Coda Change

Veteran Airforce Pararescueman turned critical care paramedic, Mike Lauria discusses the

Rob MacSweeney and Paul Marik debate whether the assessment of fluid responsiveness in the resuscitation of patients with shock a waste of time? Both Marik and MacSweeney agree that many of the traditional methods of assessing patients volume status are flawed and of no value. Marik goes on to argue that the only clinically meaningful outcome that we should measure in response to a fluid challenge is Stoke Volume. In at least 50% of patients there is no improvement in stroke volume and further treatment with fluid boluses will only likely cause harm. Marik goes on to argue that we must know where our patients are position on their Frank-Starling curve to predict whether they are fluid responsive and we can assess this with passive led raise.

Pretty much everything I learned as a resident in terms of the sequencing of airway management in ED has changed over the past 15 years. No longer is there simply RSI or stick a laryngoscope in with nothing and use pure brute force to intubate a patient; we have a host of different options and pathways when approaching airway management in the emergency department.

This lecture discusses some of these updated ways of getting from a sick patient requiring airway management to a tube between the cords…with only minor technical mishaps.

Daniel Kornhall's is an introduction to snow avalanche physiology and the realities of mountain rescue.

Dying in an avalanche is an extremely rare cause of death but for us who live in mountain regions and who enjoy winter mountain sports it is a thing that needs to be dealt with. The overall mortality in avalanche incidents is roughly 20% but this increases to 50% in the buried victims, which is why my talk, and most avalanche medicine, focuses on the buried victims. Asphyxia causes the vast majority of deaths, accounting for roughly 80% with trauma in second place at 20%. Hypothermia as the primary cause of death in avalanche victims is extremely uncommon. Asphyxiation causes a dramatic plunge in survival from 80% down to 30% within the first half our of avalanche burial. This is why timely location and extrication of the victim is of vital importance.

Kornhall explains why organised rescue service rarely, if ever, manage to get to the victim within this critical asphyxia phase. Survival rather depends on immediate bystander or companion rescue. Extrication times can be reduced by being properly equipped with avalanche transceivers, quality snow shovels and avalanche probes.

Kornhall briefly discusses the avalanche airbag, a fairly recent innovation that may reduce the likelihood of being buried if you get avalanched. In the last part of my talk i describe modern extrication techniques and how implementing these into rescue training dramatically improves extrication times.

Two legends of medical education, doctors Johnathan Sherbino and Robert Cooney go head to head debating whether assessment is a barrier to learning. Sherbino argues that assessment is in fact a first essential step in the learning process.

TBA

• Shared mental model of team and task.
• Implicit co-ordination/communication
• And, how to create this in an ad hoc team.

TBA

Rapid response systems (RRSs) have become a routine part of the way patients are managed in general wards of acute care hospitals. They have been adopted by national health and safety organisations in North America, Canada, the United Kingdom and Australia and are increasingly being used in other parts of the world. Studies have almost universally shown significant reductions in outcome indicators such as mortality (up to one third) and cardiac arrest rates (up to 50%). However the validity of these outcomes is questionable as most of these studies are single-centre, before-and-after studies conducted by one or two clinical champions in Rapid Response. This presentation reveals that the implementation of an Intensivist led Rapid Response Team in an Australian quaternary hospital did not demonstrate such dramatic results. In fact, after one year of service the standardised mortality ratio and the in-hospital cardiac arrest rate remained similar. The presentation explores some of the operational impacts of a RRS including the replacement of critical thinking with reliance on protocols and the progressive super-specialisation of medical teams. Despite these impacts and relatively static patient outcome data, the service has rapidly become an integral part of the hospital. Barriers between Intensive Care and ward staff have broken down and quality outcome results have consistently shown ward nurses and doctors feel better prepared, educated and supported in managing clinical deterioration. These surprising results raise the question; should we place more value in quality outcomes?