, resulting in over 50,000 deaths, 100,000 hospitalizations, and 1.1 million emergency department visits annually.
2. Secondary injury after initial TBI can lead to further brain damage through various pathological mechanisms like excitotoxicity, inflammation, and apoptosis.
3. There are established and emerging pharmacological strategies to reverse the effects of drugs that may exacerbate bleeding after TBI, like aspirin, Plavix, warfarin, and newer oral anticoagulants, but more research is still needed
Meditation Performance and Critical Care: Scott Weingart
The document discusses the results of a study on the impact of COVID-19 lockdowns on air pollution. Researchers found that lockdowns led to significant short-term reductions in nitrogen dioxide and fine particulate matter pollution globally as economic activities slowed. However, the impacts on greenhouse gases and long-term air quality improvements remain uncertain without permanent behavior and economic changes.
Forgotten Cardiovascular Physiology by Myburgh
The human circulation is a complex system that has evolved over millenia, primarily designed to promptly respond to conditions of stress - the fight and flight response. The traditional physiological approach focuses on the heart as a pump, adapting to changes in volume and metabolic states.
These principles are underpinned by the Starling equation and incorporated into an adaptation of Ohm\'s law. These principles have been maladapted, punctuated by an increasing reliance on surrogate and derived variables that have little to do with teleological haemodyanamic responses. Insights into the central role of the autonomic nervous system are provided by Guytonian theory that in part explain the physiological fallacy germane to many clinical protocols and practices. These fallacies have been amplified by commercial studies directed at short-term physiological improvements that have little to do with patient-centred outcomes in the medium and longer term. Such effects have been demonstrated in recent high-quality RCTs that force a re-appraisal of seductive short-term physiologically-based gratification.
Goodbye GCS! - Mark Wilson
Goodbye GCS!
Summary by: Mark Wilson
Consciousness comprises “wakefulness” (that’s the brain stem, opening your eyes component) and “content” (that’s the supratentorial, thinking, “someone’s home” component). You can have wakefulness without content (e.g. persistent vegetative state) but not content without wakefulness.
Describing a “level” of consciousness, converting this multifaceted human brain ability into a linear scale was possibly the biggest neuroscience break through of the 20th Century. The 1974 Lancet paper in which Brian Jennet and Sir Graham Teasdale proposed the Glasgow Coma Scale (GCS) is certainly the most cited neuroscience paper. We had even put a man on the moon before this had been created. It’s relative simplicity and repeatability meant GCS was rapidly taken up across the world. Now 40 years on, is it out of date?
There are problems with the GCS – it doesn’t include pupil response, it doesn’t look at ventilation or other autonomic functions hence other systems such as the 4 score system have been proposed. But these take longer, and are poorly known so cannot be used like GCS to rapidly convey in a meaningful way the level of consciousness of a patient between clinicians.
In this talk Mark Wilson goes through the history of the GCS and other conscious measures… is it time to say Goodbye to GCS?
Remote Ischaemic Conditioning and Critical Care
Remote Ischaemic Conditioning and Critical Care by Paul Young. Paul delves into the pitfalls of clinical research. Coda Podcasts.
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When to Transfuse in Acute Brain Injury: Oli Flower & Simon Finfer
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Andrew Naidech - Intracerebral Hemorrhage: Down, Not Out
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Similar to Simon Carley - Are You as Good as You Think?
Samples Of Reflective Essay
This document discusses reflective practice in nursing. It defines reflective practice as critically analyzing experiences to further professional development. Reflection models help nurses learn from practice. The document also discusses how getting personally involved with patients can hinder care by interfering with accurately understanding their experiences. It notes the importance of detachment to avoid stress from patient suffering. The reflection concludes that having more experience with different patients provides insight into how to avoid personal involvement that could cloud judgment.
Normality Cwl
The document discusses various topics related to assessing mental health, including:
1. The three main types of psychological assessment are clinical interviews, behavioral observations, and psychological testing.
2. Clinical interviews involve structured questioning to understand a person's mental health history and current state. Behavioral observations provide information on how a person acts in natural environments. Psychological testing uses standardized measures to evaluate areas like personality and intelligence.
3. Classification systems like the DSM-IV-TR provide standardized criteria for diagnosing mental illnesses based on patterns of symptoms. A diagnosis involves evaluating a person across five axes of information.
Critical thinking
This document provides an overview of critical thinking and the nursing process. It defines critical thinking as an organized cognitive process used to carefully examine one's own and others' thinking. Critical thinking aims to make evidence-based judgments rather than rely on assumptions. The nursing process involves assessing clients, diagnosing actual or potential health problems, planning and implementing interventions, and evaluating outcomes. Effective use of critical thinking and the nursing process requires gathering and analyzing client data, considering various options, and making well-reasoned clinical decisions.
Neurodevelopmental Treatment and Cerebral Palsy- Research
An alternative description of my Critically Appraised Topic on Neurodevelopmental treatment when used on children with cerebral palsy. This presentation focuses more on the process of the research.
There's more than meets the eye to motivation
This document discusses self-determination theory (SDT) and regulatory focus theory (RFT) as they relate to coaching. It summarizes key concepts from each theory, including:
- SDT posits three innate psychological needs (autonomy, competence, relatedness) and that autonomy supportive contexts nurture intrinsic motivation versus controlling contexts undermining it.
- RFT distinguishes between promotion and prevention focus, where individuals are motivated to achieve goals (promotion) or avoid failures (prevention) and matching feedback to one's focus increases motivation.
The document then describes studies on:
- Autonomy supportive coaching increasing needs satisfaction and motivation more than controlling coaching.
- Framing feedback to match one
Psychological Assessment Tools
Clinical interviews and psychological tests are important tools used by psychologists to assess patients. The clinical interview involves a conversation between psychologist and patient to diagnose issues and plan treatment, and can be structured or unstructured. Common psychological tests include intelligence tests like WAIS and WISC, personality tests like MMPI and Rorschach, and achievement and aptitude tests. Psychological assessment also involves behavioral observation, mental status exams, and collecting demographic and medical history information.
Wdms
This document summarizes key concepts related to mindfulness for physicians. It discusses mindfulness as non-elaborative awareness of current experience with curiosity and acceptance. Mindfulness can cultivate exquisite empathy and self-awareness while holding contradictory truths. It addresses burnout rates among physicians and residents and how mindfulness can promote well-being, quality of care, and quality of caring. Formal and informal mindfulness practices are presented that can be used in clinical settings. Reflective questioning is encouraged to promote openness and honesty in interactions with patients and colleagues. Patients have noted improved communication and satisfaction when physicians practiced mindfulness.
Mental Health Unit Intro
This document provides an overview and expectations for a mental health nursing unit. It consists of 3 units - mental health, obstetrics, and pediatrics. Students must achieve a passing grade of 76% and instructors will determine theory and clinical grades. The document outlines expectations for students including keeping an open mind, eliminating biases, developing trusting relationships with clients, and maintaining professional boundaries. The instructor's philosophy emphasizes therapeutic communication skills, assisting clients with mental health problems, and allowing students choice in their learning.
Teach chap. 1 - intro - w 11
The document summarizes key concepts in psychology research methods. It defines psychology as the scientific study of behavior and mental processes. The four main goals of psychology are described as description, control, understanding, and prediction. Scientific methods like the scientific method, hypotheses, theories, experiments with variables, groups, and blinds are explained. Other research methods like clinical studies, naturalistic observation, and surveys are also outlined. Different types of populations studied like case studies, longitudinal studies, and cross-sectional studies are defined.
Chnaging trends in Medical Education Oct 23.pptx
Teaching : Latest concepts in medical education
how best to optimize medical education
new trends in undergraduate and post graduate teaching in pediatrics
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This document discusses the importance of experiential and reflective learning for primary care physicians. It describes Kolb's experiential learning cycle and different levels of reflection. It also discusses portfolio-based learning and provides examples of content to include, such as learning logs, reflections on patient cases and educational events. The document provides guidance on identifying learning needs through methods like PUNs and DENs (patient unmet needs and doctor's educational needs), audits, and significant event analysis. Finally, it discusses how to develop a personal development plan to address identified learning needs through various learning activities and resources.
Abnormal Psych Pwrpt. ch03
Clinical assessment involves collecting information to determine how and why a person is behaving abnormally and how they can be helped. Clinicians use clinical interviews, tests, and observations as assessment tools, which must be standardized, reliable, and valid. The DSM-IV-TR is commonly used for diagnosis and describes diagnostic criteria across five axes. Treatment decisions are based on assessment and diagnosis information, with the goal of empirically supported and evidence-based therapies. Research shows that therapy is generally more effective than no treatment, though some therapies may be more effective than others for specific problems.
Fap5 lecture ch03
Clinical assessment involves collecting information to determine how and why a person is behaving abnormally and how they can be helped. Clinicians use clinical interviews, tests, and observations as assessment tools, which must be standardized, reliable, and valid. The DSM-IV-TR is commonly used for diagnosis and describes diagnostic criteria across five axes. Treatment decisions are informed by assessment and diagnosis, with the goal of empirically supported and evidence-based interventions. Research shows that therapy is generally more effective than no treatment, and that specific therapies can effectively treat particular disorders.
Families: Courage - Resilience - Transformation
OBJECTIVES:
If I were starting an adolescent treatment center what would I want to make sure adolescents and families learn?
Identify and Describe How Families Arrive at your door.
To Demonstrate the Power of Family Mapping and the Art and Science of Portraiture.
Clinical and Reverse Interventions - what are these and how to do?
Share Standard Vocabulary Families need to know Family Change Agreements - What are these - when to use?
critical thinking in nursing process.ppt
Critical Thinking is a complex process and new topic included for novice nurses. i hope this presentation will enhance and be helpful in understanding critical thinking
Critical Thinking
Critical thinking is an essential skill for nurses that involves systematic reasoning to analyze problems, develop solutions, and make careful decisions. It requires gathering information, considering different perspectives, anticipating needs, and reflecting on the implications and consequences of decisions. Developing critical thinking involves life-long learning, open-mindedness, integrity, and recognizing one's own biases. The T.H.I.N.K. model incorporates critical thinking into the nursing process by promoting total recall, habit formation, inquiry, creativity, and self-awareness when evaluating patients.
rolesofthern-140604011857-phpavhpp01.pdf
The roles of the nurse are varied and include coordinator, communicator, teacher, counselor, manager, leader, team player, motivator, delegator, critical thinker, innovator, researcher, and advocate. As a coordinator, the nurse plans and coordinates patient care. As a teacher, the nurse educates patients to develop self-care abilities. In the manager role, the nurse plans, organizes, directs, controls, and delegates tasks. As a leader, the nurse has a vision to energize others and encourages them to achieve goals. The nurse fulfills these diverse roles by understanding each role and continually improving skills.
Critical care class
This document discusses critical thinking in nursing. It defines critical thinking as the ability to think systematically and logically while questioning assumptions. Critical thinking involves gathering data, focusing on key issues, organizing information, analyzing situations, generating potential solutions, integrating different perspectives, and evaluating outcomes. The document provides examples of how critical thinking is used in nursing diagnosis, planning, implementation, and clinical decision making. It emphasizes the importance of critical thinking for safe nursing practice.
Techniques of Supervision
This document discusses frameworks and models for clinical supervision in healthcare. It describes Proctor's 1987 model of normative, restorative, and formative supervision. Heron's 1989 model includes authoritative and facilitative supervision interventions. Powell's 1993 model includes administrative, evaluative, clinical and supportive components. The document also discusses evidence that effective supervision improves patient outcomes, is most impactful for less experienced trainees, and depends most on the quality of the supervisor-supervisee relationship. Characteristics of effective supervisors include being empathetic, supportive, flexible and focused, while ineffective supervisors are rigid, lack empathy and support, and emphasize weaknesses.
Self Care Training Prepared by Antar T. Bush, LSW
This document summarizes a training for navigators at the Philadelphia Department of Public Health AIDS Activities Coordinating Office CLUB 1509 Program. The training covered the importance of self-care and supervision to prevent compassion fatigue. It discussed how lack of self-care and proper supervision can lead to negative consequences like negligence, malpractice, and boundary violations. The training provided strategies for developing a self-care plan, creating a support system, and maintaining work-life balance.
Similar to Simon Carley - Are You as Good as You Think? (20)
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Neurodevelopmental Treatment and Cerebral Palsy- Research
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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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The Electrocardiogram - Physiologic Principles
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
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1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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Simon Carley - Are You as Good as You Think?
- 1. Are you as good as you think?
- 2. Are you as good as you think?
- 3. Are you as good as you think? Is it?
- 4. Are you as good as you think?
- 5. Are you a better than average driver?
- 6. 93% of Americans 69% of Swedes Svenson 1981 Acta Psychologica
- 13. Influential
- 16. activity
- 20. knowledge of subject communication skills enthusiasm
- 23. feedback
- 27. Passive
- 28. Active
- 29. Tools
- 31. peer review
- 32. Peer review
- 33. Do it
- 34. I'm great
- 35. I'm great
- 39. bedside teaching procedures out patient clinics lectures small groups
- 40. bedside teaching procedures out patient clinics lectures small groups
- 41. Feedback in Emergency Medicine clinical feedback
- 43. One more thing
- 45. I will
- 46. thank you
- 47. trained teachers high volume teachers younger
- 48. do a personal reflection keep a diary follow up my patients or students be observed or peer reviewed observe/peer review someone else develop a team feedback system in my department take part in a 360 do something else I’m not going to bother because I know I’m awesome
- 51. knowledge of subject communication skills enthusiasm
- 52. Good stuff Not so good
- 53. Good stuff Easy Effortless Comes to you Trackable Interhospital comparisons Not so good
- 54. Good stuff Easy Effortless Comes to you Trackable Interhospital comparisons Not so good Vague Small speciality problems Groupings sometime unclear Often targeted reviews Fidelity low
- 56. • Passive feedback • happy sheets • departmental assessments • National training surveys • quality framework • deanery reports • ARCP outcomes?
- 58. Trainer Dept.vs
- 62. All trainees Ranking Approachability Empathy Knowledge Supervision Formal teaching Setting Feedback
- 63. All trainees Ranking Approachability Empathy Knowledge Supervision Formal teaching Setting Feedback Not you……
- 67. are you a good educator? how do you know? what are you going to do next?
- 68. –Quotes I made up to try and sound clever “we are all learners”