Coda Change

John Carlisle asks the big question – what is the risk of surgery?

It is a big question that holds implications for everyone involved in caring for patients. Like John, patients want to live a long and happy life. They would like to know whether the chances of living a long and happy life are enhanced by having surgery or not. They do not generally care whether they will be alive in 30 days or not. John explored whether or not we can accurately answer the question – what are the risks of a given surgery? Prognostic models based on a single surgical cohort are very vulnerable to chance and variation. This is even the case with large cohorts. The reason is that mortality is not that common. Therefore, the range of uncertainty in any one model is big. John explores this concept in the context of surgical intervention for abdominal aortic aneurysms. He highlights the perils prognosticating by describing the trials that influences the treatment guidelines for abdominal aortic aneurysms. John describes the current data, and the flaws in the recommendations currently being offered. John then describes a tool he has developed relating to this particular question. The tool also explains how one piece of research has been misunderstood, a misunderstanding that has resulted in two general mistakes: surgeons operating on aneurysms when they should not; surgeons not operating on aneurysms when they should.

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Karim Brohi gives an insight into his mindset as a trauma surgeon, drawing on lessons from Zen philosophy.

During this talk he discusses how we can develop the self confidence that helps us cope with stressful clinical situations.

The word confidence is often talked about in a negative context, in terms of overconfidence or arrogance.

Karim however uses this talk to highlight the importance of self-confidence. Self-confidence is important for you, your team, your department, and your healthcare system.

Zen philosophy draws on the notion of water. Water, mind like water, heart like water and core like water. How do you adopt a heart, mind and core that is like water?

Water takes the shape of whatever environment it is in. In a glass, a vase or a lake, the water fills the space. It mimics its environment. Extending this analogy, water in its resting state is calm and still.

However, throw a stone into the water and you create ripples and waves. Thereafter, the stone disappears, and the water once again becomes calm. Karim draws parallels between the properties of water and one's mindset.

At a trauma scene, panic and confusion can spread rapidly amongst all present without that panic or confusion every being named. However, if a calm and reassured team leader arrives, everything else stills around them. Like water they react to a challenge, an external stimulus, accept it, deal with it, and then return to a resting state.

This, Karim posits, is how a trauma surgeon, or team leader, should behaviour.

The notion of the Zen Garden is another useful analogy from which to draw inspiration. Zen gardens are defined by their attention to detail. This extends to medical practice. Attention to detail enables you to be prepared and deal with anything that comes through the door.

Again, it allows you to foster confidence. Compounding this, is the quality of the gardens that enhances the minimal. They are perfect not when there is no more to add, rather, when there is no more to take away. In a medial sense, Karim draws comparisons to medical imaging.

What is important? What is unnecessary? The gardens are meticulously planned.

Karim highlights the importance of planning is his practice that has helped him instil confidence in himself and his team to deal with all scenarios. Using the art of Zen you can be ready for anything and teach the mind to deal with change with confidence.

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Haney Mallemat discusses the treatment for PEA cardiac arrest.

Patients who present with pulseless electrical activity (PEA) arrest have a high mortality. The treatment of PEA requires finding and reversing the underlying cause; therefore a simple and rapid approach is required.

Traditionally we were taught to use the H's and the T's, but this diagnostic tool is cumbersome and of questionable utility overall.

Haney discusses the problems with the traditional H's and T's as well as focusing on newer approaches to PEA arrest. Haney makes the point that PEA is not a diagnosis, but a 'waste basket term' for a lot of possible diagnoses.

Rather than assisting a clinician in the assessment and treatment of a patient, it acts on to lead to pontification.

To that end, Haney wants us to do away with the H's and T's. The problem with the algorithm of diagnosing a PEA, as Haney explains, is the reliance on feeling a pulse. It lacks sensitivity and specificity, largely linked to using fingers.

They should not be used in resuscitation scenarios – as the guidelines say we should.

He describes two ways in which he thinks we can advance our care.

The first involves the QRS complex. Ask the question – is the QRS complex narrow or wide. Narrow ( 0.12 seconds), then consider metabolic problems such as hypokalaemia.

If the QRS is narrow, and you are thinking a mechanical problem then there is electrical activity, and the heart is still beating underneath. The step should be to use ultrasound immediately to find the focused cause. If it is wide, and you are considering metabolic causes, this is more aligned with a true PEA. Calcium bicarbonate should be considered in the first instance.

Haney describes the limitations with the algorithm that includes the trauma patient or those with underlying cardiac conditions.

Next Haney describes a second algorithm - PREM (pulseless with rhythm and echo motion) and PRES (pulseless with a rhythm and echo standstill). The use of ultrasound is central to this pathway. In PREM the left ventricle is not strong enough to produce a pulse. Does this patient get adrenaline or chest compressions?

Haney discusses the options. In PRES there is electrical activity, but the heart is not squeezing. Maybe these people should get adrenaline and compressions!

The ECG should still play a part in this algorithm. Haney puts it all together for you and takes you through the algorithm he uses when faced with a patient with PEA.

He includes some tips for using the ultrasound probe during cardiac arrest resuscitation scenarios.

A Revised Algorithm for PEA Cardiac Arrest: Haney Mallemat

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John Greenwood takes a broad view on pulmonary hypertension and explores the heart-lung interactions that occur in this disease process. Pulmonary hypertension commonly occurs when managing a patient with an acute critical illness. Pulmonary hypertension has a devastating impact on cardiac function. Whilst we recognise the disease itself, we don't recognise the 'upstream' effects. John explains how it is these effects that may be causing the patient to crash. John, in this talk, helps you to understand the clinical heart-lung interactions affected by pulmonary hypertension and the effect on the right ventricle. He educates you on identifying patients at high risk for pulmonary hypertension, and finally he discusses critical management strategies for patients with pulmonary hypertension. In the ICU, causes of acute pulmonary hypertension are evident daily. Microcirculatory of the lung has a strong impact on what the pulmonary pressures are. Therefore, conditions such as pneumonia, ARDS and pulmonary oedema will all lead to pulmonary hypertension. The condition can then be exacerbated by the treatments offered – namely mechanical ventilation! This brings John to the right ventricle. John explains why he feels the right ventricle is too often overlooked. He describes the form and function of the right ventricle and how it often fails in the case of pulmonary hypertension. The pumping function of the muscle does not have the necessary components to overcome high pressures as they are encountered in this disease. Finally, John provides his thoughts on the management of pulmonary hypertension, keeping in mind the importance of the right ventricle. Through his presentation he will convince you that pulmonary hypertension is common. By remembering that the right ventricle is sensitive, by judicious use of echocardiography and by proper resuscitation, John will help you treat patients with pulmonary hypertension.

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Michele Domico presents a talk on the pitfalls of common paediatric resuscitative manoeuvres in paediatric cardiac patients. Emergency and critical care physicians are all well accustomed to items such as oxygen, bolus adrenaline, intubation and cardioversion. However, as Michele explains, these 'go to' interventions may in fact be harmful for the paediatric cardiac patient presenting to the emergency department in extremis. Due to the physiology of certain complex congenital heart diseases, the usual resuscitation manoeuvres may in fact kill the patient instead of helping. Supplemental oxygen can worsen the pulmonary to systemic blood flow ratio in single ventricle patients and cause them to have rising lactate levels and cardiac arrest from low systemic cardiac output. Intubation and positive pressure ventilation may impede pulmonary blood flow in patients with a Glenn shunt and the patient can become more desaturated. With increasing PEEP and higher respiratory rates, the patients will continue to deteriorate and desaturate. Regular dosing of adrenaline boluses in patients with single ventricle physiology who are nearly arrest, can worsen their systemic output by increasing systemic vascular resistance and promoting pulmonary overcirculation. Cardioversion of a previously healthy paediatric patient might be tempting when you see what looks like a stable ventricular tachycardia. This wide complex rhythm has fooled many people into shocking it. You might in fact be dealing with something else and can make the patient infinitely worse by shocking. In her talk, Michele highlights the importance of understanding the physiology of your patients. This particularly applies to paediatric cardiac patients. In this population, the change from typical physiology means standard models of care are harmful. Tune in to hear what not to do!

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Deirdre Murphy presents everything that can go wrong in cardiac surgery. Deirdre will impress on you that cardiac surgery is by no means a safe procedure! Murphy's Law stipulates everything that can go wrong, will go wrong. Subsequently, Finagle's corollary will tell us, it will be at the worst possible moment. In this talk Deirdre attempts to prove these theories in the world of cardiac surgery. Cardiac surgery can vary from being routine elective surgery to time-critical emergency surgery. The term encompasses a broad range of procedures carried out on patients from neonates to nonagenarians. In the 63 years since the first open heart surgery was performed using cardiopulmonary bypass enormous advances have been made in the field such that an average person presenting for coronary bypass grafting in 2016 can expect a very low chance of peri-operative morbidity or mortality. When things go wrong however, they can go badly wrong and at the worst possible moment. The list of problems that occur is extensive. Deidre steps through some of the more common issues that arise post cardiac surgery. She describes pneumonia, mediastinitis, haemorrhage, ischaemia, and neurological issues, amongst others. Along the way she provides clinical pearls as to what to look for, what not to miss and what to do about it. Through her extensive experience, Deidre has seen more than her fair share of post-cardiac surgery complications. She provides a number of clinical scenarios she has encountered, and in doing so gives useful insights to be aware of. Her top tips are to prevent complications if possible. If not possible, recognise the complications early and finally train for 'avalanches' – those critical and scary situations that will put your patients at immediate risk of demise.

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The practice of emergency medicine is no longer a one size fits all approach. Furthermore, most of your patients are not usually 'average' as described in journal articles. With more data, newer analytic techniques, and a better understanding of pathologies, we can isolate the exact and most appropriate therapies for our individual patients. We're already doing it, but we should be doing it better. Learn how to be systems thinkers and become better providers. Using examples from emergency medicine, I will show how a comprehensive approach to patient care can be beneficial for guiding theories and therapies tailored for an individual. This concept of precision medicine allows us to incorporate all knowledge and processes in to one picture rather than segregating medical care in to buckets. We will also discuss some of the challenges in this type of thinking and best practices for translating in to your every day work.

When was your last paediatric/neonatal life support course update? Did it include the latest recommendations from the European Resuscitation Council (2015)? NO?! Well, let's have a look at the very latest consensus recommendations for the resuscitation of children in cardiorespiratory arrest and for neonates at birth - and explore any controversies therein.

Peter Brindley explains how burnout affects us all. It affects the cost, quality of care, organisational culture, performance and patient outcomes.

Burnout is fatigue, loss of ideals, purposelessness, presentism and the sense of being under-appreciated. It is not tiredness, exhaustion, boredom, mid-life crisis, depression, PTSD, perfectionism or narcissism.

Peter explains when and why, and to whom a burnout occurs. A major reason for burnout is the difference between expectations and reality. This drives the thought, "this is not what I signed up for."

Furthermore, he presents the 12 steps which lead to a burnout. It begins by the need to prove yourself by working harder, neglecting your needs, avoiding issues, and losing friends or hobbies. This leads to denial, withdrawal, behavioural changes, depersonalisation, inner emptiness, depression and finally burnout.

Peter suggests a few things that we can do to prevent burnout. He recommends purposeful imbalance and dividing career into thirds: learning, earning, and returning.

Evidently, burnout is a chronic condition, and although it cannot be cured, it is manageable. It might take years to manifest and hence, we must always be on the lookout for the signs.

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Francesca Rubulotta talks about disproportionate care in ICU. Disproportionate care is disproportionate in relation to the expected prognosis. Moreover, this can lead to moral distress among clinicians who think they are offering inappropriate care. There is mounting research and evidence pointing to the existence of disproportionate care. Furthermore, stress and burnout cause increased miscommunication and lead to low performance and concentration. Stress leads to absenteeism or in many cases, presenteeism. Presenteeism is when someone just shows up for work but does the bare minimum. Francesca shows the financial burden caused by absenteeism across various countries. Francesca points out that only 14% of employees feel engaged in their jobs. Moreover, data shows that companies which keep their employees engaged have higher rates of performance. Such companies have managers who are more engaged and approachable. Francesca discusses various studies that look at the appropriateness of care in ICU. She talks about the CONFLICUS, APPROPRICUS and DISPROPICUS studies, all of which point to the moral stress experienced when clinicians are forced to give inappropriate care. We must ask whether inappropriate care occurred and why. The three major factors influencing the perception of inappropriate care are client related situations, work characteristics and personal characteristics. 27% of healthcare providers (HCP) report at least one of their patients are mismanaged per day. Furthermore, 63% say that inappropriate care happens all the time. There are multiple reasons for disproportionate care taking place. Studies show that nurses associated inappropriate care to interpersonal factors while physicians ascribed it to prognostic uncertainty. Francesca discusses the methods used and results obtained in the DISPROPICUS study and self-awareness and individual development in ICU. According to her, these future studies will help to find solutions to the problems regarding disproportionate care. Evidently, authentic leaders, who can inspire others, are the need of the hour.

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