Coda Change

Karin Amrein highlights the importance of bone health in ICU. Karin asks – do fractures matter? If the presentation is a hip fracture for elderly patients, then the answer is obviously, yes! However, Karin will describe why this answer should be a resounding yes for all patients who are admitted to the ICU. Critical illness affects bone. It is not a stretch to conceptualise this. However, Karin wants to impress on you that bone affects critical illness also! Bone is an endocrine organ, the largest endocrine organ. Fragility fractures are associated with substantially increased mortality and morbidity. One year post hip fracture, 50% of the patients are either dead or in a nursing home. Prevention is crucial! After an ICU stay, patients have a largely elevated risk of fractures – up to 65%. However, this risk factor is not recognised in the literature. If you survive critical illness and get home, you have done well. If you then sustain a fracture, you are almost back to square one! Karin attempts to explain this association. The ICU population is getting older, and the very nature of an ICU admission means they are predominantly sedentary – that much is true. However, there is likely more factors at play. Inflammation, endocrine alterations, increased osteoclastic activity, hypercatabolism leading to muscle breakdown (and in turn bone breakdown), malnutrition and drugs are all likely implicated in the increased risk. Karin takes you through each factor in turn in detail. So, what can be done about the increased risk of fractures in ICU patients post discharge. Addressing each factor in turn is difficult, however Karin shows some viable options to consider in this patient population. Karin demonstrates how poor bone health, leading to fractures, produces poor outcomes. In turn, she discusses how treating the bone health, and reducing the fracture rate, leads to improved morbidity and mortality! Karin concludes with some recommendations for ICU patients providing some tangible and practical takeaways.

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Natalie May gives you the break down of paediatric trauma.

Paediatric trauma is relatively rare but terrifying. However, there are many ways we can think about paediatric trauma to make these challenging situations easier to face.

Children are inherently portable. This means that they often turn up at peripheral, non-paediatric centres that are not major trauma centres.

This highlights the importance of all physicians knowing how to deal with these cases.

Anatomy and physiology of children is different to adults. Their ability to compensate is remarkable. This means the index of suspicion of serious injury should be higher.

For instance, their ribs are a lot more pliable than those of adults, meaning hollow viscous organ injuries are more common following trauma.

Similarly, their vital signs can be more confounding. Tachycardia could simply mean fear or pain.

On the other hand, it could indicate a major internal bleed. This leads to children being under and over triaged at a high rate.

Teenagers also present challenges. Does the surly, teenage girl with limited verbal responses have a serious head injury..? Or is she being a stereotypical teenage girl?

Polytrauma is rare in children without adult involvement, such as a motor vehicle accident. However, as children develop through adolescence, the mechanisms of injury begin to resemble those of adults.

Quad bike accidents, stabbings and even shootings become more common. Isolated thoracic injuries become the second most common cause of trauma in adolescents 16 years and older.

Toddlers by comparison get isolated limb injuries more commonly. They are mobile, curious and have no sense of danger. Their height to the ground is less, making head trauma less common, and less serious.

Under one's however are more often carried by adults and lack protective reflexes making skull fractures more common. Polytrauma in this age group should also raise suspicion of non-accidental injury. External factors often need to be involved for more serious polytrauma.

Natalie suggests being suspicious of horse-riding children!

Once a child is in your department, the assessment differs slightly to that of an adult. Specifically, scanning protocols are different with less use of pan scanning and more focussed scanning. CT for heads and penetrating chest trauma and abdomen, and plain films for C-spine, limbs, pelvis, and blunt trauma to the chest.

Natalie concludes by discussing the differences in management of injuries, comparing children and adult interventions. She also discusses the outcomes of children with major trauma and the vast implications on the child, the family and society.

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

Confined Space Airway Management in Emergency and Critical Care by Ross Hofmeyr

Ross Hofmeyr discusses the ins and outs of managing an airway in a confined space.

He details the challenges, the potential solutions and his top tips when faced with an airway in a less than ideal setting.

Ross defines confined space airway management as airway management in an environment where access to the patient, normal positioning, and use of airway equipment is limited by physical constraints.

Ultimately, these situations are endless. An icy crevasse or on a mountain top. Inside a cave. Motor vehicle crash scenes. War zones with bullets flying overhead. The inside of a helicopter or the back of an ambulance.

Even inside tight Emergency Departments, cath labs or operating rooms that are full of advanced equipment. These are all scenarios in which one may find themselves faced with confined space airway management.

In this presentation, Ross addresses the locations and difficulties which can be anticipated, and then discusses the options, techniques, and evidence available for managing airways in constrained places. Learning to cope (and then excel) in abnormal fashions and positions makes us better at managing airways in both emergency and routine situations.

Ross discusses the specific techniques, equipment and alternatives that can assist a clinician in tight situations. He backs up his thoughts with literature which demonstrates which techniques may be considered.

Moreover, his primary piece of advice to managing an airway in a confined space is, don't do it! His first tip – get the patient out of the confined situation!

Evidently, this may not always be possible. If that is the case, Ross recommends a Supraglottic device. Otherwise, a channel laryngoscope is his next go too.

Failing that, Ross stresses that a clinician must be prepared, mentally and physically, to proceed with a surgical airway. The more skills, knowledge, and flexibility the clinician has means the better they will be able to cope with confined airway management.

Confined Space Airway Management in Emergency and Critical Care

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

The Role of the Immediate Responder in Mass Casualty Trauma

Christina Hernon describes a traumatic experience in gripping detail.

In doing so, she shares her deeply personal insights into what it is to be an Immediate Responder. Christina suggests that the medical system must change to support these people.

After a major formative experience at a life-threatening mass casualty incident, Christina felt incredibly unprepared despite over two decades of training in emergency and first response.

Christina reflects that all the training that students undergo does not prepare them for every scenario. The standard approach to emergency care, is this scene safe? is completely inadequate for those present the very moment an incident occurs. These people are then amidst and surrounded by an unsecured and potentially unsafe scene.

After her experience Christina had an acute stress reaction exactly like after rough calls in prehospital Emergency Medical Services.

However, Christina wasn't offered the usual support given in these circumstances. She felt somehow betrayed, but unsure who to be mad at. Therefore, Christina tried to understand why she felt so unprepared and overlooked.

In deconstructing and reflecting on the experience, she self-identified neither as bystander nor first responder. Instead she was an on scene, immediate responder, victimised rescuer. Realising that she did not fit into any already existing category, she uncovered an undefined time period that we need to give attention to.

In this definable time gap, the only available rescuers are people who are on scene when the event happens. These Immediate Responders, who are traumatised by their experience themselves, take immediate action to help another person or make the situation better.

They are present at virtually every scene and have been for all of time. However, we know very little about them, their actions, their safety, their impact, and their recovery.

By trying to understand the Disaster Gap and Immediate Responders, we can improve training, preparedness, resilience, and recovery.

The Role of the Immediate Responder in Mass Casualty Trauma

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Natalie May brings the lessons she has learnt from Sydney HEMS training and teaches you how to apply them to your practice.

What can hospital specialties learn from teaching and training in prehospital and retrieval medicine?

Natalie, a self-described medical education enthusiast, gives you her thoughts on the application of educational theory to the challenges of the prehospital environment.

Evidently, Natalie will discuss three domains of medical education – Induction, Competence and Culture.

How do you welcome new staff to your service? In Sydney HEMS there is a week-long full team training.

This teaches new clinicians to contextualise pre-existing knowledge into their new environment. Here, they combine teaching tools including demonstration, simulation, discussion and debriefs. This is often in stark contrast to in-hospital inductions that can consist of a cursory department tour and online modules.

Moreover, Natalie discusses the medical education principles that provide the basis of the importance of a well-rounded induction. Inductions are crucial to ensure that new clinicians can safely learn how to operate successfully in their new environment.

Competence is necessary for good outcomes. Training is essential in the development of competence. Natalie discusses the proven theory of spaced repetition to embed new skills. This involves regularly practicing alongside skilled clinicians – as is done in the HEMS program.

Furthermore, In-hospital, simulating cardiac arrest scenarios regularly can dramatically improve junior clinicians' competencies and highlight deficiencies in competence that can be addressed.

Natalie describes the methods of culture building that exists in Sydney HEMS. These include 'Coffee and Case' meetings, fortnightly clinical governance days and interactive lectures and journal clubs. These all acknowledge the higher order thinking processes that is involved in the care the services provided.

Natalie recommends fostering a culture of learning from practices and providing open non-judgemental clinical governance days in the in-hospital setting.

Finally, Natalie wants you to use what you have learned to inspire, teach, and motivate others.

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

Sara Gray tackles the controversial topic of disaster ethics in critical care. Most hospitals develop a disaster plan, but few jurisdictions develop a plan for triaging or rationing scarce resources when the existing supply is overwhelmed.

Rather than leaving individual health care workers to make these decisions, we should work together as a community of experts to develop ethical, practical and appropriate policies for triaging scarce resources during a disaster.

Healthcare resources are finite. In the case of large-scale trauma with large numbers of casualties, such as a disaster scenario, how do you decide who gets what?

First and foremost, avoid having to triage or ration scarce resources. Have a plan and make first part of the plan to be "Never use the plan". Mitigate all the risks and possibilities that would see the plan being enacted. This involves sharing with partner hospitals, urgently reordering supplies and repurposing what is available.

The second guiding principle relates to the ethics. Normal circumstances dictate offering the best for every individual patient. In a disaster, a shift to the utilitarian philosophy – the greatest good for the greatest number – is necessary. This means not everyone is going to get what they need, which is a difficult concept for people.

Thirdly, Sara stresses the importance of developing a disaster plan in a public way. This stops a plan being "sprung" on staff, the public and stakeholders. It encourages buy-in and engagement which makes it a smoother process should the plan ever be enacted. Sara next discusses the inclusion and exclusion criteria when dictating who should receive the finite resources of a hospital in a disaster. This, she admits, is the tricky part. She backs her thoughts up with the available data. Sara concludes with some points regarding the implementation of disaster plans.

Making these plans is tough, however not having them is tougher. Hospitals and health authorities should have a clear criteria for when a crisis is declared. This needs to come from the hospital level, if not the health region or government.

It is not an individual decision. Next a dedicated team should review de-identified patient files to allocate resources according to the inclusion and exclusion criteria. This team needs to be multi-disciplined and received adequate support. This is a tough job.

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

Liz Crowe believes that love can revolutionise the way we approach critical care. She wants every doctor to become love ambassadors for their critical care community and share love like nothing is holding them back.

Liz believes that work life balance does not exist because we spend most of our time at work. Therefore, it is essential to love and be passionate about the work we do.

Liz compares the feeling of being a novice in critical care to first being in love.

Initially, there is fear and excitement doing new procedures. However, as days go by, you lose the rhythm. This is how relationships evolve, both in life and in critical care.

Relationships with critical care is all about hanging in there and, love. Love helps to sustain it. She discusses the role of love and leadership in critical care.

Liz demonstrates that great leaders always lead with love and compassion. Leading with love does not make them weak or indecisive, instead it creates a climate of trust and intimacy that makes individuals and the team feel emotionally and physically safe.

This in turn promotes robust conversations and conflict which is beneficial to the patients. By being kind and compassionate, a leader inspires their team to work better and achieve higher standards.

According to Liz, a good leader is supportive, genuine, works hard, apologises when they are wrong, has a good sense of humour, creates an environment of trust and acts as a human shield for their team.

The most stressful thing in an intensive care is not death but being unappreciated. Being loved and supported leads to increase in brain capacity and the ability to make difficult decisions.

Liz strongly recommends having a work spouse because family and friends do not understand what critical care workers go through. The people we work with are our support and community. Love builds innovation and creativity and not the brain. She quotes the example of the three doctors whose passion made the SMACC conference a reality.

Liz discusses the role of love in dealing with patients. She believes that beginning a conversation with a patient with love, respect and compassion makes things easier because they will believe that we care about them. She feels it is as important to teach newcomers about love and compassion as it is to teach them about having boundaries.

The more we care about patients, the less likely we are to be burnt out. Liz explains the concept of Ikigai which says that you can achieve bliss if you can combine passion, mission, vocation and profession, which according to her most doctors can.

Though there are times when this job can leave you heartbroken, it is also quite rewarding and important.

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

For Ross Fisher there are things that scare him. And he knows there are things that scare you too.

Ross discusses the purpose and effect of fear in medicine and surgery. Whoever you are and whatever you do, there are things that you are afraid of. It is not stress, it's fear, it's real and it affects us.

Being afraid is recognising a threat and realising that there is a limitation to your ability, and that you have reached that point.

Ross describes three moments in his career that he has felt fear. Real fear, that was different to stress.

Moments before operating on a preterm neonate of 29 weeks.

Believing he had transected the common iliac artery in a haemorrhaging 9-year-old during a removal of a Wilm's tumour.

And being reported for malpractice by a colleague.

In each situation, Ross felt fear. What does fear do to a person? It is different to stress.

Stress in critical care medicine is part of the job. In fact, it is necessary to reach a performance state.

Fear on the other hand is when an individual is way into the "red zone". Your hands shake so much that you cannot perform tasks. Your head pounds from tachycardia and hypertension. You breathe so fast it is like you have just finished a run. Your focus is directed at one thing only and you can no longer appreciate your surrounds, nor any inputs from your senses.

You cannot think, you cannot remember, you cannot calculate, and you cannot make decisions. That is what it is to be afraid.

Fear affects us acutely. However, it also affects those around us. Similar to how a yawn will spread person to person, fear can spread through a group.

This is particularly true when the person showing fear is a senior person or leader. The reason things go wrong in stressful situations is not because of a lack of knowledge or training. Rather it is due to poor performance as a result of fear.

So, Ross wants us to acknowledge our fear. He wants us to recognise how common it is, and how we can confront our fears and no longer be fearful if we stand together.

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

Resa Lewiss gives her insights into leadership. Through her experience training and working in Emergency Medicine and Critical Care, Resa has collated a series of pearls, pitfalls, and lessons shared by leaders.

For Resa, there are leaders, and there are follows – more often than not, people know good leaders. Resa firmly believes that leaders look like leaders. She affirms that it is neither a male nor a female trait – despite what some may assume.

Resa shares her lessons on leadership.

Public embarrassment serves a purpose, however this purpose is often misguided and can be better achieved in other ways.

Resa has experienced the embarrassment firsthand and knows of its detrimental impact. A good leader will give a person an out and speak to them in private. This is much more effective.

Being indecisive can be perceived as worse than making the wrong decision. Leaders need to be confident in their decisions.

Also, know your weaknesses. For what you are not good at, reach out and bring people into your circle to complement yourself and your team.

Leadership is not about hierarchy. Leaders should make their subordinates feel respected, welcome and part of the team.

Leaders need to get over their imposter syndrome. This allows them to advocate for themselves and for their team. Never be afraid to ask for what you need.

Resa concludes by sharing ways that everyone can improve their leadership skills.

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

Medical journals have many possible functions, but the main one for most is publishing science. They are actually better at campaigning and agenda setting, rather like the mass media. Journals are now beset with problems, including failing to include data, publishing lots of poor quality material, being slow to publish, publishing research that is either not reproducible or fraudulent, encouraging waste in the system, failing to be transparent, and exploiting academics. New ways of publishing science are appearing, and a better system would be for the grant proposal, protocol, and full data to be published on a database with the whole process transparent.