Coda Change

Resa Lewiss tells you how ultrasound improves resuscitation outcomes in critical care. Ultrasound helps you make more accurate diagnoses. It allows you to perform procedures with fewer complications, and ultrasound enables you to be more time and cost efficient. However, there may be more to ultrasound - Resa enlightens you.

The ultrasound allows the clinician to interact with their patients. Further, Ultrasound enables patients to be integrated into their own care and it allows for an element of creativity.

Moreover, Resa explores the idea of reciprocal illumination – the process of exchange and education between clinician and patient. It is the dialogue that occurs between the two and allows for different and deep thinking.

Evidently, what underpins these thoughts is the idea of creativity. Resa asks you to consider how you are creative with your hands. It may be gardening, knitting, playing a musical instrument, writing, or even washing the dishes. Working with your hands is the gateway to creativity. Working with your hands in an intentional and purposeful way, on a regular basis elevates your mood and decreases stress and anxiety. The science supports this.

Furthermore, a hand-brain interaction is stimulated, fostering creativity. In bringing these ideas back to the Emergency Room, Resa explains that by using your hands through ultrasound, you are enabling creativity and open communication with your patients.

Moreover, Reciprocal illumination – enhancing both care and outcomes. Resa describes the evidence behind this idea. Patient's overwhelming welcome ultrasound at the bedside in the Emergency Department. They agree that it improves patient care and increases efficiency of their treatment.

Finally, Resa concludes by pondering the idea that ultrasound may also lead to great benefits for the clinicians themselves.

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'"Think of the danger while things are going smoothly." Chicago's own Lisa McQueen picks apart the challenges of identifying those children who genuinely need sepsis resucitation in the "pre-shock phase" and explores the pathophysiology and treatment of shock in children.

Two simulations for prehospital care - tactical and motorcycle pit crew with a panel discussion debrief following. Demonstration and discussion of the medical response to these incidents.

Haney Mallemat informs you how technology is improving healthcare. Haney's talk is grounded in a patient experience. Jim is a gentleman from a small farm in a rural area of United States. His farm is everything to him and his wife and daughter. When Jim got seriously sick, he had to have an extended stay in a major tertiary hospital. As a result, he and his family lost their farm, which was their world. Could Jim have been treated locally with the utilisation of technology? Haney thinks technology may be the way of the future in medicine. Through the utilisation of technology which already exists, patients such as Jim can stay in their communities and have more holistic outcomes. There are three areas Haney discusses. Telemedicine Defined as medical information exchanged though electronic telecommunications to improve a patient's outcomes. Traditionally telemedicine is big, bulky, and complicated. This brings with it resistance to use. However, with the advent of lighter and faster computers, telemedicine becomes more and more possible. It is also being compacted into our smartphones making the possibilities endless. Patients are not opposed to telemedicine – surveys show the opposite. They would prefer to not wait endlessly in clinics and travel unnecessarily. Robotic surgery This technology is truly remarkable. Fine movements are possible with precise control. This translates to improved patient outcomes. These include smaller incisions and shorter recovery times. Compounding these benefits, surgery can be performed from another continent. The possibilities for under resourced areas are endless. Mobilisation of products and services Drones are becoming ubiquitous. They have medical applications when thinking about the fast and efficient delivery of supplies, vaccines, and medications. This provides great benefits for hard to access areas, whether that is in developing countries, or across city in peak hour traffic. On top of this, 'paramedic drones' have been developed, delivery equipment and telecommunication hook-ups to medical professionals rapidly to accident scenes. Let Haney Mallemat educate you on the future of technology in medicine!

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Flavia Machado gives you the ins and outs of a day in the life of an ICU doctor working in Brazil. She addresses healthcare inequality, ethics, and the challenges she faces in a developing country. By sharing a blow-by-blow account of a day at work, Flavia demonstrates the challenges and inequality that exists. And whilst poverty is shocking, Flavia believes inequality is worse. Flavia's day begins in the morning with a ward round. Critical bed shortages mean that the clinicians have to make impossible decisions – which patients will get allocated one of the scarce beds? At 07:00am every morning, Flavia and her colleagues in the ICU have to play God. Inequality is plain to see. It is graphically depicted when looking at a map of the distribution of ICU beds across Brazil. In the north, an area of greater disadvantage, there are far less ICU beds per capita. Flavia continues her day, but the challenges do not stop. She checks WhatsApp later in the morning and is inundated with issues pertaining to medication shortages and equipment supply issues. The issue of a broken defibrillating is upsetting, but not unexpected – to the point of her staff using humour to cope with the desperation of the situation. Later in the day Flavia has clinical decisions to make. However, she cannot rely solely on her clinical reasoning and skill as a doctor. There are external pressures that exist – from judges, from industry, from scientist and researchers – and she feels all of them. Sometimes, Flavia feels the strain of operating in these challenging conditions in a middle-income country. Sometimes she feels the futility of it all, like pushing a stone up a mountain, or filling the impossible to fill vessel. That being said, Flavia can see the progress that is made and at the end of the day, she and her team remain happy in doing what they do!

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Dr Anne Creaton talks about the healthcare capacity building in Fiji. Fiji was struck by Cyclone Winston in 2016. It caused widespread devastation and the impact will be felt for a long time in the future. The most important thing that Fiji has taught her is faith, patience and persistence. Anne begins by talking about the three Rs that are essential in trainees who want to work in Fiji or similar situations. The three Rs being: Realistic, Resilient and Resourceful. Emotional intelligence is also very important. Most of the people are highly trained, but always in a high resource environment. Dysfunctional systems in places like Fiji, can impact the clinician's welfare and performance. Critical care systems are made up of multiple building blocks with doctors playing a small part. Anne compares critical care systems in Fiji to a game of Jenga. This is because multiple blocks that are essential for critical care systems are non-existent. Anne divides the Jenga blocks of a critical care system into three: a pre-hospital block, a hospital block, and an administration and governance block. The pre-hospital block consists of scene care, transport care, communication, hazmat, decontamination and retrieval. The hospital blocks consist of factors like triage, medical assessment, equipment, drugs and patient flow. The administrative and governance block provides data, audits, leadership and human resource activities such as training, recruitment and retention. All these blocks put together form the critical care system. This illustrates how when the different blocks in critical care services are removed, it makes it very difficult to successfully treat a patient. She explains how doctors face multiple difficulties like faulty equipment, untrained staff, lack of timely transport vehicles, inaccessibility to interventional cardiology, lack of risk management and quality improvement. They also lack hazmat, decontamination, personal protective equipment (PPE), proper communication. Anne then gives an example of using the three Rs technique to reduce VF arrest by early defibrillation. Realistic: Automatic external defibrillator (AED) for all health facilities. Resilient: Placed all AEDs in pelican cases. Resourceful: Acquired the AEDs via Twitter. Anne ends by saying that life is about expectation management and you need to understand that there will be a gap between the type of care you want to provide and what you will be able to provide in situations like Fiji.

So, are you ready to play critical care Jenga?

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The paediatric airway terrifies many of us: at the smaccMINI paediatric critical care workshop, Fran Lockie explores some real-life examples of airway challenges and considerations. He takes us through the concept of the "airway bundle" and how teamworking and communication is key to improving paediatric airway care, emphasising the concepts we can borrow from adult practice to offload some of our cognitive burden and outlining the key components of first-class post-intubation care, with pitfalls and pearls of wisdom from his experiences as a prehospital clinician. Phil Hyde follows on with the nuance of assessing paediatric ventilation, starting with simple interventions and exploring the factors that make big differences for children in respiratory distress.

Andrew Chow gives a rapid breakdown of malignant cerebral artery (MCA) infarction and the utility of decompressive craniectomy. An MCA infarction is an ischaemic stroke, affecting the total or subtotal area of the MCA. It involves the basal ganglia (at least partially) and may involve the adjacent territories. The incidence is 10-20 per 100 000 and there is a high mortality rate of up to 80%. Early clinical symptoms of MCA infarction are contralateral hemiparesis, gaze deviation and hemisensory neglect. A malignant infarction will then progress to severe headache, nausea and vomiting, papilloedema and reduced consciousness. The pathophysiology underlying these clinical signs is complex and involves a failure of sodium pumps, leading to cellular swelling, metabolic failure, tissue necrosis and breakdown of serum products. So, how do you predict who progresses to a malignant MCA infarction? Andrew will guide you through the three domains to consider: Radiological, clinical and pathological. From there, the management. Medical management is grounded in methods to reduce the intracranial pressure. This includes admissions to a stroke unit, high dependency unit or intensive care unit. Elevating the head to greater than 30 degrees and maintenance of normal clinical variables are other considerations. Surgical management involves decompressive craniectomy. This procedure first described in 1935. It is not a benign treatment and there are a number of complications. Andrew discusses the risks, and the preferred methods of the procedure to enhance outcome. He also describes the risk benefit analysis that should be undertaken before recommending this treatment to a patient with a malignant MCA infarction. In doing so, Andrew takes you through the landmark trials looking at the use of decompressive craniectomy.

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Natalie Thrutle educates on the critical issue of lead poisoning in developing countries. Critical care means different things to different people. In the context of lead poisoning, you may or may not think of developing countries such as Nigeria. The response to the Zamfara state, lead poisoning outbreak, in Northern Nigeria, is unprecedented and requires a nuanced interpretation of 'critical care'. In 2010, 400 children died from lead encephalopathy in the largest lead poisoning outbreak ever recorded, affecting more than 5000 children in Zamfara. The outbreak is ongoing. Children were presenting with intractable seizure and coma, not responsive to treatment for malaria and meningitis. 50% of these children were dying. Environmental poisoning was considered early on, due to the high levels of artisanal gold mining in the area. This increase in mining was a major economic boom to a remote and rural population much in need. MSF had never dealt with a lead poisoning outbreak before… neither had the Nigerian government. No one had ever dealt with a lead poisoning outbreak in the world before. It had never been seen. Initially there were three main aims. Chelation, remediation, and safer mining practices. Whilst chelation worked, it would have been futile without an effort to clean the environment (remediation). This in turn was futile without considering safer mining practices. The solution to the problem required by in and input from all parties. Herein lay the challenge. Parallels with the Ebola outbreak in Guinea can be drawn. In this instance there were attacks on both healthcare workers and quarantine facilities. Zamfara did not see such extreme reactions although there was certainly a feeling of animosity and resistance coming from the mining community. In this talk, Natalie highlights the successes and the ongoing challenges of facing this issue head on. Progress has been made, and challenges still exist.

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Nikki Blackwell tells her story of the emergency response to the Ebola outbreak in Nzerekore, Guinea. She chronicles the enormous challenges of providing care to some of the most vulnerable people in the world, in one of the most under resourced and challenging environments.

The Ebola virus was first isolated in 1976. Between then and 2013 there were twenty outbreaks of Ebola. However, the outbreaks, although vicious, were relatively small and in isolated areas. This outbreak was by far the most complex, with a mortality rate of up to 40%. The fruit bat is the natural host and reservoir of Ebola. They transmit it to other animals, and ultimately humans. Human to human transmission occurs from body fluids, mucous membranes, and sexual contacts.

Nzerekore, Guinea has a terrible health service and infrastructure stemming from a long period of conflict. This is further exacerbated by the scarce number of doctors. Further, what compounded the problem even more was the delayed recognition and action from the international community.

Eventually, Nikki and the Médecins Sans Frontières (MSF) had funding to launch a project, providing care to the region that was dealing with a devastating epidemic. What followed was an eye-opening experience for Nikki and her team. Nikki highlights the endless challenges she faced in delivery care in her role as Medical Director on the project. These include hot, dusty conditions with the constant stench of chlorine. Heavy, thick biohazard suits that take 30 minutes to get into and can only be worn for one hour due to the extreme nature of the dehydration and exhaustion they cause.

Lastly Nikki describes the technical and emotional difficulties of providing care to this population of people with grave illness, constantly surrounded by death, all heightened by the real fear of the staff falling ill.

Finally, Join Nikki as she tells her incredible tale of the Ebola outbreak in Nzerekore, Guinea as Medical Director for the MSF.

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