Coda Change

Pik Mukherji will change your mind on assessing risk and benefit in resuscitation. There is a bent towards action in the Emergency Department. This is for a few reasons. We are risk adverse – we do not want to miss the acutely sick patient. We do not want to miss the patient that "falls of the cliff". In fact, as Pik discusses, in emergency medicine and critical care, training is focused on looking for the sharks, even when the waters appear friendly and calm. This is highlighted acutely well by Pik in a story about an elderly gentleman. The man presentedto the ED after a minor trauma. On history and examination there was nothing to find, apart from a minor scrape. Due to the risk adverse nature of the ED, the patient got a CT scan. It showed an acute subarachnoid haemorrhage. This meant he stayed in hospital for observation. The next day he fell off a bed being transported back to the scanner and disaster followed. On review, the original CT showed no abnormalities. This story highlights the risk of the devastating harm that can come to patients in the medical system. Every time a test is ordered there is risk of incidentalomas, biopsies, and repeat visits – to name a few. Pik wants to drive the message home - not every patient can be helped. Every patient can be hurt. Time and time again, doctors overestimate the benefits of their treatments and underestimate the harms. Even armed with this knowledge and knowing the guidelines does not seem to change behaviours. Pik demonstrates this fact with the live SMACC audience where he shows this "cover my backside" mentality in real time. Unnecessary testing and over cautious approaches flying in the face of the evidence. As health care professionals we are taught to "do". We are programmed to act. The trouble is that sometimes the only person this is benefitting is the clinician. After all, we feel better having done something over nothing. Hippocrates was wrong! "Do no harm" is impossible. So, take a step outside of your comfort zone and try to do less.

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Brandon loves wavy lines. He will draw the curtain on the use of continuous EEG in neuro critical care. Brandon will first take you back to medical school with some neuroanatomy and physiology to underpin you understanding of the EEG. He then steps you through what an EEG is telling you. Bumps, lines, amplitudes and hertz are all demystified. With this knowledge, there is a lot you can do with continuous EEG. A few examples: EEG can be reflective of external stimulus – be it a shock, a sound, or a pinch. This is used to test for reactivity and is useful at the bedside. Reactivity demonstrates whether a signal is getting from the body to the brainstem, to the thalamus and to the cortex. Reactivity is one of the most conserved, independent prognostic indicators in coma – making it important to capture using EEG. EEG is fantastically active when you are asleep. In the ICU, an EEG can show atypical sleep – indicating they are very unwell. Due to sleep being a network heavy, very complicated phenomenon. If sleep is generated on Day 3 post TBI – you have the capacity to recover. With this in mind, Brandon wants you to interact with your patient's EEG and remember that EEGs are not just for seizures.

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Cliff Reid educates the audience on structured teaching of crisis resource management. Cliff works for Sydney HEMS in extreme conditions. The environment tries to kill them, and the patients try to die. He works in a big team, with a lot of the doctors never having worked in prehospital care. The team covers a huge area, completing many missions every year on both fixed wing and rotary wing platforms as well as road ambulances. Every case is scrutinised, both formally and informally. When things go wrong, it is rarely due to the clinical factors alone and often due to non-technical skills. These skills are discussed often but not taught in a structured way. Cliff presents the Zero Point Survey. A magical window before touching the patients where planning can start for when things go wrong and what can be done about it. It is as simple as STEPUP: Self, Team, Environment, Patient, Update and Prioritise. Self – get you head in the zone. Checklist's can be useful for both physical and psychological safety and preparedness. Training also plays a crucial part to ensure that a situation is perceived as a challenge and not a threat, enabling high level performance. Team – make sure everyone is on the same page. Assign roles and tasks as they are the key to smooth team flow through the mission. Have a plan for dealing with disruptive individuals. Environment – control and mitigate any safety hazards and create a safe workspace. Own your resuscitation real estate. This means adequate space, sufficient light, appropriate heat, control noise and crowd. Patient – gather information ahead of time to start planning a course of action. Update and Prioritise – throughout the mission, use constant communication and a standard operating procedure to regroup and update priorities. The simple strategy of the Zero Point Survey gives structure for both performing and debriefing resuscitations and simulations in crisis resource management.

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SMACCForce: Neemo by Marc O Griofa

Join Celia Bradford as she discusses blood pressure control in intracranial haemorrhage in neuro critical care. Intracranial haemorrhage risk factors include hypertension. The question becomes, what do you do with hypertension in the management of intracranial haemorrhage? Does blood pressure being high cause the bleed to be more severe or does a severe bleed cause increased blood pressure? It is a classic chicken or egg scenario. Celia takes you through two prominent trials in the area and gives you valuable and practical tips on how to manage these patients. The INTERACT-1 trial looked at haematoma expansion in two groups randomised to blood pressures of

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The information we consume leads us to believe that failure isn't an option. Stories and movie depictions of characters who avoid the odds at all costs, tell us that failure is unacceptable and should be avoided. We expect elite performance and hyper competence. In medicine, where we are responsible for the lives of our patients, it is easy to understand why we set the bar high for ourselves and somewhat expect ourselves never to fail. The reality is however, that this is all a myth. Any complex system you can observe from around the world has experienced failure. In fact, the biggest lessons usually come from the biggest failures. In healthcare, we work in the ultimate complex system, where nobody is hyper competent and failure will always occur. It is inevitable. According to sociologist Diane Vaughan, wherever science, technology and risk to human life coincide, failure is inevitable. The answer is in finding ways to appropriately deal with failure and to overcome these challenges. So, given that failure is inevitable, is there a better way to fail? How do we fail gracefully? We need to learn to fail and understand that we do so out of a love for our profession. By savings lives and helping others. Our system needs to allow for failure to occur but also to ensure that we fail gracefully. Kevin Fong shares a compelling talk on how to prepare to fail, how to expect failure and most importantly, how to forgive yourself for failing. A talk that Kevin describes as "useful advice for failing at everything." From DAS SMACC, we hope you enjoy this podcast and we hope that it inspires you to embrace failure in a new light.

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Laszlo Hetzman discusses cost effective high fidelity simulation training for performance in pre-hospital and hospital critical care. One the great benefits of simulation training is the diversity of training it provides for all levels of experience. Based on his own hugely positive experiences of simulation, Laszlo was compelled to implement effective simulation in his country. The trouble was budget constraints. However, with a little bit of lateral thinking, Laszlo will show you that low budget does not necessarily mean low fidelity. Laszlo discusses the three areas of fidelity that are needed to have a successful simulation. These are equipment, environmental and psychological fidelity. Life like equipment, life like environment and a strong fiction contract. The later referring to the agreement that is held between all participants and trainers that the plastic mannikin they are working on is a real-life dying patient that they must help. Laszlo divulges seven tips and tricks he has developed to make training with any budget effective and to help sign the fiction contract for less! First, use real stories in your scenarios. Get credible and well-prepared instructors - they paint the picture of the training scenario. With good instructors it is possible to minimise "God's voice" (instructions coming from people external to the scenario.) It is useful to use participants voices, or cheap applications to deliver vital signs, and having distractions/actors to steer the scenario. Similarly, background noise (be it farm noise, train stations or industrial sounds) can be found for nothing on YouTube and enhances the emotions of the situation. Clothing is important – Laszlo stresses everyone in the scenario should be dressed up to resemble the role they are playing. Additionally, models and mannikins can be altered cheapy and easily using whatever is lying around the ward or house. On the same theme, think outside the box when considering equipment. DIY is a magical thing. Laszlo describes how he has used useless junk to do everything from making ultrasound probes to simulating a thoracotomy. Finally, be sure there are no spoilers. Help all participants to be believable with their actions and words and to stay in character to enhance the experience for all. Follow these simple tips to make all simulation experiences the best they can be. As Laszlo says, medium fidelity rules.

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SMACCForce: Suspension Trauma - Discussion - Demo by Jason van der Velde & Karel Habig

A study showed that 15% of healthcare responders hesitated to start CPR because they thought that they would harm the patient. 21% didn't want to start defibrillation because they thought that they were doing something bad. Hesitation means time. We are harming the patient by not starting sooner. A culture of excellence in resuscitation relies on an excellent system, not excellent individuals. As individuals, we could have all of the training in the world but the reality is that all parts of the system need to function or we will sink. Maaret Castren suggests that culture of excellence is a choice. We need to choose to be extraordinary and we need to commit to implementing systems that aspire for excellence. Maaret inspires us to think outside of the box and to think about what we can do to be better. When you look around the world it is evident that there isn't one single system that has actually achieved excellence. We need to encourage our team not to settle. To avoid saying things like "this is the way that we've always done things." Local implementation is usually the weakest link in the chain. We have good science, we have highly educated people but we don't implement optimal systems into our normal everyday lives. This is where we go wrong. Leadership is key, even in scenarios where there are only two first responders performing a cardiac arrest. Maaret outlines the three key elements of achieving a culture of excellence: 1. Leadership 2. Training 3. Quality improvement All parts of the system need to be optimised, to allow for us to achieve greatness. From DAS SMACC, we hope that you enjoy this podcast and we hope that it inspires you to achieve a culture of excellence in your workplace.

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Simulation, assessment and technology in medical education. This session brings together a panel of educators with a track record of innovation and design in medical education. Chris Nickson, Daniel Cabrera, Jenny Rudolph, Sandra Viggers, Simon Carley, Victoria Brazil, Walter Eppich & Jesse Spurr join to discuss the past, present and most importantly the future of how we will teach and learn critical care. They address some burning questions including, what does it mean to be an educator? Is simulation the answer to everything? What do we need from medical education to encourage healthcare professionals to thrive into the future? They explore the future changing role of the medical educator from one of information delivery and assessment to co-learner and developer. This is particularly challenging when asking senior healthcare professionals to unlearn processes and to be flexible and open to new ways of doing things. We are encouraged to consider the role of culture... how can we create a culture which embraces learning and new ways of doing things? How do we establish a system where positive role models are in abundance and lead by example in challenging situations? Furthermore, the panel consider whether new technologies really change education or simply form adjuncts to traditional learning models? FOAMed is so easily accessible and is an excellent tool for learning but how do we also integrate and adapt traditional models of learning? From DAS SMACC, our panel of experts light the flame of medical education and challenge the audience to consider the complexities and role of simulation, assessment and technology in medical education. Tune in for an interesting and engaging discussion about medical education in healthcare.

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