Coda Change

Mike Abernethy runs you through the pitfalls and challenges of rural trauma resuscitation and prevention. The farm is a dangerous workplace. Accidents have an unusually high morbidity and mortality not only for the worker, but also his/her family members. The reasons are multi-factorial but are the result of a complex interaction of environment, equipment and human factors. The vast majority of agricultural deaths involve tractors. No other industry uses 70-year-old machinery operated by workers whose age ranges from 10 to 90. How can we prevent such incidents? Mike is a prehospital physician (who is a wannabe farmer & tractor mechanic) and long-time resident of an agricultural community. In this talk, he will examine the details of a life-threatening accident involving one of his neighbours which perfectly illustrates the multifaceted nature of agricultural trauma. He will then discuss agricultural trauma more broadly. The statistics are similar across the globe, from the United States to Australia, Cambodia to Ireland. Fatalities involve heavy machinery (usually tractors) and the farmer or their family. Furthermore, deaths occur between 18-60 years of age in most industries. In farming however, fatalities can occur across the whole life span. Whilst there are equipment changes that have made things safer, they have a poor uptake amongst farmers. This is due in a large part to interference with productivity and functionality. Mike believes change can only come about through community engagement and education at a meaningful, personal level. Rural and farming communities are faced with inherent risk of injury and death on a daily basis. It is pertinent to be aware of this and to educate these communities when the opportunity presents itself. After all, if it is made of steel, sharp and moving… It will %^&* you up!

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Dr Simon Carley discusses the future of emergency medicine. Simon begins by talking about how things have changed in emergency medicine since he started his career in the 1990s. He wants to shed some light on where we are going with emergency medicine, what is happening to us and what is shaping us. He believes that predictions about the future, as shown in movies like Back to the Future, might not always come true but they certainly provide clues as to what is possible. According to Simon, three major factors influence the future of emergency medicine. The first factor is the people. Population predictions show that life expectancy has gone up, leading to an increase in the number of elderly people. As the age of the population increases, the age of the people dying due to trauma becomes older. This changes the approach of emergency medicine. Moreover, the age of the workforce in medicine is also increasing. Simon believes that the rigid systems must change to encourage the next generation of healthcare workers to enter medicine. Patients, pathologies, and the workforce are changing. The second factor influencing emergency medicine is politics. There is an increased financial constraint on health services which is in part due to increases in technology. Horizontal equity, where everyone gets equal treatment, and vertical equity, where some people get more, must be balanced. This can be achieved by involving emergency physicians in the political decision making. The future points in a direction where emergency medicine divides into different specialties which according to Simon might not be the right path. Furthermore, the third factor affecting emergency medicine is technology. Technology is essentially revision and refinement making things cheaper, easier, and portable. Revolution in technology is what matters. It changes the way we approach emergency medicine in fields like decision support, disease probability models and personal diagnostics turning doctors into probabilistic clinicians. Simon believes that though we cannot actually predict the future, we can definitely get involved in shaping it, making the future of emergency medicine as exciting as the past.

Tune in as Dr Simon Carley discusses the future of emergency medicine.

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A Tribute to Dr John Hinds, Dr Janet Acheson speaks about her life with Dr John Hinds and how unexpected his death was.

John Hinds was known as the pioneer of pre-hospital trauma, a master educator and powerful orator. He was "son" to his mother Josephine, "John boy" to his father Dermot and "John" to his friends and family.

John Hinds inherited his meticulousness from his mother and sense of adventure from his father. Janet speaks about different lectures given by John Hinds during which he coined the term #ResusWankers and spoke about cricoid pressure and Cricolol.

She speaks about "Johnisms", thoughts that she and John shared; find your people and acquire memories of life; do not let wankers bring you down, learn from your mistakes and finally, make your intentions honourable - the patient is the centre of everything. She requests the audience to help trend #WhatWouldJohnDo.

Dr Fred MacSorley, a good friend of John Hinds, talks about how promising and talented John Hinds was when he entered the field of anaesthesia in 2004. His passion for motorcycling and fierce determination to help those injured, though it helped him in his career, also led to confrontations with peers who had more rigid minds.

John, however, overcame these obstacles with passion, humour and risk-taking ability. Fred reminisces about how training sessions with John would stretch on as John was a passionate teacher. He speaks about the call sign Delta 7 assigned to John while being part of the Northern Ireland Ambulance Service. Fred remembers that John always arrived first at an accident scene and worked away quietly. He was polite and had excellent people management skills. He established a relationship with his critically ill patients by talking to them and reassuring them. Fred shares stories of John's growth to become a flying doctor. He claims that John revolutionised the management of traumatic cardiac arrest.

A tribute to a legend, Dr John Hinds.

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Dr Victoria Brazil discusses the Dunning-Kruger Effect, Imposter Syndrome and quality improvement. Vic starts the podcast reminiscing about her initial days as a resuscitationist.

She talks about the two psychological phenomena noticed in people working in pre-hospital care. The Dunning-Kruger effect, where people tend to think they are better at a job than they are, and imposter syndrome, where people tend to think they are worse than they are at doing a particular job.

People's perception of their performance can impact their chances of improvement. She suggests scientific methods to reduce this gap in perception. Resuscitation quality improvement (RQI) is a machine-based assessment method to improve the quality of chest compressions that helps doctors and nurses assess and improve their chest compression skills.

An example is a person trying to intubate a patient while wearing a camera. This highlights how different his perception is of what he is doing. According to Vic, an important tool to improvement and reduce the gap in perception is feedback between the person in the field and the consultant. This is because according to Dunning, though we do not assess ourselves correctly, we are good at assessing others.

For the feedback loop to be effective it is essential to follow three basic rules. Firstly, be honest. Secondly, do it often and thirdly be good at extracting feedback. Vic suggests that everyone should start practising giving feedback by assessing speakers. She suggests that rather than giving vague comments like "Good talk mate", people should make an effort to give speaker specific comments about the talk. This could include what they liked and what could be improved.

Vic demonstrates live feedback of her 47-year-old self giving her younger self, Registrar Vic, some feedback with help from the audience. Through this act she shows how to give effective feedback and how to extract good feedback.

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Rueben Strayer provides a masterclass in droperidol for emergency management of agitation. He discusses sedation in three patient groups. Agitated but cooperative If the patient is agitated but cooperative there is no concern for a dangerous condition. They respond well to some company and a sandwich. Drug therapy in this group is relatively straightforward. Disruptive without danger You can converse and engage with this group; however, they are not responsive to suggestion. They are loud and disruptive and need to be sedated. You can do a history and exam and be fairly confident that there is no dangerous underlying condition. There is no threat to themselves or others. They can be managed by observation in an unmonitored bed. So, you can sacrifice speed of sedation to ensure safety. Simple and well worn, tried and tested methods of mixed medical sedation are fine in this situation. And Reuben stresses this… it is fine. To be better than fine, consider a single agent - droperidol. Droperidol is the most effective and safest agent for undifferentiated agitation. If droperidol is unavailable the next best choice is midazolam intramuscularly. Be careful. Dosage is trickier in this situation. You need to monitor for respiratory depression and ne prepared to manage it. It works quickly but has a narrow therapeutic window. As such, for unmonitored patients, Reuben combines drugs to get away with smaller doses. Listen in to learn how! Excited delirium This patient is rare. But this is a dangerous situation. A few clues are the patients who are thrashing, angry, incoherent, un-engageable. They may have a fluctuating level of consciousness. Have a low threshold if you are not sure – err on the side of caution and treat as excited delirium. How do you treat this person? Five strong people are needed (not including those administering care), one for each limb plus one at the head. Administer high flow oxygen via a mask immediately. Do not wait for sats or vitals. This stops spit and provides oxygen! Get the patient out of dangerous positions such as the "hogtie" position and ensure no one is applying pressure to the chest or neck. Next chemical restraint – IM shot as soon as possible. This is as opposed to any mechanical restraints. The priority is immediate control. This allows you time to properly assess and treat the patient whilst ensuring their safety and the safety of the treating team. Join Reuben for a no nonsense run through of managing the agitated patient.

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Dr Ashley Shreves discuses palliative care and critical illness. She begins by talking about a case she feels she mishandled during the initial days of her career. How she was unprepared to handle an end-of-life case efficiently. She goes on to enumerate the multiple specific challenges, a knowledge of which would have helped her handle the case more competently.

First - One must identify the dying trajectory i.e., use the background information to check the viability of the patient.

Second - Undertake a capacity assessment of the patient to ensure how much of the current situation they understand.

Third - Check for advance directives where a patient has already given instructions regarding their end-of-life care. Communicating to the relatives and/or the patient regarding the imminent death is another challenge in end-of-life care. Proper communication regarding the withholding or withdrawal of life sustaining treatment (LST) to the patient is also very important. Another crucial aspect is knowing the right treatment regimens for end-of-life (EOL) symptom management. Spiritual competency of doctors is essential as it helps to provide necessary spiritual assistance to people in their last moments. An ethical framework to guide the doctors through the management of EOL cases is crucial for a favourable outcome. Systems of care that help doctors to take care of EOL patients is necessary.

Ashley discusses various studies which show that many patients requiring end-of-life care end up dying in hospitals and the relatives and patients feel neglected most of the time. She feels that this is due to a shockingly low availability of palliative care department and workers. The solution, she feels, is to equip the Emergency Department doctors with the basic skill set to deal with the common end-of-life problems by doing Fellowship Training in palliative care. She suggests various courses like EPEC for Emergency Medicine, Palliative Care Education and Practice (PCEP) by Harvard University, online courses by University of Colorado, VitalTalk courses and information available on the Palliative Care Network of Wisconsin website.

She believes that a basic palliative care knowledge is essential for all Emergency Department doctors as all end-of-life patients should be given the best possible care in the short amount of time they have left.

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This is a fresh ICH discussion covering controversies in 2015: blood pressure control, reversal of anticoagulation, and prognosis.

Tom Bleck has been in the top echelons of neurocritical care for decades. As a highly active member of the CCM-L internet group, he was pioneering internet based crit care discussions before Twitter was ever conceived. Considered by many to be the leading world expert on status epilepticus, he brings insights from research and extensive experience you will hear from no one else. A rare treat.

A panel of neurocritical care fanatics discuss the nuances of managing aneurysmal subarachnoid haemorrhage (SAH) from pre-hospital through ED to ICU. This is a fascinating insight into international practice variations and the justification for these. It's very unusual to have such a panel of experts all in the same room speaking so frankly. This was recorded live at the SMACCBRAIN workshop in Chicago 2015.

SMACC Chicago Beat the Bug Q&A session with Kath Maitland, Mark Crislip, Flavia Machado and Chris Nickson.