The Problem with Hospital Systems: Alex Psirides
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Alex Psirides discusses the problem with major hospitals and the systems that they use. Throughout he uses a case example to highlight how and why things go wrong. Moreover, he suggests potential strategies to reframe the way care is provided in the hospital system. As patients become more complex, the tribal systems we use to look after them remain stuck in the 18th Century. Back when the treatment for everything was amputation and, if you survived, leeches. The large modern hospital is becoming a battleground of competing specialises, only concerned with their area of expertise. This leads to multiple single organ teams practising their art in a multi-organ (failure) world. Many staff lack acute medical skills. Expertise is found far away from the ward in Emergency Departments, operating theatres, and ICUs. Despite disease not knowing or caring what time it is, all hospitals operate with minimal nocturnal on-site expertise. As nursing & medical staff move more towards rotating rosters where no-one knows more than a single-sentence summary of their patient’s complex physiological, pathological & pharmacological needs, an ever-present vigilant family member may become the only hope of surviving any acute admission. Compounding these issues is the medial education system that is not keeping up with what happens with patients. Advances in medical care and technology mean that patients who would have been cared for in the ICU 30 years ago are now being looked after on the wards by junior doctors with little training or experience in critical care. Unfortunately, junior doctors often call for help when it is too late. Join in to listen to a self-professed middle-aged intensivist rant about how things were so much better ‘back in the day.’ The Problem with Hospital Systems: Alex Psirides For more like this, head to our podcast page. #CodaPodcast
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How to Spot the Sick Child in the Emergency Department
Ffion Davies gives her take on how to spot the sick child in the Emergency Department.
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So, how does one spot the sick child amongst the droves of children who will present with fever and vomiting.
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How would you like a piece of plastic placed down your throat?
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So, how does one spot the sick child amongst the droves of children who will present with fever and vomiting.
In this talk, Ffion gives a lesson on how to spot the sick children in the ‘grey’ zone – those that are not clearly sick and not clearly well.
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Less knowledge, less experience and perhaps less confidence. Compounding this is the complexities of having to deal with the stressed parents when you yourself are stressed because of the situation.
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For more like this, head to our podcast page. #CodaPodcast
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Katrin Hruska discusses the usefulness of biomarkers in Emergency Medicine.
All biomarkers are awesome predictors of badness. Elevated hS-troponins after non-cardiac surgery or an acute exacerbation of COPD are associated with increased mortality.
In seemingly healthy people, elevated D-dimer levels are associated with increased mortality. Similarly, NT-proBNP levels predict mortality in patients with end-stage renal disease.
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If we assume that biomarkers are objectively measured, there is an overestimation of their individual importance.
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There is an ever-increasing number of patients seeking to rule out serious conditions by relying on biomarker testing to provide certainty.
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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
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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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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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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.
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Although she is young, Ema provides some salient points about what doctors and nurses do well and what they can do better.
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On top of that, a patient's experience of critical illness leaves them exhausted, in pain and unable to effectively communicate.
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Ema’s mother also provides insights into the experience of the family. The broad themes include the feelings of isolation, fear, and overwhelming concern.
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Similarly, ongoing communication regarding the tests, procedures, and treatments that are planned to be undertaken is highlighted as critical in eliciting the support and buy in of the family.
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Anand argues for the use of thrombolytics.
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The document discusses the history and controversies surrounding the concept of brain death. It notes that while brain death was formalized in the 1960s to facilitate organ donation, debates continue around defining the precise criteria. Specifically, opinions differ on whether brain death requires the irreversible loss of whole brain or just brainstem functions, and how to properly determine irreversibility through clinical examinations and ancillary tests. However, the document argues that the clinical diagnosis of brain death is robust when performed by skilled examiners, and that uniform international standards could help address some of the ongoing controversies.
Is Emergency Medicine a Failed Paradigm
Scott presents the argument that whilst Emergency Physicians are amazing, as it stands, Emergency Medicine is failing.
Scott presents the system as it should be.
This involves stabilising the critically ill before admission to the ICU, seeing sick patients in appropriate time and seeing the less sick patients as you can.
The issue as it stands, is when this system breaks down. He talks about the ‘boxes’ which now includes the ‘not sick at all’ patient. This leads to Emergency Physician’s not doing what they are trained to do.
Scott discusses the issues with the outcome measurements of Emergency Departments. Hospitals measure patient satisfaction and wait times.
Moreover, Scott argues that a trip to the ED should be the worst day in a patient’s life and measuring their satisfaction is misleading.
A good medical outcome should be the indication of success.
Scott also discusses the issue of Emergency Physicians not dealing with emergencies for most of their practice. This, in Scott’s eyes, leads to cognitive dissonance, where ED doctors are not doing what they are trained to do.
Simon argues that Emergency Medicine is not a failed paradigm. Emergency Physicians are trained to help people, when people feel that they need to be treated.
He claims that doctors in this speciality want to treat a wide variety of people across a wide spectrum of disease.
Evidently, Simon discusses a ‘revolution’ in Emergency Medicine. An increasing number of people are attending Emergency Departments across the world. The generalist approach of Emergency Medicine is critical in triaging, treating, and helping these people in their moment of need.
The skills, breadth of knowledge and wisdom and ability to work across a range of specialties and in uncertainty is what makes Emergency Medicine and the physicians who work in it special.
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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.
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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.
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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.
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There are times when this job can leave you heartbroken and love gets you through.
The Problem of Disproportionate Critical Care
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
Critical Care: No place for a woman?
This document discusses gender bias and challenges faced by women in critical care medicine. It notes that while the majority of critically ill patients are women, women make up a smaller percentage of ICU trainees, consultants, editorial boards, and faculty positions. Female speakers also represent a lower percentage than male speakers at some critical care conferences. The document suggests women face biases such as being seen as less competent or committed if they are mothers, or being hired and promoted based on past accomplishments rather than potential. It calls for addressing gender bias and advocating for critical care to be a welcoming field for women.
1455 wilson
Martin Smith
The management of severe traumatic brain injury (TBI) has undergone extensive revision following evidence that longstanding and established practices are not as efficacious or innocuous as previously believed. Very few specific interventions have been shown to improve outcome in large randomized controlled trials and, with the possible exception of avoidance of hypotension and hypoxaemia, most are based on observational studies or analysis of physiology and pathophysiology. Further, the substantial temporal and regional pathophysiological heterogeneity after TBI means that some interventions may be ineffective, unnecessary or even harmful in certain patients at certain times.
Improved understanding of pathophysiology and advances in neuromonitoring and imaging techniques have led to the introduction of more effective and individualised treatment strategies that have translated into improved outcomes for patients. In particular, the sole goal of identifying and treating intracranial hypertension has been superseded by a focus on the prevention of secondary brain insults using a systematic, stepwise approach to maintenance of adequate cerebral perfusion and oxygenation. As well as being used to guide treatment interventions, multimodal neuromonitoring also gives clinicians confidence to withhold potentially dangerous therapy in those with no evidence of brain ischemia/hypoxia or metabolic disturbance.
The days of blind adherence to generic physiological targets in the management of severe TBI have been replaced by an individualised approach to optimisation of physiology which has translated into improved outcomes for patients.
Mark Wilson
The New England Journal of Medicine has published a number of articles recently that demonstrate no benefit from classic neurotrauma interventions (ICP monitoring, cooling, decompression). This is because factors such as ICP and CPP are associated with bad outcome by association rather than causation. This debate will demonstrate that critical care just complicates things and it is high time for the randomised trial between the very best Neurocritical care and NOB therapy (Naso-pharyngeal, Oxygen and a Blanket).
A Revised Algorithm for PEA Cardiac Arrest: Haney Mallemat
Haney Mallemat discusses the treatment for PEA cardiac arrest.
Patients who present with pulseless electrical activity (PEA) arrest have a high mortality. The treatment of PEA requires finding and reversing the underlying cause; therefore a simple and rapid approach is required.
Traditionally we were taught to use the H’s and the T’s, but this diagnostic tool is cumbersome and of questionable utility overall.
Haney discusses the problems with the traditional H’s and T’s as well as focusing on newer approaches to PEA arrest. Haney makes the point that PEA is not a diagnosis, but a ‘waste basket term’ for a lot of possible diagnoses.
Rather than assisting a clinician in the assessment and treatment of a patient, it acts on to lead to pontification.
To that end, Haney wants us to do away with the H’s and T’s. The problem with the algorithm of diagnosing a PEA, as Haney explains, is the reliance on feeling a pulse. It lacks sensitivity and specificity, largely linked to using fingers.
They should not be used in resuscitation scenarios – as the guidelines say we should.
Haney makes the point that despite all the advances in medicine, resuscitation has stayed essentially the same for decades.
He describes two ways in which he thinks we can advance our care.
The first involves the QRS complex. Ask the question – is the QRS complex narrow or wide. Narrow (< 0.12 seconds) leads you to consider mechanical problems, such as tension pneumothorax or tamponade. If it is wide (> 0.12 seconds), then consider metabolic problems such as hypokalaemia.
If the QRS is narrow, and you are thinking a mechanical problem then there is electrical activity, and the heart is still beating underneath. The step should be to use ultrasound immediately to find the focused cause. If it is wide, and you are considering metabolic causes, this is more aligned with a true PEA. Calcium bicarbonate should be considered in the first instance.
Haney describes the limitations with the algorithm that includes the trauma patient or those with underlying cardiac conditions.
Next Haney describes a second algorithm - PREM (pulseless with rhythm and echo motion) and PRES (pulseless with a rhythm and echo standstill). The use of ultrasound is central to this pathway. In PREM the left ventricle is not strong enough to produce a pulse. Does this patient get adrenaline or chest compressions?
Haney discusses the options. In PRES there is electrical activity, but the heart is not squeezing. Maybe these people should get adrenaline and compressions!
The ECG should still play a part in this algorithm. Haney puts it all together for you and takes you through the algorithm he uses when faced with a patient with PEA.
He includes some tips for using the ultrasound probe during cardiac arrest resuscitation scenarios.
A Revised Algorithm for PEA Cardiac Arrest: Haney Mallemat
For more like this, head to our podcast page. #CodaPodcast
Anaesthetics in Bariatric Surgery: Ben Shippey
This document discusses issues related to bariatrics and obesity from an anesthesia perspective. It lists several attitudes, assessments, and actions that should be considered when treating obese patients, including cognitive biases that can affect treatment. Several studies and papers are referenced that relate to predicting and managing challenges of anesthesia for obese patients, such as difficult intubation and oxygenation. Key factors discussed include patient size, vital capacity, positioning, and predictive metrics.
Emergency Interventions: The use of Oxygen
Kathryn Maitland describes the challenges faced with oxygen therapy as an emergency intervention in critical illness in African children.
Where Kathryn works, in East Africa, there is no access to intensive care. Caring for critically ill children is all done in the Emergency Department.
70% of the global burden of disease and deaths from pneumonia occurs in Southeast Asia and Sub-Saharan Africa. The WHO has published guidelines as to what classifies as pneumonia, severe pneumonia, and very severe pneumonia.
These classifications rely on clinical signs. However, Kathryn in her research has discovered that these classifications are rarely correlated with the actual underlying disease process.
Clinical signs are non-specific for the diagnosis of pneumonia. Oxygen is recommended for severe and very severe pneumonia.
This has led to calls to prioritise oxygen delivery in African hospitals. However, it has not led to change from a health department or funding viewpoint.
There are also oxygen delivery practicalities to consider. Often there is only one source of oxygen on a ward (if at all) with patients clustered around it.
The production of Oxygen may only happen in a few places.
Poor cylinder quality leads to leaks and therefore, low supply.
Concentrators are useful however they need regular servicing. They also rely on power, and in a region that experiences regular power outages, this can be problematic. When the power goes off, there is no oxygen available.
Kathryn asks – do all children actually need oxygen? There is still however a hidden burden of hypoxia.
Outside of Africa, Kathryn discusses the current state of equipoise on oxygen therapy.
Moreover, oxygen can be harmful if given inappropriately. This leads to concerns more broadly on the harms of oxygen therapy.
Kathryn concludes her talk by looking to the future. She discusses ongoing research and the implications for future practice in resource poor settings, and indeed the world.
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.
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A Young Person's Experience of Critical Illness
Natalie May & Roisin McNamara discuss a young person’s experience of critical illness.
They are joined by Ema, an 11-year-old girl who had a scary time when she was diagnosed with tracheitis. Experiencing critical illness is scary for anyone. However, when you are a young person, this terrifying experience is amplified.
Natalie and Roisin tell us what we as clinicians can do or think about differently to provide a better patient experience.
Although she is young, Ema provides some salient points about what doctors and nurses do well and what they can do better.
The main take away boils down to clear communication. Medical professionals often think they are explaining things thoroughly. However, the words they use, and the speed of the delivery of those words, leaves a patient feeling confused and scared.
On top of that, a patient's experience of critical illness leaves them exhausted, in pain and unable to effectively communicate.
Bringing one’s awareness to this can assist when we are deciding how and when to discuss the ongoing treatment.
Ema’s mother also provides insights into the experience of the family. The broad themes include the feelings of isolation, fear, and overwhelming concern.
Encouragingly, there are simple things that clinicians can do to alleviate these feelings. Whilst the fear and concern for one’s young child will never abate, simply taking the time to listen to all worries and ensuring understanding can go a long way towards improving the experience for both the patient and their family.
Similarly, ongoing communication regarding the tests, procedures, and treatments that are planned to be undertaken is highlighted as critical in eliciting the support and buy in of the family.
Critical illness in a young person will never be easy for the patient or their families. Listen in to this discussion to discover how to make it more bearable.
For more like this, head to our podcast page. #CodaPodcast
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
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
Rethinking Adrenaline in Cardiac Arrest
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.
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ICU year in review - Paul Young and Flavia Machado
This tweet lists two Twitter accounts, @DogICUma and @FlaviaSepsis, that discuss critical care trials and sepsis. It suggests following these accounts to stay informed on recent important clinical research findings in critical care and sepsis.
Orford - iValidate: Improving End of Life Care in the ICU
Associate Professor Neil Orford is an intensive care specialist and Director of Intensive Care at University Hospital Geelong. Neil is the clinical lead for the i-Validate program. In this podcast he discusses this collaboration between Barwon Health and Deakin University which aims to improve patient-centred end-of-life care through training in clinical communication.
Controversies in Brain Death
The document discusses the history and controversies surrounding the concept of brain death. It notes that while brain death was formalized in the 1960s to facilitate organ donation, debates continue around defining the precise criteria. Specifically, opinions differ on whether brain death requires the irreversible loss of whole brain or just brainstem functions, and how to properly determine irreversibility through clinical examinations and ancillary tests. However, the document argues that the clinical diagnosis of brain death is robust when performed by skilled examiners, and that uniform international standards could help address some of the ongoing controversies.
Is Emergency Medicine a Failed Paradigm
Scott presents the argument that whilst Emergency Physicians are amazing, as it stands, Emergency Medicine is failing.
Scott presents the system as it should be.
This involves stabilising the critically ill before admission to the ICU, seeing sick patients in appropriate time and seeing the less sick patients as you can.
The issue as it stands, is when this system breaks down. He talks about the ‘boxes’ which now includes the ‘not sick at all’ patient. This leads to Emergency Physician’s not doing what they are trained to do.
Scott discusses the issues with the outcome measurements of Emergency Departments. Hospitals measure patient satisfaction and wait times.
Moreover, Scott argues that a trip to the ED should be the worst day in a patient’s life and measuring their satisfaction is misleading.
A good medical outcome should be the indication of success.
Scott also discusses the issue of Emergency Physicians not dealing with emergencies for most of their practice. This, in Scott’s eyes, leads to cognitive dissonance, where ED doctors are not doing what they are trained to do.
Simon argues that Emergency Medicine is not a failed paradigm. Emergency Physicians are trained to help people, when people feel that they need to be treated.
He claims that doctors in this speciality want to treat a wide variety of people across a wide spectrum of disease.
Evidently, Simon discusses a ‘revolution’ in Emergency Medicine. An increasing number of people are attending Emergency Departments across the world. The generalist approach of Emergency Medicine is critical in triaging, treating, and helping these people in their moment of need.
The skills, breadth of knowledge and wisdom and ability to work across a range of specialties and in uncertainty is what makes Emergency Medicine and the physicians who work in it special.
Join in the debate as Scott and Simon argue for and against the place of Emergency Medicine.
Finally, for more like this head to our podcast page. #CodaPodcast
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
The Role of Love in Critical Care Leadership: Liz Crowe
The Role of Love in Critical Care Leadership by Liz Crowe.
There are times when this job can leave you heartbroken and love gets you through.
The Problem of Disproportionate Critical Care
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
Critical Care: No place for a woman?
This document discusses gender bias and challenges faced by women in critical care medicine. It notes that while the majority of critically ill patients are women, women make up a smaller percentage of ICU trainees, consultants, editorial boards, and faculty positions. Female speakers also represent a lower percentage than male speakers at some critical care conferences. The document suggests women face biases such as being seen as less competent or committed if they are mothers, or being hired and promoted based on past accomplishments rather than potential. It calls for addressing gender bias and advocating for critical care to be a welcoming field for women.
1455 wilson
Martin Smith
The management of severe traumatic brain injury (TBI) has undergone extensive revision following evidence that longstanding and established practices are not as efficacious or innocuous as previously believed. Very few specific interventions have been shown to improve outcome in large randomized controlled trials and, with the possible exception of avoidance of hypotension and hypoxaemia, most are based on observational studies or analysis of physiology and pathophysiology. Further, the substantial temporal and regional pathophysiological heterogeneity after TBI means that some interventions may be ineffective, unnecessary or even harmful in certain patients at certain times.
Improved understanding of pathophysiology and advances in neuromonitoring and imaging techniques have led to the introduction of more effective and individualised treatment strategies that have translated into improved outcomes for patients. In particular, the sole goal of identifying and treating intracranial hypertension has been superseded by a focus on the prevention of secondary brain insults using a systematic, stepwise approach to maintenance of adequate cerebral perfusion and oxygenation. As well as being used to guide treatment interventions, multimodal neuromonitoring also gives clinicians confidence to withhold potentially dangerous therapy in those with no evidence of brain ischemia/hypoxia or metabolic disturbance.
The days of blind adherence to generic physiological targets in the management of severe TBI have been replaced by an individualised approach to optimisation of physiology which has translated into improved outcomes for patients.
Mark Wilson
The New England Journal of Medicine has published a number of articles recently that demonstrate no benefit from classic neurotrauma interventions (ICP monitoring, cooling, decompression). This is because factors such as ICP and CPP are associated with bad outcome by association rather than causation. This debate will demonstrate that critical care just complicates things and it is high time for the randomised trial between the very best Neurocritical care and NOB therapy (Naso-pharyngeal, Oxygen and a Blanket).
A Revised Algorithm for PEA Cardiac Arrest: Haney Mallemat
Haney Mallemat discusses the treatment for PEA cardiac arrest.
Patients who present with pulseless electrical activity (PEA) arrest have a high mortality. The treatment of PEA requires finding and reversing the underlying cause; therefore a simple and rapid approach is required.
Traditionally we were taught to use the H’s and the T’s, but this diagnostic tool is cumbersome and of questionable utility overall.
Haney discusses the problems with the traditional H’s and T’s as well as focusing on newer approaches to PEA arrest. Haney makes the point that PEA is not a diagnosis, but a ‘waste basket term’ for a lot of possible diagnoses.
Rather than assisting a clinician in the assessment and treatment of a patient, it acts on to lead to pontification.
To that end, Haney wants us to do away with the H’s and T’s. The problem with the algorithm of diagnosing a PEA, as Haney explains, is the reliance on feeling a pulse. It lacks sensitivity and specificity, largely linked to using fingers.
They should not be used in resuscitation scenarios – as the guidelines say we should.
Haney makes the point that despite all the advances in medicine, resuscitation has stayed essentially the same for decades.
He describes two ways in which he thinks we can advance our care.
The first involves the QRS complex. Ask the question – is the QRS complex narrow or wide. Narrow (< 0.12 seconds) leads you to consider mechanical problems, such as tension pneumothorax or tamponade. If it is wide (> 0.12 seconds), then consider metabolic problems such as hypokalaemia.
If the QRS is narrow, and you are thinking a mechanical problem then there is electrical activity, and the heart is still beating underneath. The step should be to use ultrasound immediately to find the focused cause. If it is wide, and you are considering metabolic causes, this is more aligned with a true PEA. Calcium bicarbonate should be considered in the first instance.
Haney describes the limitations with the algorithm that includes the trauma patient or those with underlying cardiac conditions.
Next Haney describes a second algorithm - PREM (pulseless with rhythm and echo motion) and PRES (pulseless with a rhythm and echo standstill). The use of ultrasound is central to this pathway. In PREM the left ventricle is not strong enough to produce a pulse. Does this patient get adrenaline or chest compressions?
Haney discusses the options. In PRES there is electrical activity, but the heart is not squeezing. Maybe these people should get adrenaline and compressions!
The ECG should still play a part in this algorithm. Haney puts it all together for you and takes you through the algorithm he uses when faced with a patient with PEA.
He includes some tips for using the ultrasound probe during cardiac arrest resuscitation scenarios.
A Revised Algorithm for PEA Cardiac Arrest: Haney Mallemat
For more like this, head to our podcast page. #CodaPodcast
Anaesthetics in Bariatric Surgery: Ben Shippey
This document discusses issues related to bariatrics and obesity from an anesthesia perspective. It lists several attitudes, assessments, and actions that should be considered when treating obese patients, including cognitive biases that can affect treatment. Several studies and papers are referenced that relate to predicting and managing challenges of anesthesia for obese patients, such as difficult intubation and oxygenation. Key factors discussed include patient size, vital capacity, positioning, and predictive metrics.
Emergency Interventions: The use of Oxygen
Kathryn Maitland describes the challenges faced with oxygen therapy as an emergency intervention in critical illness in African children.
Where Kathryn works, in East Africa, there is no access to intensive care. Caring for critically ill children is all done in the Emergency Department.
70% of the global burden of disease and deaths from pneumonia occurs in Southeast Asia and Sub-Saharan Africa. The WHO has published guidelines as to what classifies as pneumonia, severe pneumonia, and very severe pneumonia.
These classifications rely on clinical signs. However, Kathryn in her research has discovered that these classifications are rarely correlated with the actual underlying disease process.
Clinical signs are non-specific for the diagnosis of pneumonia. Oxygen is recommended for severe and very severe pneumonia.
This has led to calls to prioritise oxygen delivery in African hospitals. However, it has not led to change from a health department or funding viewpoint.
There are also oxygen delivery practicalities to consider. Often there is only one source of oxygen on a ward (if at all) with patients clustered around it.
The production of Oxygen may only happen in a few places.
Poor cylinder quality leads to leaks and therefore, low supply.
Concentrators are useful however they need regular servicing. They also rely on power, and in a region that experiences regular power outages, this can be problematic. When the power goes off, there is no oxygen available.
Kathryn asks – do all children actually need oxygen? There is still however a hidden burden of hypoxia.
Outside of Africa, Kathryn discusses the current state of equipoise on oxygen therapy.
Moreover, oxygen can be harmful if given inappropriately. This leads to concerns more broadly on the harms of oxygen therapy.
Kathryn concludes her talk by looking to the future. She discusses ongoing research and the implications for future practice in resource poor settings, and indeed the world.
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- 1. YOUR HOSPITAL IS @psirides Thu June 16th
- 4. WATERBOARDING THE CRITICALLY ILL
- 5. When all you have is a hammer Everything you see is a nail.
- 7. “Hospitals are horrible places, like prisons. When you go to prison you’re given a number. Your clothes are taken away & you’re made to wear a uniform. Then you’re put in a confined space, not allowed to leave & have to obey orders. Finally you’re subjected to a rectal exam. What’s the difference?” Henry Marsh
- 9. Hospitals systems developed in the 17th century are completely inappropriate for 21st century clinical practice
- 10. SOD VS MOD
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- 15. “There’s no such thing as the ‘surgical’ patient; there is only a medical patient with a scar” Rinaldo Bellomo
- 16. Why do hospital systems only make staff call for help when the patient is already dead?
- 17. M E T
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- 21. How People Die Murray et al, BMJ 2008
- 22. METDECISIONTREE
- 23. 1 in 3 will have treatment limited by the MET 1 in 4 will die during this hospital admission 1 in 5 will be admitted to a critical care area
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