Smacc

Dr Suman Biswas is a UK based anaesthetist known for his musical talents. He and a fellow medical student began performing hilarious medical parody songs, perhaps the most famous is his 'London Underground song'. The two students were catapulted to fame as the "Amateur Transplants" but sadly parted ways in 2011. Suman works full-time as an NHS EnglandAnaesthetist. Here he performs live on-stage at the enormously popular medical conference SMACC (Social Media and Critical Care) in Berlin Germany 2017. The audience of over 2000 medical delegates goes wild. Tune in to hear some of your favourite songs masterfully re-purposed for Suman's medical parody. You are guaranteed to to laugh at the wit and irreverant humour. For more head to: codachange.org/podcasts/

Clare Richmond discusses medical simulation and its ability to provide a safe working environment anywhere. Simulation is a tool which allows us to rehearse our skills and scenarios before they happen in real life, to real people, our patients. Many clinicians dislike simulation, they know it is good for them, but find it challenging to drop into a world of manikins, fear performing in front of their peers and find debriefs uncomfortable. This talk will consider the purpose of simulation and its role in providing a safe working environment for clinical care anywhere. As a junior doctor Clare always found simulation hard. A combination of talking to a plastic model, having to debrief, and trying to figure out the endemic of cardiac arrests in mannikins were all challenging. However, Clare now provides a useful overview to medical simulation and some handy tips into making the most of the simulation experience. The beginning, or pre-brief, provides an opportunity to improve learning. Here there should be consid

Michelle Johnston presents her thoughts on acute myocardial infarction, thrombolysis and haemorrhage. She delves into David Foster Wallace, evolution, and what do when the thrombolysis bisque hits the fan. Michelle’s interest into acute myocardial infarction, thrombolysis and haemorrhage began one day when she received a call from a peripheral hospital. A local farmer has presented to the Emergency Department with what turned out to be a big anterior infarct. As Michelle points out, he quite appropriately underwent thrombolysis. The gentleman’s symptoms and ECG trace began to settle and a transfer to Michelle’s hospital was arranged. Then he developed massive haematemesis. And to make matters worse, the gentleman turned out to be a dear friend of Michelle. Not to worry she thought… we will just reverse the effects of the thrombolysis. However, after a brief panic, a quick review of the guidelines, and consultation with the colleagues, Michelle realised that a massive knowledge hole existed! Even after getting

A no-holes 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.

For Trish Henwood, ultrasound use in resource limited settings is a perfect fit. Nowhere has Trish seen ultrasound have more of an effect on patient care and outcomes, and save more lives, than in resource limited contexts. Trish uses the example of a training program in Zanzibar to highlight the scope that ultrasound provides. Using ultrasound on a daily basis to the medical centre is able to screen for antenatal complications that may necessitate transfer to a setting with a higher level of care. Trish also leans of health professions recounting their experience with ultrasound. Fatma – a nurse/midwife – recounts her tales of finding many cases of molar pregnancies, placenta previa, eclampsia and ruptured ovarian cysts. Through the available resource of ultrasound, she has saved many lives (of both mothers and babies.) Gabin in Rwanda has taken the basic ultrasound training he received to diagnose a multitude of cardiac conditions in his centre and Olivier tells the story of a young man with an altered ment

Marcelo Amota makes the case for why driving pressures matter during mechanical ventilation in critical care. Sao Paulo, Brazil, experiences flooding every year. This exposes locals to Leptospira bacteria. The severe form of disease this causes – leptospirosis - sees patients end up on mechanical ventilators. These machines were traditionally complicated, with a huge number of settings and buttons. Marcelo Amato trained in this setting. He, alongside his colleagues, developed methods to halt bleeding in leptospirosis by manipulating ventilator settings. He calls it “protective ventilation”. It was not long before the same principles were being applied to patients suffering acute respiratory distress syndrome. Through research, Marcelo and his team concluded that driving pressures, above all other ventilator settings, were most important for patient survival. Driving pressure is the oscillation of alveolar pressure or variation of pressures inside the lungs. It is what your lungs are sensing. Although there i

The healthcare ethics of alcohol related harm and driving change by Diana Egerton-Warburton Diana Egerton-Warburton talks about how to be a hero by championing healthcare ethics of alcohol related harm and driving change through stories and data. Have you ever saved a life? Many doctors and nurses have. But, how do you save a life without putting scalpel to skin or picking up a laryngoscope… or even having to go to a hospital? Diana Egerton-Warburton answers this question through the powerful tool of stories. Diana was put on the path of healthcare ethics over twenty years ago. She describes an emergency department shift that changed and shaped her. She sets the scene in the Western suburbs of Melbourne… Heroin bathed the streets and ocean of alcohol. One Australia Day sticks with her. In one Emergency Department shift, Diana saw seven separate episodes of alcohol related family violence. The stories still haunt Diana to this day. Broken bones, abdominal pain, an overdose, a cut lip – these were the faces and

Annet Alenyo Ngabirano was enjoying the community medical placement in the 4th year of medical school. Placed 60km from the nearest hospital, in the lush hills of Uganda, the days were filled with vaccination drives, local outpatient clinics and lazing about. That was until a frantic nurse burst into the room and rushed the three medical students to the bedside of a severely sick and dehydrated infant. There was no doctor. There was no senior nursing staff. They no training, no equipment, no backup, and no resuscitation area - yet this small group of 4th year students were the only hope this small baby had. After trying to gain IV access for over 30 minutes, Annet felt exhausted, overwhelmed, under equipped, under resourced and alone. This is emblematic of where Emergency care in Africa has come from. Over 85% of the world’s population live in Low and Middle Income countries. Health statistics in these countries are characterised by numerous deaths from treatable time-sensitive illnesses and injuries resultin

Trial design is the biggest problem with Evidence Based Medicine in the Intensive Care Unit. Paul Young wants to change that paradigm completely. He argues for research as we know it to change and to focus on clinical care with systemised and optimised treatments that reliably improves outcomes over time for all patients. Mortality measured at a particular time point (landmark mortality) is often regarded as the gold standard outcome for randomised controlled trials in Intensive Care Medicine. An important limitation of many Intensive Care Medicine trials is that they hypothesize large and potentially implausible reductions in absolute mortality. This is a major problem in trial design for two reasons. Firstly, it makes false negative trial results more likely. Secondly, the less plausible a postulated mortality reduction is the more likely that a statistically significant mortality difference will represent a false positive. This is because a p-value is defined as the probability of finding a result equal to

David Carr delivers an “old fashioned” talk, presenting his approach to the diagnosis and treatment of endocarditis in acute medicine. Whilst some may turn their nose up at what David describes as esoteric bedside medicine, the rare diagnosis of endocarditis is a bad diagnosis. It carries with it a mortality rate of between 15-30%. David attempts to rebrand endocarditis and make it sexy again. Who? There are four main suspects of getting endocarditis. If you turn up to David’s Emergency Department having had a cardiac valve replacement, the assumption is that you have endocarditis. 1% of these patient per year will develop endocarditis. A valve replacement plus fever or feeling unwell should raise the suspicion even higher. People who inject intravenous drugs are the second population of suspects for endocarditis.15% of people who inject IV drugs entering the hospital with a fever will have endocarditis. You must respect this population, and they need to come to the hospital in these instances. Marantic endoc

A no-holes 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.

South pole...North pole, hot...cold, on earth...in space, below the sea...on Mount Everest, alone and far, far away. Gaynor Prince takes you to Union Glacier in the Ellsworth Mountain Range, Antarctica, to show you how useful ultrasound can be in extreme environments Gaynor relives the story of being in one of the most isolated places on Earth when she gets a Medivac alert. One of her clients, Jack, has become acutely short of breath. With her list if differential diagnoses including high altitude pulmonary oedema, heart failure and pulmonary embolism, Gaynor was presented with an enormously difficult decision. Whilst Jack’s safety was priority number one, in a place like Antarctica, no clinical decision is easy. With the weather closing in, and a huge amount of time and money having been invested in this journey by Jack and his companions, what was she going to do? The answer? Pull out her Phillips Lumify ultrasound machine. A thorough examination with the ultrasound satisfied Gaynor that her patient was sa

Medical education and clinical programs are designed with four pillars - clinical excellence, research, education, and administration. These apply whether you build and design an ultrasound program or division, a simulation program, a toxicology or pre-hospital program or even an academic department Resa Lewiss describes the four pillars of medical education and clinical programs using a quirky anecdote of four tragic, dramatic and ridiculous stories of childhood dog deaths. Clinical excellence is providing good patient outcomes. Ensuring that staff are well educated and surrounded by working and necessary infrastructure to they can provide quality care. It is a strong and tangible pillar. Research is self-explanatory and demonstrates a program’s credibility locally, nationally and internationally. It is more difficult to uphold, including writing, grants, abstracts and writing manuscripts. Education is what the medical community does, occurring in a number of settings including the lecture theatre and bedsid

In this quick, five minute talk, Brandon updates us on Sinus Venous Thrombosis. This includes what it is, what it looks like and how to diagnose it. Brandon starts with a case – a 37-year-old woman, who is 8 weeks pregnant, presents with what she describes as the worst headache of her life. She has a history of migraines, so this is Brandon’s first thought and possible initial diagnosis. But... it turns out to be more than just a migraine... Brandon explains that what we should be looking for here is venous sinus thrombosis. This is characterised by a sub-acute onset of a headache and risk factors. In this case, hormonal changes which are related to her pregnancy, making her at higher risk. The key takeaway? A headache with risk factors (in particular anything that will cause a Hypercoagulable state) plus or minus seizures, usually means we should be looking for this condition. Brandon suggests that we need to be suspicious of this condition and that we need to look for it. Even if it isn’t obvious at first.

Fernanda Bellolio guides the listener through an approach to the treatment of wake-up stroke in neuro critical care. What time did the symptoms start? This is one of the most common questions that is asked when taking a history from a patient. However, what happens when this can not be answered. This is the case with “wake-up strokes”. A wake-up stroke is when a person goes to sleep without symptoms and wakes up with deficits. Similar problems in management arise when a person cannot accurately tell the clinician what time the symptoms began. Up to 20% of stokes are wake-up strokes and a further in a 10% of strokes the patient nor family can say exactly when it started. This presents a challenge as many therapies that currently exist are time sensitive and therefore not approved for wake-up strokes. Fernanda reviews the current evidence in the quest to answer three questions: 1) What is the evidence for tPA use in wake-up strokes; 2) Can endovascular treatments be used in wake-up strokes and 3) How can these

Rinaldo Bellomo is here to cause some trouble! He says that critical care physiology in resuscitation has problems! Whilst the rest of the medical field has advanced and evolved over time (we no longer routinely prescribe oxygen for an acute myocardial infarction), critical care resuscitation still relies on malfunctioning physiological paradigms. Critical care clinicians can change physiology with a number of tools. They can repeatedly, often, and mercilessly change physiological variables. Blood pressure, cardiac output, cardiac filling pressures, glucose levels, positive fluid balance and countless other physiological parameters can be increased and decreased at will. This kind of “numerology” is attractive because the outcomes can be immediate, and clinicians feel powerful and effective. However, outside the obvious situations where physiology is so dangerously abnormal as to threaten life, such physiological manipulations have an unproven relationship with outcome. Importantly, patients do not care wheth

Brandon Foreman gives a practical approach to the diagnosis and workup of neuromuscular disease in neuro critical care. Neuromuscular diseases are common and include chronic autoimmune disorders such as myasthenia gravis, acute demyelinating disorders like Guillain Barre, paraneoplastic disorders, and toxidromes such as botulism. The presentation of many neuromuscular diseases can be subtle: diffuse weakness, subtle swallowing difficulty, or double vision. Many patients do not present until its nearly too late, and timely diagnosis can lead to rapid stabilization of airway, autonomics, and other potentially lethal complications and expedited treatment of the underlying cause. Brandon’s first piece of advice pertaining to neuromuscular disease in critical care? You have to recognise it! There are subtle clues littered through the history and physical exam of a patient. A nasal voice indicates oropharyngeal weakness. This is important to recognise and can tip you off to the likely diagnosis. New onset eye compl

Sara Gray works in the Intensive Care Unit and sometimes connects with patients. This was especially true for a lady who was in her unit intubated due to pneumonia. When this patient experienced a failed extubation, a tricky re-intubation and subsequent tracheostomy, Sara was kicking herself. She says we have all been there… Have you ever dropped your phone? What was the internal dialogue in your head at the time? Sara calls this out inner voice. She used to think that our inner voice did not matter to high level medical performance or resuscitation skills. That was until the evidence changed her mind. The inner voice is powerful. A negative inner voice can increase anxiety, raise the heart rate, and use up valuable cognitive processing power. So, when running a complicated situation, your inner voice matters! For Sara, the critical soundtrack of the inner voice was constant. Her question was – how do I change this? This led Sara to the concept of self-compassion. She explores how she trained the inner dialo

Rhonda Cadena explains the process of diagnosing and managing meningitis. It is a skill that involves rapid identification, workup, and treatment. In most cases, the diagnosis of meningitis is not a diagnostic dilemma, but the workup and treatment are not as straightforward. Meningitis is inflammation of the lining of the brain and spinal cord. This can be caused by bacteria, autoimmune process, drug reactions, viruses, and fungi. Rhonda delves deeper into bacterial meningitis. Worldwide there are over 1 million cases per year of bacterial meningitis. This equates to 135 000 deaths. Of the survivors, half will be left with neurological deficits. So, the swift identification and treatment of this disease process is crucial. Symptoms include fever, headache, nuchal rigidity and altered mental status with almost all patients having at least two. A lumbar puncture is absolutely necessary. Only insist on a CT first if you suspect a mass lesion or increased intracranial pressure. Otherwise, the delay in antibiotics