Coda Change

We regularly have difficult conversations in critical care. We deal with sick and complex patients who may be at the end of life. The families we talk to may be in a state of shock and acute grief, unable to think clearly and make important decisions. Moreover, patient safety incidents and other challenging issues such as organ and tissue donation may further complicate the patient journey. In this talk by Jon Gatward, we follow the story of Leah and the difficult conversations that were needed in caring for her and her family. Jon examines some of the key elements that can contribute to successful communication in difficult circumstances such as: • Having a plan and a structure before embarking on these difficult conversations. • Working towards a common agenda and ensuring that everyone feels safe and able to ask questions. • Showing empathy and using silence well, allowing people the space and time to process information. • Giving people the benefit of the doubt, after all, these are their family members that we are talking about. As clinicians, our training in this type of communication may be limited to observing our mentors, and we may feel inadequately prepared. We will investigate how simulation training can be used to improve the quality of communication, increase our skill and comfort level so that we can guide patients and families through complex and challenging situations. We will also investigate how lessons learnt from simulation debriefing can be transferred to the conduct of difficult conversations in real life. Most importantly – we need to ensure that we look out for ourselves and for our colleagues. These conversations are draining and difficult. Tune in to a DAS SMACC talk by Jon Gatward on Critical Moments in the Intensive Care Unit.

For more like this, head to https://codachange.org/podcasts/

Failure is something that even the very best in the industry regularly experience. In safety critical roles, that failure can ultimately lead to death and maiming. So how do we accept failure? Martin Bromiley explores how we can understand and learn from our failures and difficult moments. He identifies the essential behaviours and mindsets that will help us make sense of those complex moments. One such mindset is being confident that you have the skills to do the job but also humble enough to know that you could be wrong. This is a delicate balance but is so crucial for personal growth. We are all human and we will all make mistakes. Taking responsibility for our mistakes is essential and is what allows us to learn from those errors. Furthermore, Martin suggests that setting a good example is key. We need our leaders to listen and to lead by example, acknowledging their own failures, to grant us permission to do the same. Failure is inevitable but understanding what we can learn from failure, is what makes us better at what we do. Unfortunately, not everyone has the platform or the ability to share their failures or difficulties. We need to encourage people to share their stories and to allow people the space to learn from their mistakes, so that they can achieve success in the future. Tune in to a DAS SMACC talk by Martin Bromiley on how to fail.

For more like this, head to https://codachange.org/podcasts/

SMACCForce: CRM Panel Discussion with Clare Richmond, Neil Jeffers (Pilot), Per Bredmose, Mike Lauria, Tom Evens

From DAS SMACC, Vera Sistenich explains why it is critical that we care about the global refugee crisis. The global refugee crisis exemplifies some of the greatest challenges facing our global institutions and liberal world order today. From human rights, to xenophobia, sexism and economic protectionism, terrorism and climate change. National and international responses to the refugee crisis are sculpting moral and political norms around the globe. It is critical that we care about the refugee crisis today because it exemplifies some of the greatest challenges to our social order. As Hannah Arendt, the German-born Jewish political theorist wrote, "The manifestation of the wind of thought is not knowledge but the ability to tell right from wrong, beautiful from ugly. ...[T]hinking gives people the strength to prevent catastrophes in these rare moments when the chips are down". It is now critical that we not only care, but think deeply, about our attitudes and policies towards refugees, wherever we come from. Tune in to an engaging and informative talk by Vera Sistenich, as she challenges us to consider how the global refugee crisis threatens liberal world order.

For more like this, head to https://codachange.org/podcasts/

John Greenwood discusses the use of vasopressors in the emergency room. His talk focuses on three areas. First, he reviews vasopressors and categorises them based on resuscitation end points. Secondly, he addresses the concept of "pressor angst" and how it can significantly impact patient mortality. Finally, he will empower you to start vasopressors early in patients with distributive shock and sepsis. The tale of a 45-year-old lady with sepsis in the context of pneumonia is retold. John asks - what do you do? Initial fluid resuscitation has improved the vitals somewhat, but she is still hypotensive. Continue to give fluids? Sure – it seems to be what happens commonly. Starting vasopressors starts a cascade of events that will consume time and resources. It impacts flow, timing, and ability to see other patients. Often, the clinician knows it the right thing to do but does not want to pull the trigger. This process of having two conflicting beliefs in your brain at the same time is cognitive dissonance. In the context of using vasopressors, John terms this "pressor angst". The hesitation to use vasopressors even when perhaps you know it is the right thing to do. It is a complex confliction of behaviours, beliefs, goals, and practices. Regarding vasopressors specifically, the clinician will be considering the logistics, bed crunch and procedures amongst other things! Why does the time matter? As John explains with reference to the literature, the time to the decision to commence vasopressors is hugely important in influencing patient mortality. There is a clear mortality benefit to starting vasopressors early. Norepinephrine started early can aid in adjusting preload, cardiac output, and afterload parameters. John steps you through the effect of norepinephrine on all metrics that contribute to. The conclusion is that early norepinephrine administration improves both macro- and microcirculatory function in vasoplegic shock. John wants you to avoid pressor angst! Do not be afraid of vasopressors and pull the trigger early. Finally, consider norepinephrine early in sepsis.

For more like this, head to https://codachange.org/podcasts/

Luke Regan presents the emerging evidence for prehospital ultrasound and telehealth in his talk from the SMACC stage. Luke has a personal interest in improving prehospital care. He lives in the north of Scotland. It is an austere and challenging environment, far from technology. Compounding this, it is underserviced and there is an absence of critical care with no critical in reach. Unfortunately, the morbidity and mortality of the area does not match the spread of care. Therefore, it is one of the motivations for his research. That being said, he is not alone in his desire for this research. Pre-hospital ultrasound topped the list of technology-based research priorities in pre-hospital critical care, as determined by a European research collaboration. This is in large part because much of what is done in pre-hospital care still exists in an evidence free zone. Luke discusses the extended pre-hospital patient journey in his practice. This presents a challenge, but also an opportunity. If time zero is further back, testing a pre-hospital intervention becomes very achievable. There is precedent for this. Benefit of pre-hospital interventions have been highlighted by the relative benefit of stopping and performing roadside ECG in transit. This has allowed road crews to receive updated treatment advice based on that ECG. This bundle of care is similar to what is possible with pre-hospital ultrasound. Currently, there is a very apparent practice creep when it comes to the use of ultrasound. This means there is an increase in the use of pre-hospital ultrasound around the world. However, it remains an evidence poor area. Luke describes two studies conducted in Scotland looking to answer the big questions in pre-hospital point of care ultrasound (POCUS). Firstly, can it make a difference? Secondly, does it take too long? Finally, who should do it and how long does it take to train them? This is done in large studies, with lots of patients and inputs from a diverse meeting of minds. Join Luke Regan as he discusses the evidence behind the application of pre-hospital ultrasound and telemedicine.

For more like this, head to https://codachange.org/podcasts/

Sara Gray discusses the complex topic of prognostication post cardiac arrest in neuro intensive care. There is a short list of things that keep Sara up at night. She describes a specific cardiac arrest nightmare she has. She is looking after a patient post cardiac arrest. They remain in a coma after cooling. As they meet brain death criteria and they are an organ donor, they are transferred to the operating room. Whilst there, they regain spontaneous respirations. Although this is terrifying, these situations do happen! And cases like this defy all efforts at accurate prognostication in post cardiac arrest patients. Prognostication matters. It matters for the patient, their family and got judicious resource management. The trouble is, that varying guidelines around the world do not agree. In patients who have not been cooled, then you may start prognostication 72 hours post return of spontaneous circulation (ROSC). Before that time the brain may not have had adequate time to heal from the arrest and the clinical indicators may not be accurate. In the hypothermia group there is differing guidelines. Some guidelines suggest doing it the same way – prognostication after 72 hours. Others suggest 72 hours after achieving normothermia. This equates to 4.5 days. Why the difference? Different medicolegal environments may play a part. However, as Sara explains, some guidelines may be guided by concern over the emerging data about people who wake up late. Sara fears looking a family in the eye and telling them the patient won't wake up and being wrong. Her advice is to wait 4.5 days. She then recommends starting with a subgroup of patients with a low motor score on GCS. From there you can use indicators with the best accuracy which are bilateral absence of pupillary response, corneal reflex, and somatosensory evoked potentials. Bilateral absence of all three equals a dire prognosis.

For more like this, head to https://codachange.org/podcasts/

A no-holds barred series of 6 provocative medical interrogations. We challenge the state of research, social media, pharmacology, social work, women in medicine, medicine in the developed work, and the health of healthcare workers. It should be novel, it may get heated, and it is not scripted. Sometimes to comfort the afflicted you also need to afflict the comfortable. This is why no prisoners will be taken, no topic is out of bounds, and no ego will be pampered. It may even offend: you have been warned.

Raed Arafat describes the amazing lessons he has learnt about functional systems for emergencies, mass casualties and disasters. SMURD (Mobile Emergency Service for Resuscitation and Extrication) is in Emergency Rescue Service in Romania. It was set up by Raed Arafat in 1990 to respond to a largely non-existent and broken system. By doing so, he created a pre-hospital care system that he could be proud of. SMURD has today transformed into an integrated, country wide, emergency response system providing high quality care. Romania is one of the only countries in Europe where you have a right of emergency care. That is, you cannot be charged for being rescued or accessing emergency healthcare. This is largely due to Raed Arafat. He has created a functional system that deals not alone with daily emergencies, but also disasters and mass casualties. The national monitoring system and coordination service responds to fires, emergency incidents, critical transfers, and supports the whole country with resources from a national level. To highlight the amazing work that SMURD does, Raed describes in detail the service's response to two tragedies involving Romania. The first happened in Montenegro, in 2013. A Romanian tourist bus fell 40 metres off a cliff. 19 people were killed and 28 were injured (12 of whom were in a critical condition). What followed was a large scale patient transport and casualty repatriation effort that included local ambulances, SMURD vehicles and military aircraft. The second incident was a tragic fire in a nightclub set off by fireworks. 400 people were trapped inside. The emergency response was mobilised an arrived in 11 minutes. In the minutes, hours and days that followed, SMURD coordinated the mass rescue, treatment, and transfer of patients. This included sending 41 patients to other countries, due to the high number of them that were critical. Despite these extraordinary efforts, SMURD consistently faces backlash and criticism. Raed takes the opportunity to answer his critics from the stage. Listen in to Raed as he demonstrates the enormous capability of SMURD. From disaster response to resource management and deployment, their reach is impressive. As Raed says – it all boils down to teamwork and functional systems that work both from the bottom up and the top down.

For more like this, head to https://codachange.org/podcasts/

Haney Mallemat states the case for ultrasound in cardiac arrest resuscitation. He tells the story of Stephen, a 43-year-old male who suffers a cardiac arrest. Unfortunately, whilst looking for reversible causes with a transthoracic echocardiogram (TTE), chest compressions stopped, and Stephen died. Enter the trans-(o)esophageal echocardiogram (TEE). A trans-esophageal echocardiogram is an amazing diagnostic tool. It works in exactly the same way as any other ultrasound – there is a transducer on the end of a handle. The difference is that the stem is flexible and inserted down a patient's oesophagus. This provides fantastic clear images in any patient, with no soft tissue or bones in the way. The beauty is, if you already know how to look at transthoracic echocardiogram, then there is no learning curve. The images are just flipped. TEE can rapidly identify reversible causes of cardiac arrest, for instance a pulmonary embolism, a clot in transit, aortic dissections or papillary muscle ruptures. It can do this without causing any interruptions to the resuscitation effort, including the chest compression. TEEs can also demonstrate the effectiveness of CPR in real time – goal directed chest compressions. In a similar vein, TEE can measure the depth of compressions providing valuable information for the team involved in resuscitation. Back to Stephen. Instead of interrupting chest compressions, a TEE was used instead. A TEE echocardiogram elicited fine ventricular fibrillation that was not picked up on telemetry. This led to a lifesaving intervention, and Stephen walked out of the hospital a few weeks later. Henry will convince you that TEE is a game changer in cardiac arrest resuscitation. TEE provides high quality images of the heart without interruption in CPR. Additionally TEE provides useful information about compression depth and quality that no other diagnostic tool provides.

For more like this, head to https://codachange.org/podcasts/