Coda Change

Annet Alenyo Ngabirano was enjoying the community medical placement in the 4th year of medical school. Placed 60km from the nearest hospital, in the lush hills of Uganda, the days were filled with vaccination drives, local outpatient clinics and lazing about. That was until a frantic nurse burst into the room and rushed the three medical students to the bedside of a severely sick and dehydrated infant. There was no doctor. There was no senior nursing staff. They no training, no equipment, no backup, and no resuscitation area - yet this small group of 4th year students were the only hope this small baby had. After trying to gain IV access for over 30 minutes, Annet felt exhausted, overwhelmed, under equipped, under resourced and alone. This is emblematic of where Emergency care in Africa has come from. Over 85% of the world's population live in Low and Middle Income countries. Health statistics in these countries are characterised by numerous deaths from treatable time-sensitive illnesses and injuries resulting from inadequacies in health systems, particularly Emergency Care. However, across the world, Emergency Care continues to grow, and every country has a story to tell. There are similarities in our stories: the overwhelming sense of responsibility, the exhaustion and feeling of being undervalued. But there are also glaring differences in quality. Africa can be better and it should be. 2017 marks 10 years since the first Emergency Medicine Physician graduated in Africa. From one single Residency program in 2007, there are now 11 more in 9 of Africa's 54 countries. 2009 saw the formation of The African Federation for Emergency Medicine (AFEM) supporting Emergency Care development across Africa. AFEM's projects include: - The biennial African Conference on Emergency Medicine (AfCEM), the only scientific conference on African emergency care. - The Annual Consensus Conference that addresses various aspects and challenges of Emergency Care in Africa. - A quarterly international, peer-reviewed journal, publishing original research on topics relevant to Africa, freely available online and offering free publication support to African researchers through Author Assist. - Supadel, a peer-to-peer sponsorship program funds attendance of practitioners to AFEM-affiliated conferences on African soil, allowing them to network and learn valuable lessons in Emergency Care to improve systems in their countries. Emergency Care is a specialty that allows our humanity and compassion to touch and connect with people - not just patients, families, and communities but the whole of humanity. It brings us together. By recognising Ubuntu - the belief in a universal bond of sharing that connects all humanity – Annet knows that Emergency Care in Africa can, should and will be better.

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Trial design is the biggest problem with Evidence Based Medicine in the Intensive Care Unit. Paul Young wants to change that paradigm completely. He argues for research as we know it to change and to focus on clinical care with systemised and optimised treatments that reliably improves outcomes over time for all patients. Mortality measured at a particular time point (landmark mortality) is often regarded as the gold standard outcome for randomised controlled trials in Intensive Care Medicine. An important limitation of many Intensive Care Medicine trials is that they hypothesize large and potentially implausible reductions in absolute mortality. This is a major problem in trial design for two reasons. Firstly, it makes false negative trial results more likely. Secondly, the less plausible a postulated mortality reduction is the more likely that a statistically significant mortality difference will represent a false positive. This is because a p-value is defined as the probability of finding a result equal to or more extreme than that actually observed, under the assumption that the null hypothesis is true. This means that the greater the pre-trial chance or prior probability that the null hypothesis is correct, the lower the chance that a p-value below a particular significance threshold will represent a true positive. In Paul's words, p-values suck! The biggest single problem with the current evidence base is that most hypotheses being tested have low prior probability. This leads to the two most likely results being 1) no difference or 2) a false positive. We need a new research paradigm to address this problem, particularly in relation to the fundamentals of Intensive Care Medicine. Paul argues for an approach based on the Bayesian approach, utilising big data sources about patients under current care and then randomising treatment in real time. Intensive Care therapy is fundamentally about providing supportive care, including airway support, oxygen therapy, ventilation therapy and haemodynamic support amongst others. These treatments can be uncertain. Under such conditions of uncertainty and idiosyncratic practice variation, treatment should be randomised. Randomised treatment is likely to be the best treatment is these situations due to inherent cognitive biases. Using this data, Paul stipulates that we will rapidly learn from every patient, ensuring improved outcomes for each subsequent patient. As knowledge grow, prior probability can be adjusted, skewing the randomisation process. This continues until the treatment has either proven effective, or been shown to be equivalent. Every patient contributes information that enhances the care of every subsequent patient. And, importantly, p-values no longer matter. Effective research is important. As Paul states, "Optimising ICU care is a priority for global public health." By increasing the probability that patients will get the treatments that work even before we know what those treatments are the Intensive Care Unit can not only save money, but most importantly and critically, save lives. That is the way research should work.

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David Carr delivers an "old fashioned" talk, presenting his approach to the diagnosis and treatment of endocarditis in acute medicine. Whilst some may turn their nose up at what David describes as esoteric bedside medicine, the rare diagnosis of endocarditis is a bad diagnosis. It carries with it a mortality rate of between 15-30%. David attempts to rebrand endocarditis and make it sexy again. Who? There are four main suspects of getting endocarditis. If you turn up to David's Emergency Department having had a cardiac valve replacement, the assumption is that you have endocarditis. 1% of these patient per year will develop endocarditis. A valve replacement plus fever or feeling unwell should raise the suspicion even higher. People who inject intravenous drugs are the second population of suspects for endocarditis.15% of people who inject IV drugs entering the hospital with a fever will have endocarditis. You must respect this population, and they need to come to the hospital in these instances. Marantic endocarditis (or nonbacterial thrombotic endocarditis) occurs in patients with active cancer – making this group the third group in whom you should consider the disease. Finally, lupus patients can develop endocarditis - Libman–Sacks endocarditis – related to their antiphospholipid syndrome causing a hypercoagulable state. Four patients, four suspects. These patients present with an association. David presents this as "fever PLUS one". Fever plus any one of stroke, back pain, heart failure or arrhythmias should raise suspicions of endocarditis. So how should these patients be examined? Well first measure and confirm the fever. Secondly, dust of the stethoscope because up to 90% of patients with endocarditis will have a murmur. Forget the classical signs and look in the mouth at the teeth. Dental procedures in the two weeks prior to presentation is highly suggestive in the right patient. David concludes the talk with management principles. Blood cultures – three sets, three sites! Resist the temptation to give antibiotics in the first hour while you are doing this. Look up or ask colleagues about the blood culture results, and if the bacteria doesn't fit the crime, be nervous! Lastly, managing endocarditis is a team game so involve the team early including cardiologists, cardiac surgeons, and the infectious disease doctors. Join David as he rebrands endocarditis providing you with the framework to identify the disease and avoid the pitfalls in preventing you nailing down this diagnosis.

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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.

South pole...North pole, hot...cold, on earth...in space, below the sea...on Mount Everest, alone and far, far away. Gaynor Prince takes you to Union Glacier in the Ellsworth Mountain Range, Antarctica, to show you how useful ultrasound can be in extreme environments Gaynor relives the story of being in one of the most isolated places on Earth when she gets a Medivac alert. One of her clients, Jack, has become acutely short of breath. With her list if differential diagnoses including high altitude pulmonary oedema, heart failure and pulmonary embolism, Gaynor was presented with an enormously difficult decision. Whilst Jack's safety was priority number one, in a place like Antarctica, no clinical decision is easy. With the weather closing in, and a huge amount of time and money having been invested in this journey by Jack and his companions, what was she going to do? The answer? Pull out her Phillips Lumify ultrasound machine. A thorough examination with the ultrasound satisfied Gaynor that her patient was safe and stable. Dry lungs, no elevated right pressures, and no signs of DVT of lower limb – meant Jack could stay at the South Pole. Not for the first time, the ultrasound saved Gaynor's bacon and highlights why it helps her sleep easier at night. Ultrasound will make extreme environments less intimidating for the doctor by enhancing your diagnostic capability, honing your therapeutic management, and fitting into your pocket. This is a brief tale of a journey to Antarctica with a Phillips Lumify ultrasound. Find your passion and reach for the stars.

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Medical education and clinical programs are designed with four pillars - clinical excellence, research, education, and administration. These apply whether you build and design an ultrasound program or division, a simulation program, a toxicology or pre-hospital program or even an academic department Resa Lewiss describes the four pillars of medical education and clinical programs using a quirky anecdote of four tragic, dramatic and ridiculous stories of childhood dog deaths. Clinical excellence is providing good patient outcomes. Ensuring that staff are well educated and surrounded by working and necessary infrastructure to they can provide quality care. It is a strong and tangible pillar. Research is self-explanatory and demonstrates a program's credibility locally, nationally and internationally. It is more difficult to uphold, including writing, grants, abstracts and writing manuscripts. Education is what the medical community does, occurring in a number of settings including the lecture theatre and bedside. It is fun, interactive and in real time. Administration is less glamorous, and involves making sure processes work, relationships work and things work. Through the stories of her four family dogs and their demise, Resa illustrates the four ways pillars of medical educational and clinical programs fail. They fail through silent, indolent process – cancer. They can be derailed by others, people and processes who do not want you to succeed – homicide. The clinical program can be the architect of it's own demise, not publishing, not researching and not conforming to standards – suicide Finally, they can become stale, irrelevant and outdated – old age. Join Resa Lewiss as she remembers the tragic dog deaths of her childhood and what they taught her about medical education and clinical program design.

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In this quick, five minute talk, Brandon updates us on Sinus Venous Thrombosis. This includes what it is, what it looks like and how to diagnose it.

Brandon starts with a case – a 37-year-old woman, who is 8 weeks pregnant, presents with what she describes as the worst headache of her life.

She has a history of migraines, so this is Brandon's first thought and possible initial diagnosis. But... it turns out to be more than just a migraine...

Brandon explains that what we should be looking for here is venous sinus thrombosis.

This is characterised by a sub-acute onset of a headache and risk factors. In this case, hormonal changes which are related to her pregnancy, making her at higher risk.

The key takeaway? A headache with risk factors (in particular anything that will cause a Hypercoagulable state) plus or minus seizures, usually means we should be looking for this condition.

Brandon suggests that we need to be suspicious of this condition and that we need to look for it. Even if it isn't obvious at first.

Next, Brandon takes us through a second case which tells us that bilateral stroke usually means venous sinus thrombosis, until proven otherwise.

From DAS SMACC, tune in to an interesting and quick update by Brandon Foreman on how to identify and diagnose this condition.

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Fernanda Bellolio guides the listener through an approach to the treatment of wake-up stroke in neuro critical care. What time did the symptoms start? This is one of the most common questions that is asked when taking a history from a patient. However, what happens when this can not be answered. This is the case with "wake-up strokes". A wake-up stroke is when a person goes to sleep without symptoms and wakes up with deficits. Similar problems in management arise when a person cannot accurately tell the clinician what time the symptoms began. Up to 20% of stokes are wake-up strokes and a further in a 10% of strokes the patient nor family can say exactly when it started. This presents a challenge as many therapies that currently exist are time sensitive and therefore not approved for wake-up strokes. Fernanda reviews the current evidence in the quest to answer three questions: 1) What is the evidence for tPA use in wake-up strokes; 2) Can endovascular treatments be used in wake-up strokes and 3) How can these patients be approached clinically? tPA has not been approved for this patient population due to the inability to know the time of the stroke. However, utilising advanced imaging techniques including MRI, it is possible to get a estimation of the temporality. Using these methods, studies have looked at the use of tPA and shown likely benefit, with acceptable rates of intracranial haemorrhage. Despite this, imaging techniques such as used in the studies are not widely available. Endovascular therapy has a wider window of availability, and the early research indicates this therapy can be beneficial. Thrombectomy similarly showed good outcomes in early trials when compared to tPA. Fernanda sums up the overall approach to the wake-up stroke presentation. Treat it as an emergency, get the history, send off labs and request imaging. Be guided by the stroke protocols that exist in your hospital. For management – at this stage Fernanda highlights that no routine therapy can be offered based on the evidence at the time of the talk. However, multiple ongoing trials will guide future treatment selection.

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Rinaldo Bellomo is here to cause some trouble! He says that critical care physiology in resuscitation has problems! Whilst the rest of the medical field has advanced and evolved over time (we no longer routinely prescribe oxygen for an acute myocardial infarction), critical care resuscitation still relies on malfunctioning physiological paradigms. Critical care clinicians can change physiology with a number of tools. They can repeatedly, often, and mercilessly change physiological variables. Blood pressure, cardiac output, cardiac filling pressures, glucose levels, positive fluid balance and countless other physiological parameters can be increased and decreased at will. This kind of "numerology" is attractive because the outcomes can be immediate, and clinicians feel powerful and effective. However, outside the obvious situations where physiology is so dangerously abnormal as to threaten life, such physiological manipulations have an unproven relationship with outcome. Importantly, patients do not care whether their cardiac output has been increased from 5L/min to 6 L/min. They only care whether they live or die, get out of hospital intact and return to their previous life. Thus, physiological gain is not patient centred. Moreover, all research focusing of the physiology of a specific intervention inevitably deals with the effect on a specific set of variables. For example, a fluid bolus may or may not increase cardiac output in the short term. However this effect is not sustained much past 20 minutes. Similarly, no studies examine the effect of such fluid bolus on anything other than haemodynamics. No one measures what the effect is on the immune system, cerebral oedema, the glycocalyx, interstitial oxygen gradient, pulmonary congestion, body temperature, haemoglobin, or white cell function. Thus, all physiological studies are "blind" to the broader effects of their intervention. Rinaldo claims that in critical care resuscitation physiology, the measurable is made important but the important may not be measured. Clinicians need to reflect on this before they become seduced by physiological manipulation. Rinaldo's challenge to you? Look at the literature, consider biological plausibility, follow evaluated evidence, balanced, accept doubt with a smile and practice known medicine of the time whilst understanding that today's medicine will be the source of derision in the future.

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Autoimmune versus infective encephalitis by Ronan O'Leary