Coda Change

Marietjie (MJ) Slabbert describes the unseen enemy, fatigue in critical care medicine.

MJ does 24 hour shifts every other day with just three to four hours of sleep.

Though many would claim that this is more than enough, MJ thinks otherwise.

Physicians are killing themselves while trying to save others because fatigue kills. MJ points out that sleep is one of the basic necessities in Maslow's hierarchy of needs.

Fatigue often affects the go getters or type A personalities. Among doctors, the critical care and emergency doctors are at a higher risk of being fatigued.

MJ points out the dangers of being fatigued. Driving while tired is as dangerous as drunk driving or speeding. Fatigue also puts patients at risk as it increases medical errors and safety compromising behaviour. Studies show that the response time of anaesthetists increased twenty times when they were sleep deprived.

Doctors are at a higher risk of getting cancer and this has led WHO to consider shift work as a carcinogen.

Sleep deprivation increases the risk of developing obesity, depression, compassion fatigue, diabetes, wrinkles due to collagen breakdown, heart attacks, strokes, arrhythmia and even early onset Alzheimer's. It makes people weak and angry as they become less capable of handling stress.

According to MJ, there is no one size fits all solution to dealing with fatigue. However, the first step is to acknowledge the problem and to change the "tough guy" medical culture.

Doctors have to realise that they are part of the human race and need to rest. Doctors must help themselves so as to help their patients better. Taking breaks must be acceptable.

MJ encourages taking naps during free times at work. She wonders if doctors ever notice if their team is tired. She asks if it is measures or if hospitals have fatigue policies.

MJ ends by asking everyone to fight the battle against fatigue by waking up and going to sleep.

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James Tooley discusses the sheer terror that comes with the challenge of managing children in the pre-hospital environment.

As James explains, although many clinicians may think that they do not need to (or may not want to) think about the paediatric population, it is something that every clinician would do well to mentally prepare for.

James shows a video clip of a large-scale paediatric trauma and challenges you to consider being dispatched to the scene. How do you prepare for that?

Simulation, as usual, is key. Through simulation one can discover knowledge gaps, limitations of equipment and guidelines, and coping strategies.

James takes you through some specific pointers regarding equipment that one should carry when anticipating dealing with pre-hospital paediatric emergencies.

Next, James discusses pressure and how it degrades performance. A clinician should be aware of where their pressure limit is. The importance lies in recognising when you reach your cognitive overload.

Once you recognise this point you can be aware of it, deal with it and train to prevent it.

James continues to talk about simple ways to approach the pre-hospital paediatric emergency. The primary survey does not, and should not, go out the window in paediatric cases.

Similarly, simple analgesia can be a fantastic starting point to take control of a situation.

Lastly, James points out that just because young people are small and can be moved off scene easily, does not always make this the right choice. Stabilise, and then move is his message.

James contends that clinicians train and prepare for adult emergency situations and he challenges the audience to treat paediatric emergencies in the same regard.

Challenges in pre-hospital management of children

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Flavia Machado and Paul Young present the top 10 ICU trials of the recent past SMACC style. Their list of trials includes a number that challenge dogma and establish interesting new lines of scientific enquiry. In addition, they also include all the recent clinical trials that should change your practice. If you want to know what's new in critical care then this is the talk for you.

Anand Swaminathan and Iain Beardsell debate the use of thrombolytics in the treatment of submassive pulmonary embolism (PE).

PE is a spectrum of disease. Patients should be treated differently depending on where they are on the spectrum.

Subsegmental PE may need no treatment at all, whereas massive PE is unlikely to improve without thrombolytics.

Anand argues for the use of thrombolytics.

Evidently, time is critical when dealing with patients and Anand posits that thrombolytics gives the physician control over time.

Submassive PE can deteriorate, leading to massive pulmonary embolism. A proportion of these patients will die. The data is not conclusive for the use of thrombolytics in terms of mortality, however long term outcomes do improve.

Finally, Anand concludes by suggesting that the decision to use thrombolytics relies on sound clinical reasoning and decision making, informed by the available data. He argues for nuanced treatments and use of these drugs.

Iain takes a different approach in his reply.

Some of the most difficult topics in medicine attract considerable debate. The use of thrombolysis for submassive PE is one of these.

In this argument Iain attempts to highlight some of the most pertinent evidence against the use of thrombolysis. And he does so through song!

Submassive PE should be Thrombolysed: Anand Swaminathan and Iain Beardsell

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Ryan Wubben discusses the standards in Helicopter HEMS.

He asks the question, what standards?

The development of Helicopter EMS (HEMS, or as the Federal Aviation Administration recently coined it: "Helicopter Air Ambulance" or "HAA") services in the United States has taken a different path in recent years compared to other countries.

The widespread use of single engine, VFR only aircraft, owned and operated by for profit companies is a uniquely American phenomena. This is at odds with most other countries who have developed HEMS programs around the world.

This has resulted in significant direct competition between HEMS programs. Additionally, it has drawn attention to highly questionable billing practices.

Ryan examines the origins of this development. This includes the use of the US "Airline Deregulation Act" to prevent states from regulating HEMS programs.

More recent efforts in the US to tie reimbursement and program accreditation to the levels of care provided and minimum standards of equipment are still nascent at this time.

Efforts by the US National Transportation Safety Board (NTSB) to mandate improved safety equipment standards have been met with resistance by the industry and the FAA. This has resulted in wide variability in US HEMS programs. Moreover, it has resulted in the adoption of IFR standards, mandating NVG use, twin-engine aircraft and risk assessment strategies.

There is also increasing scrutiny being placed on appropriate utilisation criteria in the face of skyrocketing bills and questionable billing practices by for-profit companies.

The Standards in Helicopter EMS (HEMS)

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Natalie May & Roisin McNamara discuss a young person's experience of critical illness.

They are joined by Ema, an 11-year-old girl who had a scary time when she was diagnosed with tracheitis. Experiencing critical illness is scary for anyone. However, when you are a young person, this terrifying experience is amplified.

Natalie and Roisin tell us what we as clinicians can do or think about differently to provide a better patient experience.

Although she is young, Ema provides some salient points about what doctors and nurses do well and what they can do better.

The main take away boils down to clear communication. Medical professionals often think they are explaining things thoroughly. However, the words they use, and the speed of the delivery of those words, leaves a patient feeling confused and scared.

On top of that, a patient's experience of critical illness leaves them exhausted, in pain and unable to effectively communicate.

Ema's mother also provides insights into the experience of the family. The broad themes include the feelings of isolation, fear, and overwhelming concern.

Encouragingly, there are simple things that clinicians can do to alleviate these feelings. Whilst the fear and concern for one's young child will never abate, simply taking the time to listen to all worries and ensuring understanding can go a long way towards improving the experience for both the patient and their family.

Similarly, ongoing communication regarding the tests, procedures, and treatments that are planned to be undertaken is highlighted as critical in eliciting the support and buy in of the family.

Critical illness in a young person will never be easy for the patient or their families. Listen in to this discussion to discover how to make it more bearable.

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Maxime Valois and John Christian Fox argue the role of POCUS in critical care.

POCUS changes everything. It has helped physicians throughout the world to make easier, more accurate and faster diagnoses.

It has contributed to enhance the diagnostic possibilities in resource-scarce environments However, as it gains more widespread acceptance, its use is becoming more and more common.

Maxime contests that this poses a problem. No longer is ultrasound only in the domain of specialists and technology-eager early adopters of the technology. He proposes that this will lead to difficulties as non-specialists take up the technology.

Maxime warns against being hypnotised against the seductive nature of ultrasound. Research and use of fancier, new or more advanced applications are likely to help the global advancement of POCUS and even medicine in general. But as POCUS enters fully in its stage of normal science, this will inevitably induce some degree of scientific esotericism.

This has been the case of all past scientific revolutions.

Point-of-care ultrasound is already generating some important difficulties. If these go unattended, Maxime believe POCUS itself might rapidly be a problem.

It is maybe only a problem for the radiologist holding down their turf in a small hospital that has been shielded from the world wide web.

John argues that POCUS is changing the way medicine is practiced for the better. John makes the point that ultrasound makes the clinician better, faster, and stronger. It does so without exposing patient to harmful radiation.

Furthermore, John contends that POCUS enables the physician to bridge the gap between patient and doctor in increasingly complex healthcare system. It allows him to spend more time at the bedside and in doing so deliver better care for his patients.

John makes his point with a range of clinical situations, driving his point home that POCUS certainly has a place in the future of medicine.

Is Point of Care Ultrasound (POCUS) a problem?

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Scott presents the argument that whilst Emergency Physicians are amazing, as it stands, Emergency Medicine is failing.

Scott presents the system as it should be.

This involves stabilising the critically ill before admission to the ICU, seeing sick patients in appropriate time and seeing the less sick patients as you can.

The issue as it stands, is when this system breaks down. He talks about the 'boxes' which now includes the 'not sick at all' patient. This leads to Emergency Physician's not doing what they are trained to do.

Scott discusses the issues with the outcome measurements of Emergency Departments. Hospitals measure patient satisfaction and wait times.

Moreover, Scott argues that a trip to the ED should be the worst day in a patient's life and measuring their satisfaction is misleading.

Scott also discusses the issue of Emergency Physicians not dealing with emergencies for most of their practice. This, in Scott's eyes, leads to cognitive dissonance, where ED doctors are not doing what they are trained to do.

Simon argues that Emergency Medicine is not a failed paradigm. Emergency Physicians are trained to help people, when people feel that they need to be treated.

He claims that doctors in this speciality want to treat a wide variety of people across a wide spectrum of disease.

Evidently, Simon discusses a 'revolution' in Emergency Medicine. An increasing number of people are attending Emergency Departments across the world. The generalist approach of Emergency Medicine is critical in triaging, treating, and helping these people in their moment of need.

The skills, breadth of knowledge and wisdom and ability to work across a range of specialties and in uncertainty is what makes Emergency Medicine and the physicians who work in it special.

Join in the debate as Scott and Simon argue for and against the place of Emergency Medicine.

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Ashley Shreves:

There are nearly 100 billion stars in the Milky Way – and almost that many articles published every year. Luckily for you, we read them all – or, at least, the ones in the domain of EM (Emergency Medicine). Catch up with where the new literature is leading you, leading you astray, or just plain bonkers. Sit back and let us inspire you to take your own deep dive into all the great foundational science. We'll swing through new stroke treatments, the ketamine blow-dart, the best medications for reanimating the dead, and many more!

Ryan Radecki:

It has been exciting and surprising year in the EM literature. We'll be hitting all the highlights and letting you know what's hot and what's not. Topics to be addressed include, but are not limited to, abscess management, medications for renal colic, imaging for subarachnoid, new anticoagulant reversal agents, use of opiates, and the diagnosis of PE

Ben Shippey discusses the important anaesthetic considerations in bariatric surgery. Obesity surgery can induce a strong response in healthcare professionals. These biases must be overcome to facilitate efficient and safe services. Evidently, Bariatric surgery provides many challenges.

To begin with, healthcare professionals can associate negative thoughts with obesity. Secondly, these patients present complex respiratory and cardiovascular physiology that must be considered. Ben highlights three important considerations when preparing for, and delivery anaesthetics in the bariatric population. These are Attitude, Assessment and Act.

Attitude - Encompasses the attitude of the physicians, theatre team and the patient themselves. One must recognise and change their thinking about the obese patient. Ben's team does this by realising the complex psychological background these patients invariably have.

Assessment - Furthermore, a multidisciplinary team must undertake a broad assessment. Specifically for the anaesthetic team, there is a complex decision pathway, especially with managing the airway. The broad principle should be to shorten the time between the awake, vertical, spontaneously breathing obese person and the supine, anaesthetised, intubated and positively pressure ventilated patient.

Finally, Act - As Ben states, the previous two points are null and void if it does not change practice. The key element to act is to plan! This involves having a clear action plan for the intubation of the patient and failing that, clear points at which Plan B, C and D will be initiated. He encourages his theatre staff to alert him when a cut off Sp02 is reached so he can move to the next course of action. He comes prepared - for example, by having the cricothyroid membrane marked out. Furthermore, it is important to consider putting the patient to sleep and waking them up. As Ben puts it – pay attention to the take off as well as the landing! Lastly, the post-operative care is significantly important. Remember patient positioning in bed (not slumped) and encourage early mobilisation. These patients need to be up and moving, as well as having the appropriate DVT prophylaxis in place. The obese patient presents unique challenges to the anaesthetist.

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