Coda Change

Alex Psirides discusses the problem with major hospitals and the systems that they use.

Throughout he uses a case example to highlight how and why things go wrong. Moreover, he suggests potential strategies to reframe the way care is provided in the hospital system.

As patients become more complex, the tribal systems we use to look after them remain stuck in the 18th Century. Back when the treatment for everything was amputation and, if you survived, leeches.

The large modern hospital is becoming a battleground of competing specialises, only concerned with their area of expertise. This leads to multiple single organ teams practising their art in a multi-organ (failure) world.

Expertise is found far away from the ward in Emergency Departments, operating theatres, and ICUs.

Despite disease not knowing or caring what time it is, all hospitals operate with minimal nocturnal on-site expertise. As nursing & medical staff move more towards rotating rosters where no-one knows more than a single-sentence summary of their patient's complex physiological, pathological & pharmacological needs, an ever-present vigilant family member may become the only hope of surviving any acute admission.

Compounding these issues is the medial education system that is not keeping up with what happens with patients. Advances in medical care and technology mean that patients who would have been cared for in the ICU 30 years ago are now being looked after on the wards by junior doctors with little training or experience in critical care.

Unfortunately, junior doctors often call for help when it is too late.

Join in to listen to a self-professed middle-aged intensivist rant about how things were so much better 'back in the day.'

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Anthony Baca provides a focused talk on prehospital critical care response to the active shooter.

Coming from the United States of America setting this is unfortunately not a rare occurrence.

Anthony will discuss the real-world violence that exists, and what are the most important considerations for first responders in such situations.

Anthony speaks about prehospital critical care team responses to mass shootings. He explores how emotional and physiological barriers run amok making the simplest logistical and clinical decisions extremely difficult.

Moreover, Anthony provides real world advice should you ever find yourself called to a scene with an active shooter. This includes the importance of staying "left of bang", incident recognition, initial confusion, and the critical nature of incident acceptance.

Further, he reviews staff and patient safety priorities and basic concepts of tactical combat casualty care (TCCC).

Finally, Anthony concludes with thoughts about your role as care provider when on duty as part of a pre-formed team, and what to do if off duty facing an active shooter.

Today is the day to ponder actions you must take the moment an active shooter begins taking lives at an astonishing rate; that moment when the choices you make next will be the most important of your career.

The choices you make today will affect the milliseconds and millimetres that determine survival… patient survival, your survival, and the survival of those waiting at home for you to walk back through the door.

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Scott Weingart discusses post-intubation sedation – a topic that tends to aggrieve him on a regular basis.

Scott explains in simple terms why he is bemused at the lack of understanding surrounding intubated patients who become agitated or aggressive.

How would you like a piece of plastic placed down your throat?

The problem, as Scott explains, is that sedation does not blunt pain. Sedation without analgesia leads to delirium.

In simple terms delirium leads to poor outcomes and death.

Moreover, concerningly, the early sedation strategy of intubated patients has long term and far-reaching outcomes during their course of critical illness.

So, what can be done? Scott explains that we need patients properly sedated, however not too deeply sedated.

The goal needs to be a patient who is oriented, safe and with a normal sleep-wake cycle. Paralysis is not the answer. What is the answer?

Scott walks you through A1 sedation – meaning analgesia first. Once pain is controlled, then sedation comes in to play.

Scott stresses with analgesia first, the sedation needed is less. He explains how he achieves this in practice in detail. He then provides some clinical examples and how he would approach them including which specific medications he uses in practice.

Scott's main points are simple. Control the pain and very few patients will need a lot of sedation.

In addition, if you adequately control the pain, very few patients will have delirium in the Emergency Department.

Join Scott as he passionately discusses post-intubation sedation.

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Katrin Hruska discusses the usefulness of biomarkers in Emergency Medicine.

All biomarkers are awesome predictors of badness. Elevated hS-troponins after non-cardiac surgery or an acute exacerbation of COPD are associated with increased mortality.

In seemingly healthy people, elevated D-dimer levels are associated with increased mortality. Similarly, NT-proBNP levels predict mortality in patients with end-stage renal disease.

A biomarker, in its broadest sense, is defined as "a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention" (NIH Biomarkers Definitions Working group, 2001).

This definition includes everything from laboratory tests to blood pressure measurements or an ultrasound scan. The clinical assessment in the Emergency Department is based on the subjective history of the patient and all available biomarkers (and their change over time).

If we assume that biomarkers are objectively measured, there is an overestimation of their individual importance.

In a clinical context the ease of getting a laboratory test leads to a lower threshold for testing. This increases testing without affecting relevant clinical endpoints. Also, when a biomarker becomes part of the standardised workup for a certain symptom, primary care centres and emergency telephone services will refer patients to the Emergency Department for testing, even when the pretest probability is low.

Katrin contends this bias is not an inherent problem of biomarkers themselves, but of the decision-making process of clinicians. The human brain fears uncertainty. Anything that adds to the feeling of knowing is rewarding, which is the most probable explanation of over testing in settings where medico-legal risks for the clinicians are low.

There is an ever-increasing number of patients seeking to rule out serious conditions by relying on biomarker testing to provide certainty.

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Chris Hicks delves in to how to optimise performance in a team environment in emergency medicine and critical care. When teams fail and fall apart, we are quick to analyse the performance. We pick it apart and see what went wrong, and why. Chris suggests that we should do the same thing for over-performing teams. We should analyse how and why they perform at optimum levels. In doing this, in reaching a higher understanding of elite performance, we can harness the techniques used, simulate and train them, and thus improve performance across the board. This is not a new concept. High performance in elite sport is driven by athletes searching to push themselves in new and more extreme ways during training. They do this so when they are faced with stressful situations in competition, they have seen it all before. High performers talk about being 'in the zone'. This is a state of body and mind where optimum performance comes naturally and easily. Research suggests that when an individual is 'in the zone', areas of the brain go quiet. Your ego and your inner critic dampen down. Other more useful and helpful areas light up. These tend to be deeper areas and are related to information processing and linkage between ideas. They often are drawing on prior experiences. These are less conscious processes. Chris contends that conscious thought is expensive and time consuming and by tapping into this 'flow' state, you optimise performance. Chris then discusses how to utilise this research and methods used in other industries. He brings the lessons that are apparent from outside sources and describes how these can be implemented in medical training and simulation. He describes a method to play with perceptions. Rather than seeing situations as threatening, Chris highlights the benefits of embracing them as challenging – an opportunity to demonstrate elite performance. Further, he discusses a three-step process to practically implement the lessons he is talking about. So to improve performance whilst working in teams in emergency and critical care medicine, listen in to Chris Hicks discuss all things high performance.

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Adrian Plunkett describes how to learn from excellence in critical care. Learning from excellence is an initiative which began at Birmingham Children's Hospital. Firstly, Adrian shares an anecdote regarding how the initiative begun. He sent a letter to the CEO of a hospital appreciating one of the doctors who treated him for cancer. The doctor unfortunately never received it. This caused Adrian to ask - is appreciation and gratitude undervalued? Evidently, noticing excellence will lead to two things: learning new insights and increasing staff morale. Adrian raises the question, why we do we not focus on the good things? We spend all our time improving safety and quality even though accidents and disasters are only a small percentage of what we do. Moreover, Adrian claims that people inherently have negative biases. This is evident in healthcare, so how can we combat this? The solution is to focus on excellent care. This led to the formation of a reporting system called Learning from Excellence (LfE), where people answer two questions: Who did something excellent? What did they do? LfE is a formal system for reporting and providing positive feedback and appreciation to the healthcare workers. It is a beneficial and constructive way of learning from excellence. Finally, Adrian explains, "Saying 'thank you' or 'well done' is the easiest quality improvement intervention of all."

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Jo Anna Leuck discusses fatigue in critical care.

Is there a specific time during our shift when we are too fatigued to safely practice?

That was the question that led to Jo Anna's research project comparing the clinical performance of providers during the first hour of a day shift and the final hour of a string of night shifts.

The providers were pulled out of their real-time clinical duties and video-taped while performing simulated critical care cases.

The hypothesis was that the day shift providers would out-perform the night shift, but surprisingly the opposite proved true. Blinded reviewers assigned the day shift providers lower performance scores. Furthermore, they noticed some surprising medical errors committed during these simulated cases.

She raises examples such as coming in to work after a few days off, or after an extended break and posits that performance will be negatively affected in these circumstances.

Perhaps clinicians, similar to others who are elite in their field, truly need daily practice or some type of deliberate exercise prior to a shift to perform at the highest levels of care.

How can we determine when we are not at our maximum level of mental sharpness during a shift?

Can we improve our abilities in real time?

Jo Anna concludes by suggesting some strategies to counteract these drops in performance. Allowing more time to get to work to reduce cognitive load, utilising mental rehearsal and taking advantage of checklists are all explored.

In this talk, Jo Anna discusses mental fatigue and critical care-based shift work. She focuses on techniques to recognise and potentially mitigate any clinical sluggishness and improve patient care.

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Karin Amrein talks about the challenges for women working in the critical care world.

Incredibly, despite female prevalence, Critical Care is considered a man's world.

We've all heard the notion, "big boys with big toys." The false assumption is that men are more interested in the latest equipment and technology. However, Karin thinks that the "soft factors" like love, care and teamwork are what will make the biggest difference in the future.

Moreover, women are judged by their appearance and not their accomplishments. They are subject to questions like "Are you really a doctor?" or comments like "But you don't look like a professor."

Patients and their families are often insecure when a woman oversees their treatment.

One review showed that women have to be 2.5 times more productive to be given the same score in peer review. Another study showed that papers received better reviews when authored by a man.

Karin presents statistics regarding women in critical care with 31% of ICU trainees and 21% of ICU consultants being women. However, only 7% of the ICU editorial board members were women which was the lowest among all other departments.

Some things can be easily fixed, such as ensuring female speakers are on conference panels. She applauds SMAAC for having an equal distribution of male and female speakers, participants and organisers.

Karin encourages everyone to ask themselves the question "What would you do if you were not afraid?" and to do that without worrying about the consequences. Critical care is in fact, a great place for women.

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Motorcycle Trauma Simulation and discussion

Ashley Liebig is a senior flight nurse and helicopter rescue specialist with STAR Flight.

She talks with passion about her job, her vocation.

Ashley divulges a deeply personal and deeply traumatic story from the SMACC stage.

Pre-hospital medicine, emergency medicine and critical care are difficult jobs. There is a human toll to be paid when working in these areas.

Ashley wonders if the stress, the emotion and the trauma torments all listeners. She believes it does not matter. Because it affects some. And it has affected Ashley.

Ashley implores you to be nice. She wants her colleagues to understand her, communicate with her, and respect her.

She explores the physiological maladaptive response when humans experience trauma and relates this to her experience.

Ashley goes on to share how she has, and is, dealing with the chronic stress she is experiencing. It involved adaptation and behaviour changes.

She educated herself on the effects of chronic stress and engaged strategies such as exercise, laughter, and human touch to counteract these. She engaged in communication with her family, so they were aware of what she needed.

Moreover, she started having more honest conversations with her colleagues.

Through her brave relaying of her own experience, Ashley wants to convey the importance of being aware of chronic stress, recognising it in oneself and others, and continue to strive to face it and deal with it together.

Dealing with Chronic Stress in Critical Care

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