Coda Change

Claire Park delivers a riveting talk, bringing military trauma lessons from MERT (Medical Emergency Response Team) back home. Claire tells two stories from her tours in Afghanistan. The first begins in the early hours of the morning when the MERT team is tasked on a job. They receive word of five casualties including two above knee amputations and one unconscious without a radial pulse. On arrival to the scene the paramedics leave the helicopter to triage and bring the casualties aboard to Claire and her team. They begin to take enemy fire. The second experience was delivering care to an Afghan national soldier with a gunshot wound to the neck. He was alert when he came onboard the helicopter but quickly deteriorated. Claire decided he need to be intubated. However, there was an expanding haematoma across his cricoid area with a deviated trachea. An extremely difficult airway in an extremely difficult environment. The lessons from her experiences as a part of the MERT? Do the basics well. This means prioritising the problems as a team. The hinderance here is becoming too tasked focus. That is why Claire alongside her colleagues developed a time out. With eyes up, they would ask themselves two questions. What have we got? What are our priorities? She advises – trust your clinical decision making in the moment. Experienced clinicians will have "blink" moments – where they make unconscious conscious decisions. The importance is learning from them in the aftermath. On that theme, Claire has experienced firsthand how different people remember events in vastly different ways. She calls them different black box recordings. This makes the debrief essential. Use it as an opportunity to learn from mistakes and errors. Finally, Claire speaks about passion. Passion can eliminate fear. It can turn threats into challenges. Her thoughts are if you do not feel and do not care – you should not be doing the job. Take these military trauma lessons from Claire's time in MERT and use them to strive to do your best for your patients, every time.

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Join the debate between Bill Knight and Fernanda Bellolio as they go head-to-head, discussing diagnosing subarachnoid haemorrhage in neuro critical care headache. Should you rely on CT and lumbar puncture or, CT followed by CT angiogram. Why should you care? Acute headache accounts for 4% of all visits to the emergency departments. These patients will often describe the "Worst headache of life" – a phrase which can ring the alarm bells in the clincian's mind. 88% of these will be from benign causes including migraine, tension and cluster. However 10% will have a subarachnoid haemorrhage, of which the vast majority are caused by an aneurysm. These are frequently missed - up to 51% of the time in all settings and 6% of the time in the emergency department. It is in face one of the largest sources of US litigation claims and settlements. So – what is the best way to diagnosis subarachnoid haemorrhage? Bill asserts that the lumbar puncture (LP) following the CT is the way to go. He stresses that the "miss rate" needs to be 0% for subarachnoid haemorrhage. He argues that with the combination of CT and LP the sensitivity for subarachnoid haemorrhage is 100% Fernanda on the other hand is a big proponent of using the combination of CT followed by CT angiogram (CTA). She discusses the very low incidence of subarachnoid haemorrhade and takes this into account when calculating the pre- and post-test probability for her patients. She argues that if the pre-test probability is higher for a patient, then a CTA can be utilised. Bill Knight and Fernanda Bellolio present a compelling case for both sides when identifying the best way to diagnose subarachnoid haemorrhage in neuro critical care headache.

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Prehospital high acuity transport by air rescue has the capability to deliver the sickest of patients to high quality, advanced care, and support. However, not all patients are transferred. Why? Per Bredmose tells the tale of Emma. Emma is a 12-year-old girl who developed a cough. She is admitted to local peripheral hospital, correctly diagnosed with pneumonia, and treated with IV antibiotics. Emma continues to deteriorate and is transferred to an ICU where she fails a trial of BiPAP and is intubated. She continues to deteriorate. She requires high pressure ventilation and vasopressor support – advanced, high end, specialist interventions. The truth… this never happened. This talk from Per is about all the future Emma's. Someone in the hospital system (either the sending or receiving hospital) decided that Emma was too sick to be retrieved. Per challenges this notion of "Too sick to be retrieved". He says it is rather a case of being in the wrong place at the wrong time. Or getting the wrong disease in the wrong place. Patients will inevitably be in hospitals that lack essential equipment or knowledge for a given condition. Small hospitals do have some deficiencies. Per advocates for the development of retrieval medicine teams and systems that can assist these patients and bring them to centres that can provide the best care. This requires a team including paramedics, pilots, flight nurses and yes, retrieval doctors who have high end specialist training and experience. The teams need to understand the system, the equipment and be able to calculate the risk-benefit ratio of retrievals. They need access to hardware – whether this be ambulances, planes, or infusion hardware. And they must be able to work within the system in which they are operating. Per advocates for a strong retrieval system, comprised of well support and trained happy teams. This leads to safe retrieval and transport and better outcomes for patients.

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Dr Suman Biswas is a UK based anaesthetist known for his musical talents. He and a fellow medical student began performing hilarious medical parody songs, perhaps the most famous is his 'London Underground song'. The two students were catapulted to fame as the "Amateur Transplants" but sadly parted ways in 2011. Suman works full-time as an NHS EnglandAnaesthetist. Here he performs live on-stage at the enormously popular medical conference SMACC (Social Media and Critical Care) in Berlin Germany 2017. The audience of over 2000 medical delegates goes wild. Tune in to hear some of your favourite songs masterfully re-purposed for Suman's medical parody. You are guaranteed to to laugh at the wit and irreverant humour.

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Clare Richmond discusses medical simulation and its ability to provide a safe working environment anywhere. Simulation is a tool which allows us to rehearse our skills and scenarios before they happen in real life, to real people, our patients. Many clinicians dislike simulation, they know it is good for them, but find it challenging to drop into a world of manikins, fear performing in front of their peers and find debriefs uncomfortable. This talk will consider the purpose of simulation and its role in providing a safe working environment for clinical care anywhere. As a junior doctor Clare always found simulation hard. A combination of talking to a plastic model, having to debrief, and trying to figure out the endemic of cardiac arrests in mannikins were all challenging. However, Clare now provides a useful overview to medical simulation and some handy tips into making the most of the simulation experience. The beginning, or pre-brief, provides an opportunity to improve learning. Here there should be consideration of psychological safety for the participants. It is a chance to immerse the learners for their improved learning. The scenario is where all the learning migrates from. It is central to the exercise. The case must come from reality. However, Clare cautions against a case that has truly come from real life. Instead draw from a real case a condition and cause, complications, and co-morbidities. Add to the case a sense of humanity, be it a husband, a child, a family, or a story. This reflects the complexity of real life. Do not forget to challenge participants to remove them from the comfort zone and into the learning zone. Every twist and turn must have a reason for being there. Keep it real and authentic and align it with the objectives of the experience. Keep the simulation somewhat real. This means real equipment and real collaborations with other health care professionals where possible. Also consider using humans as real patients. Lastly, debrief and reflect on the learning experience. This should be approached with curiosity. Re-run scenarios if need using the 'pause, reflect, repeat' model. Clare finally advises all to prepare for the expected and rehearse for the unexpected. Things do happen. Medical simulation ensures you will be as prepared as you can be.

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Michelle Johnston presents her thoughts on acute myocardial infarction, thrombolysis and haemorrhage. She delves into David Foster Wallace, evolution, and what do when the thrombolysis bisque hits the fan. Michelle's interest into acute myocardial infarction, thrombolysis and haemorrhage began one day when she received a call from a peripheral hospital. A local farmer has presented to the Emergency Department with what turned out to be a big anterior infarct. As Michelle points out, he quite appropriately underwent thrombolysis. The gentleman's symptoms and ECG trace began to settle and a transfer to Michelle's hospital was arranged. Then he developed massive haematemesis. And to make matters worse, the gentleman turned out to be a dear friend of Michelle. Not to worry she thought… we will just reverse the effects of the thrombolysis. However, after a brief panic, a quick review of the guidelines, and consultation with the colleagues, Michelle realised that a massive knowledge hole existed! Even after getting the opinions of a haematologist, a neurologist, a respiratory physician, a cardiologist, an intensivist and an emergency physician on how to reverse thrombolysis – no clear and satisfying answer was forthcoming. Michelle was left with a big, fat, pile of questions. This led Michelle down the path of investigating how to reverse thrombolysis. This quest took her on a deep dive into the mechanism of tissue plasminogen activator (tPA), and the coagulation-fibrinolysis system. All this via the dinosaur museum, Carl Sagan, human evolution and irreducible complexity. She provides an entertaining and fascinating tour of what is known (or rather not known) about this human physiological mechanism. Through her pursuit of knowledge, Michelle comes to recognise that we either know an incredible amount or absolutely nothing. Michelle concludes that the future of thrombolysis reversal probably lies in not having to reverse it at all. Rather it would be better to have something that removes the clot more effectively and safely in the first place.

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A no-holes 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.

For Trish Henwood, ultrasound use in resource limited settings is a perfect fit. Nowhere has Trish seen ultrasound have more of an effect on patient care and outcomes, and save more lives, than in resource limited contexts. Trish uses the example of a training program in Zanzibar to highlight the scope that ultrasound provides. Using ultrasound on a daily basis to the medical centre is able to screen for antenatal complications that may necessitate transfer to a setting with a higher level of care. Trish also leans of health professions recounting their experience with ultrasound. Fatma – a nurse/midwife – recounts her tales of finding many cases of molar pregnancies, placenta previa, eclampsia and ruptured ovarian cysts. Through the available resource of ultrasound, she has saved many lives (of both mothers and babies.) Gabin in Rwanda has taken the basic ultrasound training he received to diagnose a multitude of cardiac conditions in his centre and Olivier tells the story of a young man with an altered mental status on whom he diagnosed infective endocarditis using ultrasound. These real-world examples show a tiny fraction of the benefit of ultrasound in resource limited settings. Although there are challenges to initiating training programs including resources and equipment limitations, focusing on the bright spots is important. Similarly, the scale of need, wide burden of disease, and complex systems challenges can at times be overwhelming in the global health arena. Focusing on small wins and long-term investment is key to programmatic success and sustainability. Training clinicians in bedside ultrasound effectively uses the same human resources to help shrink the gap between the broad imaging needs of a population and limited consultative capacity of radiology. The result is enhanced patient care, provider empowerment, and improved job satisfaction. Growing point-of-care ultrasound trainees into trainers themselves allows for local solutions to ongoing education needs and helps develop and address the most relevant home-grown research questions, results of which may have broader international practice implications. Building broader networks for bilateral point-of-care ultrasound training and research opportunities will be of global benefit.

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Marcelo Amota makes the case for why driving pressures matter during mechanical ventilation in critical care. Sao Paulo, Brazil, experiences flooding every year. This exposes locals to Leptospira bacteria. The severe form of disease this causes – leptospirosis - sees patients end up on mechanical ventilators. These machines were traditionally complicated, with a huge number of settings and buttons. Marcelo Amato trained in this setting. He, alongside his colleagues, developed methods to halt bleeding in leptospirosis by manipulating ventilator settings. He calls it "protective ventilation". It was not long before the same principles were being applied to patients suffering acute respiratory distress syndrome. Through research, Marcelo and his team concluded that driving pressures, above all other ventilator settings, were most important for patient survival. Driving pressure is the oscillation of alveolar pressure or variation of pressures inside the lungs. It is what your lungs are sensing. Although there is an obsession with tidal volume, which is displayed on ventilators, Marcello explains, driving pressures are easily calculated and more important. Marcelo discusses the increasing mortality with mechanical ventilation. The medical community, especially physiologists, are traditionally wrapped up in the concept of volutrauma. However, it is the gradient of pressures oscillating inside the lung (the driving pressure) that is causing lung injuries. So, the question became - would the lessons learnt the study on mechanical ventilation for leptospirosis be transferable to reducing risk in acute respiratory distress syndrome? Marcelo presents over twelve years of research. In doing so he highlights the changing dogma of the protective role of small tidal volumes. Research shows that the size of the tidal volume does not matter in terms of mortality. What matters is the pressure that is generated. The force with which the lung is deformed is much more important than the size of the deformation. The message: Do not look at absolute pressures, rather look at the swings in pressure. The only way a patient can survive is through a decrease in driving pressure, and not through a decrease in tidal volume.

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The healthcare ethics of alcohol related harm and driving change by Diana Egerton-Warburton Diana Egerton-Warburton talks about how to be a hero by championing healthcare ethics of alcohol related harm and driving change through stories and data. Have you ever saved a life? Many doctors and nurses have. But, how do you save a life without putting scalpel to skin or picking up a laryngoscope… or even having to go to a hospital? Diana Egerton-Warburton answers this question through the powerful tool of stories. Diana was put on the path of healthcare ethics over twenty years ago. She describes an emergency department shift that changed and shaped her. She sets the scene in the Western suburbs of Melbourne… Heroin bathed the streets and ocean of alcohol. One Australia Day sticks with her. In one Emergency Department shift, Diana saw seven separate episodes of alcohol related family violence. The stories still haunt Diana to this day. Broken bones, abdominal pain, an overdose, a cut lip – these were the faces and tales of the alcohol related violence that arrived in the Department that day. They were all survivors of domestic violence on Australia's National Day. Through this experience, Diana was motivated to make a change. However, what she thought was a potent advocacy tool in research left her feeling frustrated and thirsty for more. Any one research project only applied to a small portion of patients. To make matters worse, policy makers did not listen, to the results, even in the face of clear data. There was just no traction in policy change. Diana's answer? Use stories to make data real and to give it superpowers. This is the story of the ACEM Alcohol Harm (AHED) project. For the first time on a national scale the project quantified the level and effect of alcohol harm presenting to Emergency Departments (ED) in Australia and New Zealand. Over 100 EDs and more than 2000 ED clinicians have been involved. AHED provided an evidence base to advocate for measures to reduce alcohol harm through using evidence and clinician anecdotes. Through this strategy, clinicians are placed in a powerful position to influence culture and policy change The change in approach has yielded fantastic results in other areas. Needle and syringe exchange programs and naloxone prescribing Melbourne, decreasing blood alcohol driving limits New Zealand and data sharing amongst emergency providers to reduce alcohol related violence occurring in Cardiff have all been driven by individual clinicians with a story. So, the challenge is there. Draw your sword, raise your shield, and become everyday heroes through the power of stories and data.

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