Coda Change

Nikki Blackwell provides an insight into critical care in humanitarian emergencies.

Through her experiences in hunger emergencies, epidemics, natural disasters and conflict zones, Nikki has gained a wealth of wisdom and lessons.

She shares these from the SMACC stage.

Nikki talks about some of the practical things she does when working in resource poor settings. It starts with hospital hygiene to reduce nosocomial infections, and often entails Nikki working alongside the cleaners due to resource limitations.

Hand hygiene is difficult without running water and Nikki champions using the WHO Handrub Formulation.

Other challenges include cold chain storage, blood donations, limited monitoring and food and nutrition.

Nikki also discusses the challenges of working in different environments. Invariable the environment will be too hot… or too cold!

On top of this, working in remote locations often entails living with the other medical professionals you are working alongside. This presents interpersonal challenges.

Moreover, Nikki touches on the personal dangers of working in some of the more politically unstable locations around the world. Training becomes hugely important in resource poor settings when you are dealing with complex medical and surgical cases. Especially with less-than-ideal resources and equipment.

Nikki expands on what is possible with good training, intuition, and a Swiss army knife. If you do not do anything stupid, and you have basic resources backed up by sound training, it is amazing what you can achieve and who you can help.

She concludes by touching the future direction of care in resource poor settings highlight the potential for technology to make huge changes and advances.

Critical Care in Humanitarian Emergencies: Nikki Blackwell

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

Kathryn Maitland describes the challenges faced with oxygen therapy as an emergency intervention in critical illness in African children.

Where Kathryn works, in East Africa, there is no access to intensive care. Caring for critically ill children is all done in the Emergency Department.

70% of the global burden of disease and deaths from pneumonia occurs in Southeast Asia and Sub-Saharan Africa. The WHO has published guidelines as to what classifies as pneumonia, severe pneumonia, and very severe pneumonia.

These classifications rely on clinical signs. However, Kathryn in her research has discovered that these classifications are rarely correlated with the actual underlying disease process.

Clinical signs are non-specific for the diagnosis of pneumonia. Oxygen is recommended for severe and very severe pneumonia.

This has led to calls to prioritise oxygen delivery in African hospitals. However, it has not led to change from a health department or funding viewpoint.

There are also oxygen delivery practicalities to consider. Often there is only one source of oxygen on a ward (if at all) with patients clustered around it.

Poor cylinder quality leads to leaks and therefore, low supply.

Concentrators are useful however they need regular servicing. They also rely on power, and in a region that experiences regular power outages, this can be problematic. When the power goes off, there is no oxygen available.

Kathryn asks – do all children actually need oxygen? There is still however a hidden burden of hypoxia.

Outside of Africa, Kathryn discusses the current state of equipoise on oxygen therapy.

Moreover, oxygen can be harmful if given inappropriately. This leads to concerns more broadly on the harms of oxygen therapy.

Kathryn concludes her talk by looking to the future. She discusses ongoing research and the implications for future practice in resource poor settings, and indeed the world.

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

Francesca Rubulotta argues in favour of the ICU being no place for the elderly.

She describes the ICU as a horrible monster, a very dangerous place. Furthermore, she suggests the ICU is on par with climbing a mountain in terms of risk and exposure to catastrophise.

She continues to make the point that once a person reaches adulthood, the healthcare system is a one size fits all model.

This extends to the type of treatment required – whether it be for an acute or chronic condition.

Whilst hospitals, and ICU specifically, may be suited to assist those with acute conditions, it is perhaps less appropriate to deal with chronic conditions that avail the elderly.

Francesca concludes that for the elderly, there needs to be a new model.

Karin Amrein provides a counter argument. She bases this initially through a personal story of her grandmother. This provides the basis for her argument that advanced age does not predetermine outcomes in healthcare.

'Elderly' is a large spectrum and age alone is a poor individual determinate for health. At an individual level, age cannot tell one how a person will fare in the ICU, and it can be an appropriate setting for the right 'elderly' patient.

Karin contends that all patients are worthy of care in all settings depending on their personal context. Whilst with elderly patient one might consider conditions such as sarcopenia or dementia, this should not render them unworthy of care.

Karin suggests this is discrimination.

For Karin, age is just a number, and it is the person that should be treated – including in the ICU if appropriate.

Join Francesca Rubulotta and Karin Amrein as they debate whether ICU is a place for the elderly.

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

Darren Braude and Karim Brohi debate over the utility of hard cervical collars.

Darren argues that it is time to do away with hard cervical collars. He raises some assumptions.

The first being that movement of the spine is bad. As he explains, movement is not the problem.

Rather, energy deposition in the spine causes injury, not simply movement. With that being said, the problem is that the hard collar does not prevent movement!

Surely, the benefits of the hard collar outweigh the risks. Darren argues otherwise.

He discusses the effects of the hard collar on ICP and venous drainage of the brain. The issue here is that the patients with the highest risk of cervical injuries also carry the highest risk of concomitant brain injuries – and we as clinicians should not tolerate any increased risk to the brain.

Finally, Darren argues that the hard cervical collar impairs airway management which is the priority for any emergency situation.

Karim argues in favour of hard cervical collars. He contends that the lack of quality evidence in this field is problematic.

Furthermore, Karim believes it is easier to suggest harm than to prove harm.

Likewise, it is also easier to suggest harm than to prove benefit. With that being said, Karim concedes that some of the harm Darren raises are possible and can occur.

However, he states that no one recently has practiced medicine in a world without cervical collars. The improvements in spinal care therefore cannot be separated from the use of hard cervical collars.

He asks the question; do you want to mess with these improved outcomes?

Karim also points out, that patient complaints about spinal care are rarely about the cervical collar specifically. He goes on to discuss how to navigate patient concerns.

Tune in to this enthralling debate between Darren and Karim.

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

PRO:

Medicine is a complex craft. Acute medicine is more complex. Excellence is delivering effective acute care depends on recognising the broad base of basic sciences, clinical experience, and results of clinical trials. Central to all decisions has to be how these will benefit the patient – both in the short term as well and longer term so that survivors of acute illness are left with the best possible outcome for that patient, their caregivers and the community at large. This is a daunting concept under time-limited, information-limited conditions. Clinicians are often left with uncertainty about the impact of decisions and rely on short-term surrogate measurements to justify treatment options. Consequently, assessing outcomes are invariably confounded by associations that bear little relationship to causation or biological plausibility. Such confounders are often demonstrated in observational studies and RCTs with low levels of internal validity, particularly those conducted in single centres and/or driven by protagonists of a particular intervention. Carefully conducted RCTs with high levels of internal validity – those that produce believable results from rigorous study design and those that produce results that are generalisble to specific patient populations remain the only way to mitigate bias and produce clinically-relevant answers to improve patient-centred outcomes. Critical Care Medicine leads the way in producing high-fidelity RCTs that have fundamentally changed clinical practice, not only in terms of producing better patient-centred outcomes, but also by producing unequivocal evidence to stop or avoid using of previously harmful treatments that had been enthusiastically embraced by clinicians and guideline developers. Such examples of benefit include the CRASH-2 and ARDS-net trials, and of preventing harm, the SAFE, NICE-SUGAR, RENAL, CHEST, DECRA and FEAST studies among others. The net impact of these pivotal trials has been the prevention of millions of deaths and the saving of millions of dollars. Such is the basis of GOOD clinical practice and these trials must be seen as a source of knowledge, science and pride … that ultimately improve patient outcomes .

CON:

This speaker is pretty certain he is going to lose...but he's going to go down fighting. He will argue against the mighty Dr John Myberg (whom, incidentally, he admires mightily). RCTs do certainly matter, but clinical judgment and prompt bedside attention matters far more. Moreover, RCTs so often fail to address the questions that really matter. RCTs also commonly fail to improve quality, effectiveness, safety, and reliability in modern complex acute medical care. A vote against the blinkered focus on RCTs is a vote for better (not biased) patient care. Myberg and his myopics must be defeated...come join me!

Martin Smith and Mark Wilson debate whether neurocritical care improves outcomes in severe TBI.

He concedes that longstanding and established practices are not as efficacious or innocuous as previously believed.

Very few specific interventions have been shown to improve outcomes in large randomised controlled trials. With the possible exception of avoidance of hypotension and hypoxaemia, most are based on analysis of physiology and pathophysiology.

Further, the substantial temporal and regional pathophysiological heterogeneity after TBI means that some interventions may be ineffective, unnecessary, or even harmful in certain patients at certain times.

Martin however, contends that improved understanding of pathophysiology and advances in neuromonitoring and imaging techniques have led to more effective and individualised treatment strategies. Ultimately, this has led to improved outcomes for patients.

In particular, the sole goal of identifying and treating intracranial hypertension has been superseded by a focus on the prevention of secondary brain insults. This is done by using a systematic, stepwise approach to maintenance of adequate cerebral perfusion and oxygenation.

Similarly, multimodal neuromonitoring also gives clinicians confidence to withhold potentially dangerous therapy. Particuarly in those with no evidence of brain ischemia/hypoxia or metabolic disturbance.

The New England Journal of Medicine has published several articles that demonstrate no benefit from classic neurotrauma interventions (ICP monitoring, cooling, decompression). This is because factors such as ICP and CPP associate with bad outcomes by association rather than causation.

This debate will demonstrate that critical care just complicates things. Evidently, it is high time for the randomised trial between the very best neurocritical care and NOB therapy (Naso-pharyngeal, Oxygen and a Blanket).

Join Martin and Mark as they discuss the pros and cons of neurocritical care in the management of severe TBI.

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

Anthony Holley and Marietjie 'MJ' Slabbert debate the value of prehospital doctors in trauma.

He does so with the upmost respect for prehospital doctors and having worked in this setting himself. He makes the point that across the globe, the employment of doctors in the prehospital setting is a rarity.

Working in this environment is diverse and every situation encountered requires a different skillset. This presents a logistical challenge.

Anthony continues to discuss the evidence, or lack thereof, in this space. He raises the point of competing interests from paramedics, flight nurses and doctors themselves.

This leads to apples being compared to oranges most of the time.

Anthony goes on to suggest all the advanced clinical interventions that are necessary in prehospital situations can be competently undertaken by paramedics.

In doing so, she concedes that the evidence base for prehospital medicine is scarce.

This is due to inherent biases, the difficulty of gathering data and the issues with methodology. However, MJ believes that care provided outside of the hospital should be of the same level as care received in hospital.

This provides a seamless patient journey from the prehospital setting into the hospital and improving the chain of survival.

Furthermore, MJ posits that prehospital doctors not only improve care of patients outside of the hospital, but care for those in the hospital and clinics too.

Prehospital physicians add value wherever they practise. They bring leadership, knowledge, additional skills, and training as well as innovation and collaboration.

Tune in as Anthony and MJ debate over the value of prehospital doctors in trauma.

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

Resuscitation of the critically ill trauma patient involves a myriad of high-stakes, time-sensitive management decisions. The landscape is shifting rapidly: new evidence on hemostatic resuscitation and component therapy in hemorrhagic shock, peri-arrest point-of-care ultrasound, novel approaches to resuscitative thoracotomy and trauma RSI have at once clarified and muddied the waters. In this rapid-fire, case-based session, Petro and Hicks will debate some of the recent and potentially practice changing literature to assist with key inflection points in the care of the sickest -- and sometimes deadest -- trauma patients, and engage in some trauma dogmalysis in the process.

Alex Psirides and Sara Gray debate over whether 'Do Not Resuscitate' (DNR) should be the default choice for all patients. Alex contends that application of 'CPR-for-all' is the ultimate evidence drift. A treatment that is completely appropriate for dropping dead whilst running a marathon has almost no place in acute healthcare facilities where chronic irreversible complex co-morbidities abound. 90% of doctors would not choose CPR for themselves, yet 100% are trained in how to administer it to patients. Defaulting to 'CPR-for-all' removes a patients' ability to provide informed consent for assault whilst they die from another disease. Remember – 2 weeks in ICU can spare you 5 minutes of difficult conversation. Sara on the other hand argues that DNR should not be the default position. Across the globe, patients are assumed to be full code to allow for prompt resuscitation, until code status can be discussed and clarified. There are numerous excellent reasons for this. Can you imagine if our systems decreed that DNR was the default? "Let's not shock that VF, until we can clarify his code status." Or, "let's not resuscitate that child, after all, DNR is the default and her mother isn't here yet!" Making DNR the default is not a good solution to ICU or hospital over-crowding. Let's not mandate DNR, let's mandate having reasonable code discussions early and often. Join Alex and Sara for a stimulating, engaging and entertaining debate!

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

In a 2 min rant about medical tribalism, Dr. van der Velde questions which medical specialty, if any, owns prehospital physician response. What is more important: skillset or specialty? Is there a role for tiers of physician response? Is there a future in a stand-alone specialty?