Coda Change

Brandon Foreman gives a practical approach to the diagnosis and workup of neuromuscular disease in neuro critical care. Neuromuscular diseases are common and include chronic autoimmune disorders such as myasthenia gravis, acute demyelinating disorders like Guillain Barre, paraneoplastic disorders, and toxidromes such as botulism. The presentation of many neuromuscular diseases can be subtle: diffuse weakness, subtle swallowing difficulty, or double vision. Many patients do not present until its nearly too late, and timely diagnosis can lead to rapid stabilization of airway, autonomics, and other potentially lethal complications and expedited treatment of the underlying cause. Brandon's first piece of advice pertaining to neuromuscular disease in critical care? You have to recognise it! There are subtle clues littered through the history and physical exam of a patient. A nasal voice indicates oropharyngeal weakness. This is important to recognise and can tip you off to the likely diagnosis. New onset eye complaints or proximal muscle weakness will likewise lead the clinician to consider neuromuscular weakness. If a patient presents with a history of difficulty rising from a chair or double vision think of disorders such as Guillain Barre or myasthenia gravis. A big question in the early management of patients with neuromuscular weakness is the need for intubation. Brandon advises throwing away some of the traditional methods of answering this question that rely on lung function testing and often involve a respiratory physician. Instead, he runs through a handy list of diagnostics, possible at the bedside to determine the need for mechanical ventilation in this population. Brandon discusses clinical pearls to hone in out what a patient is presenting with. Test such as Simpson's test or the "ice bag test" are useful addition to any clinician's toolbox. Finally, Brandon takes you through the initial workup of patients presenting with likely neuromuscular weakness, equipping you with the knowledge to start the process before calling the neurology registrar!

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Sara Gray works in the Intensive Care Unit and sometimes connects with patients. This was especially true for a lady who was in her unit intubated due to pneumonia. When this patient experienced a failed extubation, a tricky re-intubation and subsequent tracheostomy, Sara was kicking herself. She says we have all been there… Have you ever dropped your phone? What was the internal dialogue in your head at the time? Sara calls this out inner voice. She used to think that our inner voice did not matter to high level medical performance or resuscitation skills. That was until the evidence changed her mind. The inner voice is powerful. A negative inner voice can increase anxiety, raise the heart rate, and use up valuable cognitive processing power. So, when running a complicated situation, your inner voice matters! For Sara, the critical soundtrack of the inner voice was constant. Her question was – how do I change this? This led Sara to the concept of self-compassion. She explores how she trained the inner dialogue, which is a skill to learn and practice. Self-compassion has been shown to reduce the heart rate, reduce sympathetic surges, reduce stress induced immune responses and in practical terms make your hands shake less when is high stress environments in the ICU. Sara expands on the benefits. She suggests that once you are a competent clinician with good theoretical and procedural skills, it can be hard to take it to the next level. However, serious psychological skills are all part of excellent bedside resuscitation. When reflecting on her experiences in her practice, Sara highlights how medicine views calling for help as an act of weakness. In a profession where tiny mistakes lead to life and death consequences, staying silent can lead to shame and isolation. This in turn manifests as burnout, depression, addiction, and suicide. Everyone in healthcare is at risk. It is the price of a culture of silence. The answer to reverse this includes self-compassion. Self-compassion is not a light switch – rather it is something you must work at and practice. Sara tells a story that everyone in healthcare will relate to and walks you through examples of useful resources to assess and work on self-compassion. After this talk learn to listen to your inner voice, practice self-compassion and use skills and empathy to take care of yourself and your community. Self-compassion can make work performance and life better.

Resources to consider:

1. www.Selfcompassion.org This is Dr Kristin Neff's website, complete with a self-compassion quiz, and then exercises and resources for those who fail the quiz! She also has a book if you prefer that format.

2. Pema Chodron. Fail, fail again, fail better. A short, and lovely commencement address with excellent advice for failing better. https://www.amazon.ca/Fail-Again-Better-Advice-Leaning/dp/1622035313

3. Angela Lee Duckworth. Grit. A marvellous book about the essence of perseverance. Or if you don't like books, consider her TED talk at https://www.ted.com/talks/angela_lee_duckworth_grit_the_power_of_passion_and_perseverance

4. Brene Brown. The Gifts of Imperfection. A book about failure, and acceptance of failure. Again, if books aren't your thing, she has a hugely popular TED talk about vulnerability: https://www.ted.com/talks/brene_brown_on_vulnerability and a website/online learning community: https://www.courageworks.com/

Rhonda Cadena explains the process of diagnosing and managing meningitis. It is a skill that involves rapid identification, workup, and treatment. In most cases, the diagnosis of meningitis is not a diagnostic dilemma, but the workup and treatment are not as straightforward. Meningitis is inflammation of the lining of the brain and spinal cord. This can be caused by bacteria, autoimmune process, drug reactions, viruses, and fungi. Rhonda delves deeper into bacterial meningitis. Worldwide there are over 1 million cases per year of bacterial meningitis. This equates to 135 000 deaths. Of the survivors, half will be left with neurological deficits. So, the swift identification and treatment of this disease process is crucial. Symptoms include fever, headache, nuchal rigidity and altered mental status with almost all patients having at least two. A lumbar puncture is absolutely necessary. Only insist on a CT first if you suspect a mass lesion or increased intracranial pressure. Otherwise, the delay in antibiotics can lead to an increased morbidity and mortality. Labs are next in the workup. All the common labs should be ordered along with a procalcitonin which can be diagnostic for a bacterial infection (although it will be positive with any bacterial infection so make sure it fits the clinical picture!) Likewise, fungitell can be useful in looking for some of the more common fungal infections. Blood cultures will guide antibiotic coverage. Steroids can be beneficial for prevention of neurological sequalae in patients who are infected with pneumococcal meningitis. They should be started in anyone with suspected meningitis. You can then cease if cultures come back negative for pneumococcus. Importantly steroids must be started before or during antibiotics. Finally Rhonda discusses prophylactic treatment. This is necessary for contacts of patients with Neisseria infections. Think household member, day care contacts, and anyone exposed to secretions. This scintillating talk addresses the challenges during the workup, which labs to send during the initial workup, and how specialized labs such as CSF lactate, procalcitonin, and fungitell may help in the workup along with helpful advice for management.

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Neuro Imaging Nibble: Subtle Subarachnoid haemorrhage on CT by Jordan Bonomo

Jonathan and his wife Anna thought they were coming to the emergency department for a routine sickle cell pain crisis. However, his illness takes him down an unexpected spiral of multi-system organ failure and critical illness. What was a routine patient encounter becomes a much more personal human interaction that causes the provider to question her perspective on chronically painful conditions and realise the effect our words and subtle actions have on our patients. Jessica Mason utilises the powerful tool of narrative storytelling, adapted to a live lecture format, to tell Jonathan's story from his own perspective. In doing so, Jessica makes Jonathan the teacher. Jessica hopes you will remember the story and remember the medicine. In 2016 Jessica received an email from Jonathan's wife. The email was to inform her of Jonathan's death, from complications of sickle cell disease. He was 43. This stark note gave Jessica pause, and prompted her to reflect on her interactions with Jonathan and his wife and wondered what lessons could be learnt about how we view chronically painful conditions and the unconscious biases we carry. By reliving her interactions with Jonathan and utilising interview audio with Jonathan, Jessica highlights the struggles that face patients with painful, chronic conditions. They are often burdened by fear of judgement or fear of being undertreated when accessing medical services. Concurrently, healthcare providers can be afraid of turning people into heroin addicts or be fearful of having their compassion exploited. Jessica posits this is all driven by the stigma of opioid use in emergency departments. Jessica used to believe pain crises from sickle cell disease were relatively easy to manage. However, Jonathan's powerful narrative provides a wonderfully effective teaching opportunity about sickle cell disease and other chronically painful conditions and how they are managed. Join Jessica Mason as she mixes medicine with the human condition to pass on valuable wisdom from the patient's perspective. In the words of the Jonathan's wife Anna, "If you don't teach others about what you have, no one will know."

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Trauma is an epidemic so what is the future for prehospital trauma resuscitation? The statistics are shocking – 14,000 people a day and 5 million people every year die from trauma. Injuries accounts for 9% of deaths worldwide and they are the biggest killer of under 40s across the world. Incredibly, these numbers are only rising. Dr Brian Burns describes what is largely a silent killer… many critical care doctors and nurses may never get the chance to see, treat or save the patient, because they often do not make it to the emergency department. Death often occurs in the first hour post trauma and 90% of trauma deaths are due to exsanguination. We pick up the story of Paul. Paul is driving alone when he loses control and crashes his car. There are no witnesses. No one to call for help. No emergency responders. Paul bleeds and dies. The emergency system that is currently used is not specific or sensitive enough – and we need to do better. The meercat is the animal world exemplar of the early warning system. Meercats knows where danger is, know how to look for it and on finding danger, they sound an alert that raises an immediate and appropriate alert from the collective. Brian applies the meercat model to Paul. Brian describes a new response, one driven by data, and fast and accurate access to that data. He draws parallels to the data gathering and sharing of Formula One teams. Brian takes a deep drive on predictive algorithms to calculate the likelihood of injury, automate the response and alert the dispatchers. He describes a response that utilises real time images, biosensors sending biometric analysis and the use of drones to deliver equipment ahead of retrieval teams – all while being supervised by a trauma team leader in a trauma centre. Brian re-tells Pauls tale in the future, the future of prehospital resuscitation. He describes a situation where technology is used to do better for Paul, and the countless others like him. Join Brian as he makes the case for computerised algorithms and decision-making assistance in medicine and implores the pre-hospital community to do better by utilising technology.

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Dying is not very sexy, but sometimes, dying is the right thing to do. Death is one of the many things that we only get one shot at. There is no second chance at death.

400 years ago, death was everywhere. Everyone was exposed to dying on a regular basis and people were encouraged to prepare for their death. Things have changed thanks to the intervention of the medical profession. Resuscitation teams, pain killers and the concept of "dying in comfort" have altered the trajectory of dying, leading to a mystique surrounding the concept.

Dr Psirides argues that death has replaced sex as the new taboo – and the result is a society removed from death. This has led to poor choices in medical interventions towards the end of life.

Furthermore, Inappropriate decisions made by medical teams are likely to delay death, decrease quality of life and cost money, all without changing the ultimate outcome… death. This sparks a discussion around a new perspective on "doing everything". Medical Intensivists have been shown to be bad at knowing the outcomes of their patients. They also overestimate the benefits and underestimate the harms of the interventions they prescribe.

Alex discusses the affect that "doing everything" has on families. Families of patients that had received more life sustaining treatments towards the end of life had higher rates of depression following the death.

Finally, the financial cost of extending lives is explained. Alex questions the efficacy of spending greatly to advance life trivially. Underpinning these hard decisions around death is the enormous importance of early discussions of death and dying with patients and their families. Is doing everything the best thing doctors, families and society can do for patients? Alex asks you to give patients the death you would want and make dying great again.

Tune in to a discussion on The Ethics of Death by Alex Psirides.

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Achieving excellence in healthcare communication requires multiple skills. When conflict arises we are programmed to respond with exasperation and negative judgment. In healthcare, this is especially dangerous. When your patient is in a critical state, the decision about whether to intubate before or after a trip to the CT is best reached with minimal conflict. Jenny Rudolph takes a refreshing angle on the practise of mastering yourself in difficult moments so that patient care is not compromised, and professional and personal relationships are not weakened. Conflict can be healthy when constructive. When making difficult decisions for patient treatment and care this friction or conflict can be even more important. This is because at this critical moment we should be sceptical about our decision making process, when we tend not to be. Equally, in a disagreement, we are often certain when we ought not to be. However, if there is too much prickly feedback and defensiveness on both sides, solutions are often difficult to deliver. When faced with such challenges in communication, Jenny discusses how to reset, and to reframe the situation and avoid reacting with negative emotion She explains the battle between judgement and curiosity when faced with difficult situations. They are both normal. It just so happens we are naturally curious about that which fascinates and interests us and judgemental about the irritating and appalling. By challenging listeners to get curious, Jenny explores techniques to manage conflict in high stress, time pressured, critical care conversations. She advocates for the efficiency and effectiveness of infusing positive regard into our interactions. Join Jenny as she guides you through reconciling curiosity and judgement, providing practical tips to use in the Emergency Department or Intensive Care Unit, alongside moments of catharsis!

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Sarah Yong is an impressive person. Advocacy, Training, Representation and being a new fellow of the College of Intensive Care to boot.

Theres a lot to talk about when you sit down with Dr Sarah Yong. Let's make it easy by focussing on three big issues;

Gender issues; Women in Intensive Care Network. www.womenintensive.org

Training issues; The Critical Care Collaborative and the Victorian Primary Examination Course for CICM. www.vpecc.com

Representation issues; New Fellows Rep on the Board of the College of Intensive Care Medicine. www.cicm.org

Where to start?

Women in Intensive Care Network www.womenintensive.org @WomenIntensive

If my sources are correct there pretty much the same number of women and men out there in the world. Further it seems that there are roughly the same number of women and men presenting to intensive care units. This pattern does not repeat itself in terms of the Intensive Care doctors.

Let's talk about this. Let's listen to the people that are raising awareness about this. The Women in Intensive Care are talking about it and publishing about it too. You may have heard about the Medical Journal of Australia article; "Female representation at Australasian specialty conferences".

Darren Braude discusses the concept of Rapid Sequence Airway (RSA).

The evolution of this concept goes back to the start of the 21st century. Here, the practise of 'archaic' airway management was common. This involved getting that plastic tube down the patient's trachea no matter what.

However, gradually, the risks of hypoxaemia during airway management become evident. This led to a movement towards extraglottic airways. If the oxygen saturation was dropping and there had been two failed attempts.

This movement continued to involve towards operators deciding to move to other methods when only one attempt had failed. This was largely due to the increased training and skill of clinicians. The thinking being if they could not get it in one shot, they probably weren't going to get it at all.

This evolution was the catalyst for the movement towards faster airways, and less emphasis on intubation.

Rapid Sequence Airway is pharmacology and preparation as in RSI, with the planned placement of an extraglottic device, without any intention to intubate.

Moreover, in this talk Darren takes you through the advantages and disadvantages of RSA. It is a fast and highly successful technique with minimal airway trauma.

On the flip side, some patients are not good candidates for extraglottic devices. RSA necessitates a secondary procedure and it does not provide a 'definitive' airway.

RSA is an alternative airway management strategy that may be ideal for preoxygenation of hypoxemic patients as well for prehospital and in-flight use. Darren provides the ins and outs of Rapid Sequence Airway in this talk, as well as providing the data and his real world experience of using this concept.

Finally, for more like this, head to our podcast page. #CodaPodcast