Smacc

Cognitive offloading for critical care retrieval by Stephen Hearns Everyone’s cognitive capacity is limited. It is easy to become overloaded and subsequently for our performance to be impacted. In medicine however, an overloaded cognitive capacity could be the difference between life and death. There is little room for healthcare professionals to be unfocused, yet retrieval medicine is comprised of unpredictability, critical time pressures and fast-paced emergency responses. Let’s face it, there’s never a time where we are more cognitively overloaded than at a multi-casualty incident. Cognitive overload in retrieval medicine results in an unsafe environment and compromised decision making. We need to rely on strategies and processes to reduce our cognitive burden. Eliminating the need to make decisions, allows for a better response to unpredictable scenarios. One strategy is to identify the predictable recurring components and plan for them. Practice implementing the plan, fine tuning the response and ensurin

Critical care is viewed from different perspectives. How to clinicians, patients and families experience this life changing part of the health care system?

Jack Iwashyna discusses his research into persistent critical illness in the ICU. While much of resuscitation focuses on the dramatic early minutes to hours of critical illness, many patients stay for days or weeks in the ICU. Jack wants to know, why do patients get stuck in the ICU, and what might we do better to improve their care? Jack became an ICU doctor because he loved drama. He wanted to find the golden hour. The golden hour describes the time to intervene, to make a difference, and to save people’s lives. It is an extraordinary thing to be able to do this, and it is sometimes possible. However, sometimes, it is not. Sometimes the golden hour is not there. Jack describes his experience with patients who would come into the ICU unwell. They would be treated aggressively and begin to get better. However, they would then take a turn for the worse. He describes this as a chronic critical illness. His patients were stably critically ill, and he could not work out why. This led Jack on a sabbatical year whe

The ethics of incidental findings: James Rippey Ultrasound is an incredibly useful tool for clinicians. According to James Rippey, there are two main groups of clinicians who use ultrasound. First, there are the POCUS providers, who have a specific, focused question and use the ultrasound machines accordingly. Then, there are the ultrasound experts, who look beyond the specific questions and embrace ultrasound as a valuable diagnostic tool. The advancement of high quality, handheld ultrasound machines means that we will all have imaging available at our fingertips. Notably however, questions are raised regarding the impact that these machines can have on families and the ethics behind incidental findings. James shares a personal story about how using a handheld ultrasound machine on his son, incidentally found a retroperitoneal tumor. Luckily James’s son survived, however it raises questions as to the risk-benefit ratio in the discovery of an incidental finding. This extends not only to the likelihood of the

Critical Care survivors: Margaret Herridge In this podcast, Margaret Herridge considers this well-known quote from Nietzsche, “That which doesn’t kill us makes us stronger.” But… Does it? What about our patients who suffer from a critical illness? The continuum of critical illness and what lies ahead for recovery should not be underestimated. Post critical illness, it is not uncommon for patients to suffer from a functional disability, a neuropsychological disability, or a decline in their general sense of wellness and vitality. Patients who have suffered from a critical illness regularly have trouble trying to reintegrate back into normal life. What about the mental illness concerns for both patients and their families post critical illness? We know that post traumatic stress disorder is common for recovering patients and their families. So… knowing this, are our patients actually stronger post illness? Traditionally, the focus of critical care has simply been on keeping patients alive. This is not enough, n

David Menon discusses the complex and fraught world of managing traumatic brain injury (TBI) in the ICU. In particular, David discusses the management of intracranial pressure and cerebral perfusion pressure in these patients. Although the Brain Trauma Foundation provides guidelines for the management of severe TBI, including targets for ICP and CCP, there is no Level 1 recommendation for the use of any intervention to modulate ICP/CCP. General principles remain simple in theory, if not in practice. David describes good basic intensive care, which he describes as doing lots of little things well. The main focuses should be maintaining blood pressure high enough to get oxygen to brain, optimising oxygenation and modulating carbon dioxide. This is in combination with other modalities such as hypertonic saline, cooling people, and using metabolic suppression. The trouble lies in the fact that there is no evidence base for second line therapy. In fact, some of these therapies have been shown to cause harm. When c

We regularly have difficult conversations in critical care. We deal with sick and complex patients who may be at the end of life. The families we talk to may be in a state of shock and acute grief, unable to think clearly and make important decisions. Moreover, patient safety incidents and other challenging issues such as organ and tissue donation may further complicate the patient journey. In this talk by Jon Gatward, we follow the story of Leah and the difficult conversations that were needed in caring for her and her family. Jon examines some of the key elements that can contribute to successful communication in difficult circumstances such as: • Having a plan and a structure before embarking on these difficult conversations. • Working towards a common agenda and ensuring that everyone feels safe and able to ask questions. • Showing empathy and using silence well, allowing people the space and time to process information. • Giving people the benefit of the doubt, after all, these are their family members t

Failure is something that even the very best in the industry regularly experience. In safety critical roles, that failure can ultimately lead to death and maiming. So how do we accept failure? Martin Bromiley explores how we can understand and learn from our failures and difficult moments. He identifies the essential behaviours and mindsets that will help us make sense of those complex moments. One such mindset is being confident that you have the skills to do the job but also humble enough to know that you could be wrong. This is a delicate balance but is so crucial for personal growth. We are all human and we will all make mistakes. Taking responsibility for our mistakes is essential and is what allows us to learn from those errors. Furthermore, Martin suggests that setting a good example is key. We need our leaders to listen and to lead by example, acknowledging their own failures, to grant us permission to do the same. Failure is inevitable but understanding what we can learn from failure, is what makes u

SMACCForce: CRM Panel Discussion with Clare Richmond, Neil Jeffers (Pilot), Per Bredmose, Mike Lauria, Tom Evens

From DAS SMACC, Vera Sistenich explains why it is critical that we care about the global refugee crisis. The global refugee crisis exemplifies some of the greatest challenges facing our global institutions and liberal world order today. From human rights, to xenophobia, sexism and economic protectionism, terrorism and climate change. National and international responses to the refugee crisis are sculpting moral and political norms around the globe. It is critical that we care about the refugee crisis today because it exemplifies some of the greatest challenges to our social order. As Hannah Arendt, the German-born Jewish political theorist wrote, "The manifestation of the wind of thought is not knowledge but the ability to tell right from wrong, beautiful from ugly. ...[T]hinking gives people the strength to prevent catastrophes in these rare moments when the chips are down". It is now critical that we not only care, but think deeply, about our attitudes and policies towards refugees, wherever we come from. T

John Greenwood discusses the use of vasopressors in the emergency room. His talk focuses on three areas. First, he reviews vasopressors and categorises them based on resuscitation end points. Secondly, he addresses the concept of “pressor angst” and how it can significantly impact patient mortality. Finally, he will empower you to start vasopressors early in patients with distributive shock and sepsis. The tale of a 45-year-old lady with sepsis in the context of pneumonia is retold. John asks - what do you do? Initial fluid resuscitation has improved the vitals somewhat, but she is still hypotensive. Continue to give fluids? Sure – it seems to be what happens commonly. Starting vasopressors starts a cascade of events that will consume time and resources. It impacts flow, timing, and ability to see other patients. Often, the clinician knows it the right thing to do but does not want to pull the trigger. This process of having two conflicting beliefs in your brain at the same time is cognitive dissonance. In th

Luke Regan presents the emerging evidence for prehospital ultrasound and telehealth in his talk from the SMACC stage. Luke has a personal interest in improving prehospital care. He lives in the north of Scotland. It is an austere and challenging environment, far from technology. Compounding this, it is underserviced and there is an absence of critical care with no critical in reach. Unfortunately, the morbidity and mortality of the area does not match the spread of care. Therefore, it is one of the motivations for his research. That being said, he is not alone in his desire for this research. Pre-hospital ultrasound topped the list of technology-based research priorities in pre-hospital critical care, as determined by a European research collaboration. This is in large part because much of what is done in pre-hospital care still exists in an evidence free zone. Luke discusses the extended pre-hospital patient journey in his practice. This presents a challenge, but also an opportunity. If time zero is further

Sara Gray discusses the complex topic of prognostication post cardiac arrest in neuro intensive care. There is a short list of things that keep Sara up at night. She describes a specific cardiac arrest nightmare she has. She is looking after a patient post cardiac arrest. They remain in a coma after cooling. As they meet brain death criteria and they are an organ donor, they are transferred to the operating room. Whilst there, they regain spontaneous respirations. Although this is terrifying, these situations do happen! And cases like this defy all efforts at accurate prognostication in post cardiac arrest patients. Prognostication matters. It matters for the patient, their family and got judicious resource management. The trouble is, that varying guidelines around the world do not agree. In patients who have not been cooled, then you may start prognostication 72 hours post return of spontaneous circulation (ROSC). Before that time the brain may not have had adequate time to heal from the arrest and the clini

A no-holds barred series of 6 provocative medical interrogations. We challenge the state of research, social media, pharmacology, social work, women in medicine, medicine in the developed work, and the health of healthcare workers. It should be novel, it may get heated, and it is not scripted. Sometimes to comfort the afflicted you also need to afflict the comfortable. This is why no prisoners will be taken, no topic is out of bounds, and no ego will be pampered. It may even offend: you have been warned.

Raed Arafat describes the amazing lessons he has learnt about functional systems for emergencies, mass casualties and disasters. SMURD (Mobile Emergency Service for Resuscitation and Extrication) is in Emergency Rescue Service in Romania. It was set up by Raed Arafat in 1990 to respond to a largely non-existent and broken system. By doing so, he created a pre-hospital care system that he could be proud of. SMURD has today transformed into an integrated, country wide, emergency response system providing high quality care. Romania is one of the only countries in Europe where you have a right of emergency care. That is, you cannot be charged for being rescued or accessing emergency healthcare. This is largely due to Raed Arafat. He has created a functional system that deals not alone with daily emergencies, but also disasters and mass casualties. The national monitoring system and coordination service responds to fires, emergency incidents, critical transfers, and supports the whole country with resources from a

Haney Mallemat states the case for ultrasound in cardiac arrest resuscitation. He tells the story of Stephen, a 43-year-old male who suffers a cardiac arrest. Unfortunately, whilst looking for reversible causes with a transthoracic echocardiogram (TTE), chest compressions stopped, and Stephen died. Enter the trans-(o)esophageal echocardiogram (TEE). A trans-esophageal echocardiogram is an amazing diagnostic tool. It works in exactly the same way as any other ultrasound – there is a transducer on the end of a handle. The difference is that the stem is flexible and inserted down a patient’s oesophagus. This provides fantastic clear images in any patient, with no soft tissue or bones in the way. The beauty is, if you already know how to look at transthoracic echocardiogram, then there is no learning curve. The images are just flipped. TEE can rapidly identify reversible causes of cardiac arrest, for instance a pulmonary embolism, a clot in transit, aortic dissections or papillary muscle ruptures. It can do this

Pik Mukherji will change your mind on assessing risk and benefit in resuscitation. There is a bent towards action in the Emergency Department. This is for a few reasons. We are risk adverse – we do not want to miss the acutely sick patient. We do not want to miss the patient that “falls of the cliff”. In fact, as Pik discusses, in emergency medicine and critical care, training is focused on looking for the sharks, even when the waters appear friendly and calm. This is highlighted acutely well by Pik in a story about an elderly gentleman. The man presentedto the ED after a minor trauma. On history and examination there was nothing to find, apart from a minor scrape. Due to the risk adverse nature of the ED, the patient got a CT scan. It showed an acute subarachnoid haemorrhage. This meant he stayed in hospital for observation. The next day he fell off a bed being transported back to the scanner and disaster followed. On review, the original CT showed no abnormalities. This story highlights the risk of the deva

Brandon loves wavy lines. He will draw the curtain on the use of continuous EEG in neuro critical care. Brandon will first take you back to medical school with some neuroanatomy and physiology to underpin you understanding of the EEG. He then steps you through what an EEG is telling you. Bumps, lines, amplitudes and hertz are all demystified. With this knowledge, there is a lot you can do with continuous EEG. A few examples: EEG can be reflective of external stimulus – be it a shock, a sound, or a pinch. This is used to test for reactivity and is useful at the bedside. Reactivity demonstrates whether a signal is getting from the body to the brainstem, to the thalamus and to the cortex. Reactivity is one of the most conserved, independent prognostic indicators in coma – making it important to capture using EEG. EEG is fantastically active when you are asleep. In the ICU, an EEG can show atypical sleep – indicating they are very unwell. Due to sleep being a network heavy, very complicated phenomenon. If sleep i

Cliff Reid educates the audience on structured teaching of crisis resource management. Cliff works for Sydney HEMS in extreme conditions. The environment tries to kill them, and the patients try to die. He works in a big team, with a lot of the doctors never having worked in prehospital care. The team covers a huge area, completing many missions every year on both fixed wing and rotary wing platforms as well as road ambulances. Every case is scrutinised, both formally and informally. When things go wrong, it is rarely due to the clinical factors alone and often due to non-technical skills. These skills are discussed often but not taught in a structured way. Cliff presents the Zero Point Survey. A magical window before touching the patients where planning can start for when things go wrong and what can be done about it. It is as simple as STEPUP: Self, Team, Environment, Patient, Update and Prioritise. Self – get you head in the zone. Checklist’s can be useful for both physical and psychological safety and pre