Coda Change

Imogen Mitchell's SMACC Chicago talk 'Morphing the Recalcitrant Clinician' talks us through the steps to engage the reluctant physician when implementing change. Imogen initally touches on the stages of physician engagement from aversion, to apathy, to engaged and then outlines the steps to morphing the reluctant physician. 1. Seek out a clinical champion 2. Establish a common purpose/vision 3. Standardise what is standardisable 4. Communication, communication, communication 5. Work out barriers and overcome them 6. Deal with the 'Whats in it for me?'WIFM

David Juurlink SMACC Chicago talk 'Drug Interactions That Can Kill (and How to Avoid Them)' takes us on a journey of drug interactions, case studies, and avoidance strategies.

Juurlink starts by educating us on the two different drug-drug interactions (DDI) - effects of one drug altered by the use of another . First of which is Pharmacokinetic where by one drug alters the level of another, the second Pharmacodynamic being no change in drug levels, and uses this as a basis for his following case studies.

Juurlink speaks of the dreadful literature that is available on the thousands of drug interaction per year, stating that most information comes from case reports and volunteer studies, and suggests that majority of these interaction are avoidable.

Juurlink then goes on to discuss the findings of 4 case studies involving the following Drug-Drug Interactions and their effects on the patients.

SMX/TMP + sulfonylureas Macrolides + digoxin APAP + warfarin SMX/TMP + ACEI/ARB

Juurlink provides us with a short list of trigger drugs that we should be aware of, a list of meds that warrant extra caution and list of possible safer alternatives. He also suggests that it is of the up most importance to have a good pharmacist to turn to as they are given more information on drugs interactions then physicians. And, to utilise resources such as pharmacy times - where you can get information on drug interactions at a push of the button.

Juurlink also suggests that an Informed patient is a very useful safety mechanism.

Rick Body's SMACC Chicago talk 'Is compassion a Patients Right?' takes us on a journey of emotions in critical care. Starting with his rendition of john Lennons 'Love'. Body, explains the origin of the word compassion - a move to act based on someone else suffering, a sharing of suffering with. Body, initially focuses on a study conducted within his hospital of 125 patients, who were interviewed when admitted to their emergency department and when they where discharged. From the study it was depicted that, what patients truely wanted was simple human intervention; reassurance, friendliness, explanation, basic care. These responses were then coded into 5 different themes to depict how patients believe their suffering should be addressed; 1. Emotional distress 2. Physical symptoms - including pain (but not restricted to) 3. Information - Included reassurance and explanation 4. Care - Basic care 5. Closure - patients want to put this horrible episode behind them Body notes that patients are telling us that they want something positive from us. They don't want us to focus on what we shouldn't do. They want us to be thinking about what we can do to help… suggesting that if we follow the above 'EPPIC' we could provide more compassionate care. The problem is this is not compassion as compassion is an emotion and needs to be felt. Body then explores whats stopping us (care providers) from showing compassion? Sighting the The Good Smaritian Study: that depicts the more in a rush one is the less likely they are to show compassion. The By Standers Affect: if a large crowd is doing nothing, you are more likely to do nothing. Unclear of Who is Responsible: less likely for anyone to respond and Personal Reasons: the responsibility for other peoples lives, fatigue, tough, resilient to showing emotion, emotion been seen as a weakness and a feeling as doctors we are not meant to show emotions. Body, then shows a picture of a doctor crouched slumped over and inconsolable, shortly after the image was taken the doctor loses a 19 year old patient he was treating and minutes later the he walks back into the emergency room and continues working. This picture went viral on social media and the doctor pictured was seen as admorable. Body sites this example to state that clearing having compassion and showing compassion is right, but is it a right?. And, asks the question 'Would you prefer the surgeon who shaking with emotion as you go into surgery or the surgeon who is composed, objective, calm, tough, resilient, unmovable and efficiently get on with the task in hand?'. Body believes that patients don't have a right to compassion as it is an emotion and means to suffer with but asks for health providers to be emotionally intelligent. Explaining that emotional Intelligence recognises that there is a difference between traditional intelligence, IQ and our ability to form effective forms of interpersonal relationships. Siting the 5 domains of emotions intelligence as; 1. Know your emotions - know what we are feeling 2. Manage your emotions - cool rational and object in the rests room, show emotion with patients and family 3. Motivating ones self 4. Recognising emotions in others - empathy 5. Handling Relationships - interpersonal Skills - relate to other people Body suggest that these are skills that can be developed as ones life goes on and by building skills in emotional intelligence that maybe one can be both a compassionate and effective doctor. Body concludes by asking the question 'How are you going to care more for your patients?'

Andrew Healey takes us on an exploration of the early phases of donor management in ICU and Emergency Medicine in his heart felt SMACC Chicago talk Optimizing the Care of the Organ Donation Patient. Which focuses on the processes of managing donor patients and their families, while they ride their ICU/ ED journey through to organ donor.

Jeremy Cohen took us on an Adrenal Function journey at SMACC Chicago with his talk Raging Hormones in Critical Care.

Cohen explores the natural roll of cortisol in the human body, various schools of thought and recent research in the areas of sepsis and cortisol resistance.

Deborah Stein SMACC Chicago talk Trauma is Risky Business - delves into the risk patients and physicians undergo when treating or being treated for Trauma.

Stein's speaks of the Risk Benefit Determination that physicians make daily and how this is used to best answer on going questions such as; can a patient have?, how do we care for this patient? and how do we best make all the these decisions?.

Stein's suggests a thorough Risk Benefit Determination will include: # Analysis of best available data # Use of best available judgement # Gathering of different opinions # An understanding that you won't always make the right decision # To document the 'crap' out of it! # And, to remember you'll never know what you prevented from not occurring. Stein's also focuses on the risk to patients due to missed injuries, stating that 1.3-39% of injuries in trauma are missed (a majority of which present as orthopaedic cases). And, touching on the processes designed to prevent missed injuries such as; Territory Trauma Survey, Roles of Clinical Decision Rules, to scan the living 'crap' out of them - whole body CT scans (can decrease mortality but comes attached with its own risks).

Stein's then delves into the risks trauma providers (physicians) face on a daily bases. Stating that in the USA trauma providers are one of the highest categories of physicians to be sued, have higher indemnity payment awarded against them and achieve a higher risk score in studies for being sued. While, lawsuits are more likely to increase the chance of physician burnout, career burnout, depression and are emotionally and physically exhausting. Steins sights recent studies that suggest the more open, honest and forthright a physician is with their error with their peers and their hospital, the likelihood of being sued reduces.

Stein's also notes that needle stick injuries in most departments have decreased in recent years due to universal precautions, yet have increased in trauma care due to the nature of the ER environment and proper precautions not being taken. Violence is of risk to attending ER nurses, physicians and paramedics, sighting an Australian study that 79% of triage nurses have experienced physical violence from patients. And, the emotional harm the trauma environment can have on trauma providers.

Steins suggests that trauma providers must be aware and learn how to manage risk better to ensure patient and provider safety.

Walter Eppich engages us on the topic of Interprofessional Communication: Challenges and Opportunities.

Summary by: Rosy Wang

Lactate has been viewed as a byproduct of anaerobic metabolism and an indicator of tissue hypoperfusion since the 1900s. This theory is still widely believed. Paul busts the myths surrounding lactic acidosis, anaerobic metabolism, tissue hypoxia and the role of lactate in sepsis. Key take-away facts include: - The production of lactate actually consumes hydrogen ions. Lactic acidosis is really lactic alkalosis. - Lactate is produced physiologically and is a precursor for gluconeogenesis. - During exercise, skeletal muscle exports lactate as the primary fuel for the heart and brain. - At VO2max, intracellular oxygen stays the same. Anaerobic metabolism in cells only occur as a pre-terminal event. The exception is in complete arterial occlusion. - Adrenaline promotes lactate production - Lactate infusion has been shown to increase cardiac output in septic and cardiogenic shock - Lactate is a survival advantage!

Summary By: Rosy wang

You don't have to be Bear Grylls to stay alive in the wild. Remember the rule of three - you can live 3 minutes without air, 3 hours without shelter, 3 days without water and 3 weeks without food.

The two biggest killers in the wild are cold and heat. Justin discusses the physiology of our body's responses to cold and heat and the pathophysiology of hypo- and hyperthermia. He also talks about the simple of ways of preventing cold and heat injury, including staying dry, adding layers, drink any water you can get your hands on - just not sea water.

Lastly - don't panic.

Kath Maitland takes the perspective that we should be cautious with how we give IV fluids. She argues that the underlying physiological evidence supporting the benefits of giving fluids is not there. The findings of the FEAST study are clear. Kath describes how during FEAST, the administration of fluids made the children look better, and improved the recorded physiological parameters. However these surrogate outcomes did not translate to a mortality benefit - fluid boluses were associated with increased mortality.

Nick, a paeds intensivist, retaliates with how it's really about understanding physiology. He defends the position we take at the moment and discusses the issues with the parameters used to assess fluid responsiveness, but urges that we shouldn't change everything we do at the moment until we understand the physiology better. He also has nice description of the glycocalyx - "the pubic hair of the blood vessels, only more useful".