Coda Change

Kathleen Thomas describes her harrowing experience of a warzone whilst working in the ICU and ED of the Médecins Sans Frontières run Kunduz Trauma Centre (KTC) in northern Afghanistan.

Kathleen describes her work during a week where she found herself caught up in an eruption of war. The Taliban forcibly took control of Kunduz from the US backed Afghan Military.

This marked the beginning of a challenging week of heavy conflict in which the hospital was the only facility providing impartial medical care to war wounded civilians and soldiers from both sides of the conflict.

Despite the proximity of the rapidly changing front line, Kathleen believes that the hospital is the safest place. Both warring parties had agreed to respect the protection provided to us under International Humanitarian law.

Kathleen's work in KTC came to a grinding halt when a US Gunship fired over 200 missiles into our hospital. This destroyed the main building and killed 42 people including 14 of her colleagues.

More than 250 hospitals in Syria and 130 in Yemen have been attacked. This shows a growing disregard for the rules of war. Despite the condemnation by the UN, the attacks on medical facilities continue, unabated.

Following an eyewitness account of the attack on KTC, Kathleen asks some important questions: Is international humanitarian law no longer respected by warring parties?

Are we entering into a new paradigm of war where hospital attacks are a legitimate military tactic?

What does this mean for the future of critical care delivery in war zones across the world?

Bombing of Hospitals in Warzones: Kathleen Thomas

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Trish Henwood talks on all things point of care ultrasound (POCUS) in resource limited environments.

According to the World Health Organisation, 80-90% of all diagnostic problems can be solved by basic radiograph (x-ray) and ultrasound (US) examinations. However, the problem is that two-thirds of the world's population currently has no access to imaging technologies.

From refugee camps in Greece, to rural clinics in Australia, to Everest Base Camp, POCUS is one of the most powerful diagnostic and procedural tools in any austere clinical setting. This transformative technology allows front line providers who have direct responsibility for patient care to rule in or rule out diagnoses rapidly. Moreover, it ensures safety in performing procedures with real-time image guidance.

For example, POCUS training can allow a midwife to identify a massive amount of free intra-abdominal fluid in a 30 year-old Ugandan mother presenting to gynaecology clinic with her third pregnancy and new abdominal pain. She can then notify the surgeon of her concern for a ruptured ectopic pregnancy.

Waiting for imaging facilities and specialists leads to delay in definitive care and poor outcomes for patients.

Ultrasound machines have become increasingly portable, user-friendly, and less expensive over the last decade. This is resulting in a growing presence in otherwise resource poor environments.

POCUS trained clinicians can afford imaging capacity to health facilities that may have very limited on-site diagnostics. There is no ionising radiation, nothing invasive, and it is cost-efficient.

POCUS provides the potential to quickly narrow differential diagnoses by facilitating a look inside the body during the patient encounter. Research studies support its use to solve information gaps in resource-limited settings.

Moreover, the potential for this digital technology to be shared – and to leverage global expertise and consultation – increases the range of application beyond one individual's knowledge base.

Join Trish as she highlights the amazing capacity of POCUS with real world stories.

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David Carr teaches you how not to miss the diagnosis of aortic dissection.

David breaks down the key pearls on history and physical exam that guide you into correctly suspecting a dissection.

Aortic dissection is a challenging diagnosis that you cannot afford to miss. The talk aims to give you the framework to avoid missing the diagnosis.

Firstly, David begins by teaching you what questions to ask in the history to raise the suspicion of an aortic dissection. These include onset, quality, and radiation.

As he explains, these simple three questions will raise the suspicion in the vast majority of cases.

Secondly, David goes on to an in-depth explanation of the pain patterns that can present in an aortic dissection. He describes the concept of chest pain plus one. David delves into what he sees as the questions and considerations only a 'master clinician' will think of. He implores you to join this group.

Evidently, the physical exam provides vital clues to the diagnosis of aortic dissection.

In this talk, David breaks down the key points that he always considers in a busy and noisy Emergency Department to lead him towards the correct diagnosis.

Next is the diagnostics, where David will spend some time sharing his insights into the diagnostic tests of choice when ruling in or out an aortic dissection.

He discusses the plain x-ray which may or may not be useful, troponin, which need to be interpreted with care and d-dimer.

Finally, David concludes by giving some pearls surrounding the judicious use of imaging, how to begin the treatment promptly and how to become a champion in the diagnosis of aortic dissection.

Sit back and be ready to see dissections in a different light.

How Not To Miss Aortic Dissections: David Carr

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Gareth Grier discusses who should be intubated following severe trauma pre-hospital.

This talk will look at current and previous pre oxygenation practices and some of the current research. It will also discuss the notion of commitment to evolution of practice, the breakdown of cognitive biases and how to move forward with adequate self reflected practice.

Peter Brindley explains why teamwork is the strongest drug in the hospital. Modern acute care medicine is eye-wateringly complex and potentially dangerous. It really can't be delivered safely without deliberately addressing our teamwork (in both acute and chronic situations). Unfortunately, historically, human factors were commonly left to chance, and recently have been threatened by decerebrate checklists and meaningless 'psychobabble'. Peter describes communication and its critical role in the effectiveness of any team. He compares the voice of a team leader to a drug. Like a drug, it can be a placebo or a nocebo, depending on its use. As such you must use the right drug at the right dose for the right patient and the right time! Moreover, other forms of communication play an integral part of any team environment. Peter discusses verbal, paraverbal, non-verbal and other forms of communication which all need attention. Rudeness, and its damaging potential is highlighted. Peter contends that rudeness alone will decrease both team and individual performance, impair diagnosis and impede procedures. Peter puts his message in to real world examples. Specifically, Peter discusses the management of airways – especially difficult airways whether that be anatomical, physiological or situation difficulties. In cases such as these, it is the clinician's job to be understood when they communicate. Practical strategies to improve communication and teamwork exist and Peter highlights these in this talk. We have much to learn but must also avoid overly simple answers to exceedingly complex problems. It's time to get back to basics. Come be part of a practical revolution and resuscitate by voice.

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Richard will cover the rationale and evidence for prehospital blood product transfusion in trauma, look at the available current and future options, suggest best clinical practice and highlight areas of future research.

William Knight presents the considerations in the management of extra-cranial injuries in patients with traumatic brain injuries (TBI).

Patients with TBI often have concomitant systemic injuries that complicate the management of the TBI.

In this talk William presents his five top areas to think about – prognostication, suitability for the operating room, use of ventilators, pressure considerations and monitoring.

Prognostication becomes difficult when a brain injury is added to other injuries due to the long-term nature of neurological damage. This means that other clinicians can be unsure when managing extra-cranial injuries in such patients.

Adding a brain injury on top of other injuries tends to make people unsure, and enhances nihilism.

However, some simple measures and tests can go a long way to reassuring the treating team of a patient's suitability for the operating room.

William describes the 'lay flat test', which is as simple as it sounds – laying a patient flat and observing the ICP. If it rises, then they are likely not appropriate. One must also consider the urgency of the proposed procedures.

William describes the ventilator as the single most lethal piece of equipment for a patient with a brain injury. The use of ventilators needs to be done appropriately and William describes the parameters to consider. Pressure is a broad category.

There are more acronyms than you can poke a stick at. William tries to make sense of them for you as he describes how he manages pressures in the TBI patient complicated by systemic injuries.

He makes the point that you need to remember other places of elevated pressure in the multi-trauma patients outside of the lungs and the brain. Consider your compartments including in the legs, arms, and abdomen.

Evidently, monitors do not save people; the use of monitors do. What does all the data mean, how do you monitor in the neuro ICU and how do you deal with contradicting data points. Using the data and taking in the whole picture in the TBI patient with extra-cranial injuries is complex.

Join William Knight as he attempts to make sense of this complex area of medicine!

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Jo Anna Leuck discusses how to learn from error in paediatric sepsis.

Rory was a healthy 12-year-old boy, known for his smile and for standing up for others. A simple fall during basketball practice caused an abrasion on his arm. This is the suspected beginning of a cascade of events that led to his death from sepsis.

Rory was seen by both his paediatrician and a local Emergency Department and was sent home with a diagnosis of a viral illness.

He returned the next day in septic shock and died shortly thereafter. A review of the medical records revealed that there were errors that occurred during his emergency department visit.

This talk will attempt to move away from the controversy of the actual article and instead focus on how these common errors could have occurred during any busy shift and what we can do to prevent them in the future.

Jo Anna's intention in giving this talk is to continue to use this case to raise awareness of both paediatric sepsis and common medical error.

When considering paediatric sepsis Jo Anna asks - Was this preventable? Were there clues? Why was this missed?

Recognition is the first step. Often procedures are used in this case. The Paediatric Sepsis Score is one such example.

Jo Anna talks about vital signs and how they are tricky in kids due to the changing reference ranges depending on age. Jo Anna recommends having easily accessed charts and stresses thinking twice about the size and age of the child in front of you.

The physical exam is as important as always. In kids, there are certain signs that should raise suspicion such as skin mottling. And in terms of treatment Jo Anna stresses rapid access, rapid fluid boluses and thorough re-evaluation alongside age-appropriate empirical antibiotics.

Lastly, Jo Anne touches on the errors that this case highlights. She provides some strategies to improve your practice.

Before discharge consider three main components. Vital signs, diagnostic studies, and communication!

Simple, but careful attention to these components of care will lead to the medical profession learning from errors and preventing them in the future.

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Kieran Henry gives his insights into hospital handovers of major trauma.

He makes the comparison between prehospital care and the life lived in a Western movie.

Kieran stresses that he does not want you to behave like a cowboy, jumping off your horse (ambulance) as it is still moving into town, without much dialogue and with no one really knowing what is happening.

Instead, be the preacher man! Be cool, concise, and clear in your messaging. Prepare, practice and be professional.

Much like the preacher man, you will be listened to if this is how you carry yourself. You will then be able to convert the non-believers.

Delivering the handover message effectively and efficiently is crucial.

Tune in to Kieran to learn how to convert the non-believers into believers and do good patient handovers.

Hospital Handover of Major Trauma: Kieran Henry

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