Coda Change

Becoming competent in airway management requires good decision making and and technical skills. Ultimately what matters is how your clinical performance impacts patient outcomes. For this we need to have a clear understanding of what defines success ensuring that its more than just 'getting the tube'. Come to this talk and you'll experience a Canadian take on Guinness, adventure sports, flying a plane and how other factors including failure influence airway management outcomes.

Ellen O'Sullivan presents an outline of the Difficult Airway Society (DAS) Guidelines on airway management.

Airway management is a fundamental responsibility and skill of all involved especially for emergency physicians, anaesthetists and critical care physicians.

She provides a few harrowing examples.

The 2015 Difficult Airway Society guidelines, published in the British Journal of Anaesthesia in December 2015, provide a sequential series of plans (A to D) to implement when tracheal intubation fails.

They promote patient safety by prioritising oxygenation and minimising trauma. Furthermore, they highlight the role of neuromuscular blockade in making airway management easier. The guidelines recognise the difficulties in decision making during an emergency and stress importance of human factor training.

The guidelines include steps to assist the anaesthetic team by providing a common stem of options (a simple algorithm) for maintaining oxygenation, limiting the number of airway intervention attempts, encouraging declaration of failure by placing a Supraglottic Airway Device and overtly recommending a time for stopping and thinking.

They emphasise the importance of considering discontinuing anaesthesia and waking the patient up (if appropriate) when tracheal intubation has failed. The guidelines recommend videolaryngoscopy and second generation Supraglottic Airway Devices. All anaesthetists, intensivists and emergency medicine physicians should be able to use these devices.

There is limited evidence relating to the management of the 'can't intubate can't oxygenate' situation (CICO) PLAN D. However, all anaesthetists should be able to perform a surgical cricothyroidotomy (and trained accordingly).

Join Ellen as she provides you with what you need to know for management of the difficult airway, in line with the DAS Guidelines.

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Reuben Strayer presents a masterclass on airway management with laryngoscopy.

In the past two decades, airway management has been revolutionised by the development of video laryngoscopy, hyperangulated blade geometry, optical stylets, laryngeal masks, and a host of advances in airway pharmacology and technique.

The core skill of airway management, however, remains laryngoscopy. Reuben provides his take on how to perform this procedure with success.

This includes the common mistakes made in patient positioning. Reuben shares a proposed set of parameters that the provider can use to guide positioning that is optimal for laryngoscopy. He also guides you through his take on the grip to use throughout the procedure.

Reuben talks about the effect of the grip on the operator's catecholamine production and what to do to avoid excess catecholamine levels which will be detrimental to performance.

He proposes an alternative approach that emphasises early laryngoscopy with deliberate slowness.

Reuben highlights the value of the jaw thrust – as performed by an assistant – during airway management. Then, he moves into a step-by-step analysis of laryngoscopy as the blade moves into the mouth, down the tongue and ultimately to the glottis.

This is an under-utilised device in his view. He discusses the two most important intra-laryngoscopy optimisation manoeuvres. First, optimisation of the position of the head and then, optimisation of the position of the larynx.

Reuben concludes by discussing the value of using the gum elastic bougie for both difficult and routine intubations and describe pitfalls encountered when using the bougie (and how to manage them).

In this presentation, Reuben Strayer breaks down laryngoscopy into its discrete components and describes best practice techniques at each step.

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

Ross Fisher gives his take on how to make your presentations better!

Delivering a presentation is a skill like any other, yet few people are actually develop this skill. Instead, they merely copy those they observe and reach the same level of mediocrity.

There is more to a presentation than your slides.

In Ross' view, these elements are all equally crucial to delivering a great presentation. He calls this concept 'p cubed' where each element is represented by P1, P2 and P3 respectively, and these elements are multiplied together to give the overall quality of the presentation.

The lesson here is that a small improvement in any area will garner and overall improvement in the presentation. Ross will guide you through practical tips for each of his key elements.

Firstly, your presentation needs to be grounded in an engaging concept in order for the audience to care about what is going on.

Moreover, Ross discusses the use of media and why slides of text are unhelpful and why PowerPoint sucks! Along the way he teaches you how you can utilise PowerPoint to you advantage to effectively get your point across and to avoid the strikingly common errors used.

Lastly, Ross gives his thoughts on the delivery and performance and how you can utilise these skills to improve your presentations. Ross will make you uncomfortable when he highlights the wrongs that we are all guilty of in giving presentations. The p cubed concept gives an understanding of presentation design that will change your presentations forever.

How to Give the Greatest Presentation in the World: Ross Fisher

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Suman Biswas is an anaesthetist from London, however probably more famous for his satirical song writing career, gives a poignant talk about communication.

Suman provides his ideas about talking and communicating with patients. As everyone knows, anaesthetists do not need to talk to their patients!

Quite the contrary, as Suman divulges they indeed do. They need to establish rapport, gain trust and share information – much like every other member of the healthcare team.

Therefore, Suman will provide his musings on the use of language and the words we use when we attempt to succeed in these domains. Suman touches on the use of both verbal and non-verbal communication and the importance of nailing both when attempting to get a message across.

He similarly gives guidance on communication with patients who speak a different language to your own. This includes pointers on the use of interpreters. Suman moves on to communication with colleagues.

He talks about Anaesthetic Non Technical Skills (ANTS) – teamworking, task management, decision making and situation awareness. These are most prominent when under pressure, be that in a simulation or in an emergency.

They are all crucially important – as much as gaining a successful airway! Punctuated with some classic songs and delivered with his stand-up comic timing and panache, this is what SMACC is all about: an important message that could change your practice, delivered in a unique and unforgettable way. Language warning.

Communication in Healthcare (via Music): Suman Biswas

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Jenny Beck-Esmay, Dara Kass and Stacey Poznanski tell the story of FemInEM and celebrate women in Emergency Medicine.

Jenny shares the story of Casey Drawert, a doctor who was tragically shot to death by her husband. This incident opened the discussion regarding how common domestic violence in physician relationships is.

In response to this incident, Esther Choo wrote "Intimate partner violence, a physician mother and our call to action" for FemInEM. Esther's post garnered a lot of attention and led to numerous women and physicians to come forward with their story of violence.

Dara talks about an incident regarding changing gender dynamics that led to the birth of FemInEM. A female physician received a call from her son' s school when he missed his class. This was despite the primary contact being specified as the stay-at-home father.

This incident motivated the formation of FemInEM. Even though there are multiple women organisations, women seldom know what is happening beyond the boundaries of such organisations.

Dara explains the data to prove that gender inequity exists in the field of medicine. Female doctors are only paid 64% compared to their male counterparts. She also points out the pipeline leakage where the percentage of women keeps decreasing as the job hierarchy increases.

Stacey talks about Dr Jullette Saussy who had to resign from her post as EMS and assistant fire chief in Washington D.C. This was because of the resistance that she faced at every level.

Stacey points out that FemInEM is not only about maternity leave and the gender pay gap. Instead, it is about providing support and connection to women, like Jullette, who try to make a difference in patient care.

By connecting with women through various platforms, they have been able to identify specific problems faced in emergency medicine.

FemInEM recognises the accomplishments of women in emergency medicine and has opened discussion on topics that were previously taboo. She believes that open access and open communication will have a positive impact on gender equity in emergency medicine.

The FemInEM Story: Celebrating Women in Emergency Medicine

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

Sandra Viggers delves into the art of learning medicine.

On one hand, people believe students cannot choreograph their own education for various reasons. She calls such people behaviourists who push others back in line if they do not agree with their views.

Behaviourism is a top to bottom approach. The teacher is not a facilitator but an instructor. It produces MDs with knowledge that is not applicable to real life.

On the other hand, can students choreograph their own education? In educational psychology, these people are called humanists. In the humanistic approach students are active learners.

The problem with this approach is that it is dependent on intrinsic motivation. Hence, it is important to realise when the student is intrinsically or extrinsically motivated.

Sandra points out that both behaviouristic and humanist approaches fail to include the skill of reflection. While the humanist will expect the learner to self-realise reflection, the behaviourist does not even believe in the concept.

Behaviourism trains people by correcting their behaviour. They are trained to work in an 'ideal world.' Therefore, they often fail to perform in unpredictable settings.

The humanist approach produces people who are interested in specific topics. The solution is realising that both a humanist and behaviouristic approaches are inadequate.

Students today are independent, love to learn but do not like to be forced. Importantly, they are aware of their needs and use connectivism. Connectivism believes in learning via social interaction.

According to Sandra all these theories are flawed. She believes that the solution is adaptive expertise. We want doctors to apply their knowledge to different situations.

To achieve this, we first must challenge or question everything that we have learnt. Make students aware that there is more than one solution to a problem.

The second step is to encourage reflection. Sandra endorses adaptive expertise via transfer of learning. She wants educators to create a playground where students can play, replay, fail, try and challenge themselves.

Sandra concludes by listing what she expects from her educators. She wants us to embrace learning as bidirectional and to encourage the art of reflection.

This will help students become creative, adaptive, lean mean machines of excellence.

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

Tom Evans wants to bring lessons from elite sport development and training to medical education.

Caring for the critically unwell is an important and difficult task. So, preparing our people to meet this challenge should be all about excellence. These are all true of sport – and Tom contends perhaps medical training!

There are a number of challenging tests along the way for an athlete to reach the pinnacle of representation. So hard are the tests that not everyone will make it to the end.

However, when one does make it, how the performance in those tests to get there has no bearing on how they will perform in the race or on game day. Standards are rigorous because there are no second chances. You do not get another go at the Olympic final.

Elite athletes often only have a handful of coaches during their career. Coaches are accountable for the performance of their athlete and talent will not rise on its own. Tom contests the medical training should look more like training for elite performance in sport.

He tells the success story of the Great Britain Olympic Team and how they managed to increase their gold medal tally from a single gold in the 1996 Games to 29 by the London games just sixteen years later. This was done by targeted spending by developing coaching and developing systems to identify and subsequently develop talent.

Too often, the structures and pressures that define medical training focus on competence rather than excellence. Competence is measurable. It can logged, assessed, and can be applied across big organisations. But aspiring only to competence limits us – our patients need more.

So can we learn from how other high-performance organisations train? For Olympic teams, aiming for competence just isn't good enough. These organisations develop their athletes over many years – equipping them, ready to deliver an excellent performance under pressure.

Successful coaching relationships operate on an individual level. They are long-term. They are flexible. And they are measured not by exams or assessments, but by whether the person being coached can perform in the real world.

Join Tom and discover why he believes the paradigm should shift from medical trainers to medical coaches and how we should strive not for competence but excellence.

Lessons from elite sport brought to medical training by Tom Evans

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This will be a panel discussion with a focus on the different styles of training and education in prehospital care.

Ross Hofmeyr divulges some stories from his experience of wilderness and expedition medicine.

In his words, wilderness and expedition medicine is the epitome of practical, pragmatic, minimalist and thoughtful care. Austere and extreme environments require special knowledge, critical thinking, innovative practice, and sometimes cunning improvisation.

Moreover, diagnosis in the wilderness relies heavily on clinical examination skills. Monitoring is limited and treatment options are determined by the individual practitioner's hands-on skills.

Furthermore, the implications of extreme environments – high pressures and altitude, frigid and sweltering temperatures, hypoxia, and high-intensity endurance exercise – can provide us with great insight into the physiology of humans responding and adapting to critical illness.

Join Ross as he displays his deep love of the wilderness and nature, and the lessons he has taken from the outdoors. These lessons, whilst useful for medical practice, transcend medicine. His stories are funny and engaging and show a side of medicine rarely talked about!

He discusses lions, ships, dental procedures, meningitis and much more in this fast-paced talk. In this presentation, Ross shares trials and tribulations and draws on experiences from wilderness rescue, and expeditions around the world, which provide lessons for wilderness medics.

Evidently, we can translate these lessons into practicing better acute and critical care medicine in our day-to-day settings.

Lessons from Wilderness Medicine: Ross Hofmeyr

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