Coda Change

SMACCForce: Two Minute Remote Rant Everest by Sanjeeb Bhandari

All healthcare professionals should have a strong sense of situational awareness. Particularly in uncertain and unpredictable prehospital environments, situational awareness is an important skill to master. As we know, things can go south in an instant. So, what is situational awareness? Isn't it just about paying attention? According to Mike Lauria, it is about much more than that. Situational awareness is a complex, cognitive process which involves perceiving the environment, comprehending the situation and taking steps to avoid error. If you look at every major disaster in history, a loss of situational awareness is one of the top causative factors. In the prehospital space, we need to develop ways in which we can teach our colleagues and trainees about how to be acutely aware of their external environment and what is happening around them. Mike suggests that there should be someone focused on local situational awareness and global situational awareness. Local awareness involves focusing 100% on the critical task at hand. Then, other team members should be focused on global situational awareness. This could involve scanning the other areas of the patient, looking at the monitors, looking out for teammates and observing the surrounding environment. In this talk, Mike Lauria talks us through how to build active systems of awareness and how to turn these systems into habits. He describes how to build a system of awareness and how to turn this behaviour into a habit. To do this, we must start with a cue, have a specific action sequence and provide a variable reward. Finally, we must repeat, repeat, repeat until the process becomes a habit. Tune into a talk from DAS SMACC on Situational awareness in Resuscitation and Repetitive Practice.

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SMACCForce: LIVE EMS Nation Podcast - "Feeding the Flame" by Faizan Arshad, Raed Arafat, Lamhaut and Anne Creaton

Acts of violence against paramedics is disgraceful but not doing anything about it is much worse. From DAS SMACC, Craig Wylie speaks to us about violence against paramedics in South Africa. In the four years leading up to this talk in 2017, there were 250 attacks against paramedics. In a neighbourhood where there can be up to 100 gunshots in three hours, this almost shouldn't be surprising. Craig tells a story where he was called out to an emergency where his colleagues were under attack. His first thought? Why didn't they get a police escort? But in a low to middle income country, it is rarely that straightforward. Where there is a high crime rate and may only be two police vehicles on duty, it isn't always as easy as waiting for a police escort. Additionally, if paramedics had to rely on police attending their emergencies, is this just introducing another barrier to care? Craig asks three simple questions: 1. Has our management failed our staff members? 2. Have we done enough that the paramedics that we employ can protect themselves? 3. Have we as an EMS system entirely lost the plot towards our paramedics and how we respond to patient emergencies? The solution? Craig suggests it is all in the training. Paramedics need to be trained to understand the situations, to have a strong action plan, to have an exit plan and to involve community leaders. The team need to be trained to understand how to protect themselves so that they can provide care, whilst also looking out for themselves. Tune into a talk from DAS SMACC on Violence against healthcare workers - Paramedics under siege.

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Communication is something that we all do every day. Communication in healthcare however, isn't the same as communicating in other areas of our lives. The nature of what we talk about is difficult, particularly when we are delivering bad news. This is amplified even further when communicating with children in medicine. How do we make their experience as enjoyable as possible, whilst communicating effectively with their families? One such way is to acknowledge the role of culture in communication. Culture underpins the way in which we give and receive information in all circumstances. It informs the way we think about things and in many cases, our reactions. We could provide two families with exactly the same diagnosis and information but they could respond in completely different ways. Families will react to information within the cultural framework for which they operate. We may perceive a sprained ankle as a minor injury, however for one family it could mean an inability to participate in sports which is a crucial element of their day to day lives. As healthcare practitioners, we should acknowledge that we won't change people's way of thinking by arguing with them. We need to recognise the role that culture is playing, be humble, be understanding and be flexible. Furthermore, studies show that children often understand more than we anticipate. So, it is our job to ensure that we are communicating in the best way possible. Natalie's advice? Be prepared, manage expectations and provide explanation. From DAS SMACC, Natalie May shares her tips for good communication skills in healthcare.

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From DAS SMACC, Charles Larson and Andrew Beck discuss intubating sick kids - small holes, big problems. When intubating a critically ill child we fear that they are going to arrest on induction and we consider the skill required to intubate in difficult circumstances. The most important thing to remember is that we will never be so good that we won't make mistakes. The greatest critical care physicians are those that have good skills but that are also able to identify what might go wrong. Understanding the risks and having a plan for when something goes wrong is crucial. Managing critically ill children is a difficult task. We must understand their physiology, have a plan for induction and have a plan for if things go wrong. Importantly, we need to consider that it takes several minutes for drugs to kick in for children. What matters more than what drug you give is how you give it. Children don't follow recipes so nor should you. Furthermore, some golden rules in managing airways in children: 1. Simulation and training is key: We don't want to be educating ourselves on our patients, particularly in rare scenarios. 2. We must know our equipment, know our limits and know our support systems. Being able to call down help early is priceless. 3. Assess, plan and communicate with the team. 4. Don't repeat without change. Trying to put the same size tube down the same size hole will always lead to problems. 5. Training needs to be ongoing and skills need to be revisited. Confidence does not always equal competence. Charles Larson and Andrew Beck share stories of Paediatric intubation in high pressure scenarios.

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SMACCForce: Silver Care - Panel by Conor Deasy, Gregor Prosen, Mark Wilson, Raed Arafat, Cheryl Cameron

Matt Morgan describes critical care physiology through history. Matt's story begins in Copenhagen, 1952, when an 11-year-old girl in developed acute and severe polio. The last iron lung had been used. So, a young anaesthetist, Bjørn Ibsen, organised a tracheostomy and positive pressure ventilation (PPV) and changed the world. From that point we have discovered and understood the physiology of traumatic brain injury, mechanics of PPV, HFOV, APRV and echo to name a few. However, Matt contends that this story was not the beginning of our understanding of physiology. Matt will take you back through time to show how giraffes, dogs, fish and even frogs can teach us about physiology. Giraffes can tell us about the delivery of CPP. They utilise massive mean arterial pressures and a complex system of venous valves. The MAP is achieved through massive left ventricular hypertrophy – a completely normal finding in giraffes. High frequency oscillatory ventilation was first used in the 1970s… however, dogs have been doing this for 100s of 1000s of years ago. Airway pressure release ventilation was described in the late 1980s… again this is not new. Frogs and lizards have been using this method for millennia. Finally, Matt tells us about ice fish – who live 1.5 kilometres under the Antarctic Ocean surface. The ice fish CAN transcribe haemoglobin; however, it does not bother. All its oxygen is provided by dissolved oxygen in its harsh environment. Matt will pin his tale of historical physiology on the events around one of his patients – Nathan – who suffered a TBI. During delivering Nathan's treatment, Matt relies on all these animal lessons. Matt wants you to remember these animals when thinking about physiology. In doing so, he hopes you will educate, innovate, and connect with other medical professionals.

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Join Timo de Raad as he discusses the complexities of CPR in paediatric congenital cardiac disease. Timo introduces the listener to Emma, a 4-year-old cheerful and playful girl. Emma was born with hypoplastic left heart syndrome – a condition where the left side of the heart is poorly formed. As a result, the heart cannot support adequate circulation around the body. 5 out of 10 000 live births in the Netherlands have this congenital heart defect. Timo was there for Emma's birth, and he was there for Emma's death. Treatment of hypoplastic left heart syndrome is a palliative three stage repair. The first procedure is the Norwood – within the first two weeks. Subsequently the Glenn procedure is undertaken, and finally the Fontan. In this procedure the pulmonary artery and aorta are combined to create one outflow tract from the heart. In essence, this creates one functional ventricle. As a result, there is a change in the cardiac physiology. This changes the dynamics when considering resuscitation in these patients. In Fontan hearts cardiac output is dependent on the preload which in turn is dependent on how much blood flows through the lungs. Accordingly, spontaneous breathing is critical for these patients. Constriction of pulmonary veins make it difficult for blood to flow back to the heart. When dealing with cardiac arrest in these patients Timo suggests treating it the same as any resuscitation – utilising chest compressions and epinephrine (adrenaline). He does suggest one extra thing, that being abdominal compressions. Timo describes the technique he uses. He pushes between the belly button and sternum. He recommends pushing as hard as if you were palpating the liver. In trials on awake patients, there were no complaints of pain when using this technique. Additionally, Timo discusses the ratio of 1 to 1 chest to abdominal compressions during the resuscitation. In conclusion, resuscitation of a paediatric congenital heart defect is challenging. Consider the growing evidence base on abdominal compressions whilst acknowledging the differing opinions in this space.

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Camilla Strom discusses the outcomes for elderly patients in the intensive care. Camilla recognises a persistent "negative vibe" when people talk about elderly patients. This is inappropriate. We should acknowledge older patients for what they are! They are survival masters. This group of people have experience wars, famines, and recessions. They have seen many failures and successes in their long lives. They have overcome all in their path to be where they are today. Healthcare is facing an oncoming flood of older patients. In fact, this process is already happening across the world. The challenge is that these patients cost a lot of money to care for – especially in the ICU. In the general population, there is a 10% 1-year mortality rate for those 80 years and above. This jumps to 40% if they are admitted to hospital. If a patient older than 80 years is admitted to the ICU there is a 50-90% 1-year mortality rate. Therefore, the question is, should this population be admitted to ICU at all? Camilla argues that age is really much more than a number! Life is a deteriorating process. We pay to live our lives. We pay through the accumulation of DNA damage, through shortened telomeres, diminished physiological reserves and loss of muscle function and strength. These are all unavoidable occurrences. Consequently, it is these things we must consider when caring for the elderly people in our communities. Unfortunately, there is a dearth of data when looking patient outcomes in various settings in the hospital. As a result, we have limited prognostication tools. With more research on the way utilising various scores – more concerned with frailty than age – this will change in the future. With that being said, Camilla urges us to consider the patient as more than their age. Age should not be the limit when deciding who should or should not be admitted to the ICU. Talk to your older patients. Determine what is important to them and use your clinical knowledge to help guide their decision-making process. Finally, set realistic goals and re-evaluate them regularly.

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