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Neuro Imaging Nibble: Subtle Subarachnoid haemorrhage on CT by Jordan Bonomo

Jonathan and his wife Anna thought they were coming to the emergency department for a routine sickle cell pain crisis. However, his illness takes him down an unexpected spiral of multi-system organ failure and critical illness. What was a routine patient encounter becomes a much more personal human interaction that causes the provider to question her perspective on chronically painful conditions and realise the effect our words and subtle actions have on our patients. Jessica Mason utilises the powerful tool of narrative storytelling, adapted to a live lecture format, to tell Jonathan’s story from his own perspective. In doing so, Jessica makes Jonathan the teacher. Jessica hopes you will remember the story and remember the medicine. In 2016 Jessica received an email from Jonathan’s wife. The email was to inform her of Jonathan’s death, from complications of sickle cell disease. He was 43. This stark note gave Jessica pause, and prompted her to reflect on her interactions with Jonathan and his wife and wonder

Trauma is an epidemic so what is the future for prehospital trauma resuscitation? The statistics are shocking – 14,000 people a day and 5 million people every year die from trauma. Injuries accounts for 9% of deaths worldwide and they are the biggest killer of under 40s across the world. Incredibly, these numbers are only rising. Dr Brian Burns describes what is largely a silent killer… many critical care doctors and nurses may never get the chance to see, treat or save the patient, because they often do not make it to the emergency department. Death often occurs in the first hour post trauma and 90% of trauma deaths are due to exsanguination. We pick up the story of Paul. Paul is driving alone when he loses control and crashes his car. There are no witnesses. No one to call for help. No emergency responders. Paul bleeds and dies. The emergency system that is currently used is not specific or sensitive enough – and we need to do better. The meercat is the animal world exemplar of the early warning system. Mee

Dying is not very sexy, but sometimes, dying is the right thing to do. Death is one of the many things that we only get one shot at. There is no second chance at death. Dr Alex Psirides discusses death from a patient, family, doctor and economist perspective. 400 years ago, death was everywhere. Everyone was exposed to dying on a regular basis and people were encouraged to prepare for their death. Things have changed thanks to the intervention of the medical profession. Resuscitation teams, pain killers and the concept of “dying in comfort” have altered the trajectory of dying, leading to a mystique surrounding the concept. Dr Psirides argues that death has replaced sex as the new taboo – and the result is a society removed from death. This has led to poor choices in medical interventions towards the end of life. Furthermore, Inappropriate decisions made by medical teams are likely to delay death, decrease quality of life and cost money, all without changing the ultimate outcome… death. This sparks a discussi

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Sarah Yong is an impressive person. Advocacy, Training, Representation and being a new fellow of the College of Intensive Care to boot.   Theres a lot to talk about when you sit down with Dr Sarah Yong. Let’s make it easy by focussing on three big issues;   Gender issues; Women in Intensive Care Network. www.womenintensive.org Training issues; The Critical Care Collaborative and the Victorian Primary Examination Course for CICM. www.vpecc.com Representation issues; New Fellows Rep on the Board of the College of Intensive Care Medicine. www.cicm.org Where to start? Women in Intensive Care Network www.womenintensive.org @WomenIntensive If my sources are correct there pretty much the same number of women and men out there in the world. Further it seems that there are roughly the same number of women and men presenting to intensive care units. This pattern does not repeat itself in terms of the Intensive Care doctors. Let’s talk about this. Let’s listen to the people that are raising awareness about this. The Wom

Darren Braude discusses the concept of Rapid Sequence Airway (RSA). The evolution of this concept goes back to the start of the 21st century. Here, the practise of ‘archaic’ airway management was common. This involved getting that plastic tube down the patient’s trachea no matter what. However, gradually, the risks of hypoxaemia during airway management become evident. This led to a movement towards extraglottic airways. If the oxygen saturation was dropping and there had been two failed attempts. This movement continued to involve towards operators deciding to move to other methods when only one attempt had failed. This was largely due to the increased training and skill of clinicians. The thinking being if they could not get it in one shot, they probably weren’t going to get it at all. This evolution was the catalyst for the movement towards faster airways, and less emphasis on intubation. Rapid Sequence Airway is pharmacology and preparation as in RSI, with the planned placement of an extraglottic device,

Ellen O’Sullivan presents an outline of the Difficult Airway Society (DAS) Guidelines on airway management. Airway management is a fundamental responsibility and skill of all involved especially for emergency physicians, anaesthetists and critical care physicians. Ellen makes the point that mismanagement of airways leads to severe morbidity and mortality. She provides a few harrowing examples. The 2015 Difficult Airway Society guidelines, published in the British Journal of Anaesthesia in December 2015, provide a sequential series of plans (A to D) to implement when tracheal intubation fails. They promote patient safety by prioritising oxygenation and minimising trauma. Furthermore, they highlight the role of neuromuscular blockade in making airway management easier. The guidelines recognise the difficulties in decision making during an emergency and stress importance of human factor training. The guidelines include steps to assist the anaesthetic team by providing a common stem of options (a simple algorithm

Reuben Strayer presents a masterclass on airway management with laryngoscopy. In the past two decades, airway management has been revolutionised by the development of video laryngoscopy, hyperangulated blade geometry, optical stylets, laryngeal masks, and a host of advances in airway pharmacology and technique. The core skill of airway management, however, remains laryngoscopy. Reuben provides his take on how to perform this procedure with success. Firstly, Reuben talks about positioning which is a critical step. This includes the common mistakes made in patient positioning. Reuben shares a proposed set of parameters that the provider can use to guide positioning that is optimal for laryngoscopy. He also guides you through his take on the grip to use throughout the procedure. Reuben talks about the effect of the grip on the operator’s catecholamine production and what to do to avoid excess catecholamine levels which will be detrimental to performance. Next, Reuben confronts one of the core principles of RSI,

Ross Fisher gives his take on how to make your presentations better! Delivering a presentation is a skill like any other, yet few people are actually develop this skill. Instead, they merely copy those they observe and reach the same level of mediocrity. There is more to a presentation than your slides. Ross gives his three main elements of any presentation: The story, the media, and the delivery. In Ross’ view, these elements are all equally crucial to delivering a great presentation. He calls this concept ‘p cubed’ where each element is represented by P1, P2 and P3 respectively, and these elements are multiplied together to give the overall quality of the presentation. The lesson here is that a small improvement in any area will garner and overall improvement in the presentation. Ross will guide you through practical tips for each of his key elements. Firstly, your presentation needs to be grounded in an engaging concept in order for the audience to care about what is going on. Moreover, Ross discusses the

Suman Biswas is an anaesthetist from London, however probably more famous for his satirical song writing career, gives a poignant talk about communication. Suman provides his ideas about talking and communicating with patients. As everyone knows, anaesthetists do not need to talk to their patients! Quite the contrary, as Suman divulges they indeed do. They need to establish rapport, gain trust and share information – much like every other member of the healthcare team. Therefore, Suman will provide his musings on the use of language and the words we use when we attempt to succeed in these domains. Suman touches on the use of both verbal and non-verbal communication and the importance of nailing both when attempting to get a message across. He similarly gives guidance on communication with patients who speak a different language to your own. This includes pointers on the use of interpreters. Suman moves on to communication with colleagues. He talks about Anaesthetic Non Technical Skills (ANTS) – teamworking, t

Jenny Beck-Esmay, Dara Kass and Stacey Poznanski tell the story of FemInEM and celebrate women in Emergency Medicine. Jenny shares the story of Casey Drawert, a doctor who was tragically shot to death by her husband. This incident opened the discussion regarding how common domestic violence in physician relationships is. In response to this incident, Esther Choo wrote "Intimate partner violence, a physician mother and our call to action" for FemInEM. Esther's post garnered a lot of attention and led to numerous women and physicians to come forward with their story of violence. Dara talks about an incident regarding changing gender dynamics that led to the birth of FemInEM. A female physician received a call from her son' s school when he missed his class. This was despite the primary contact being specified as the stay-at-home father. This incident motivated the formation of FemInEM. Even though there are multiple women organisations, women seldom know what is happening beyond the boundaries of such organisat

Sandra Viggers delves into the art of learning medicine. Sandra asks the question: can students choreograph their own education? On one hand, people believe students cannot choreograph their own education for various reasons. She calls such people behaviourists who push others back in line if they do not agree with their views. Behaviourism is a top to bottom approach. The teacher is not a facilitator but an instructor. It produces MDs with knowledge that is not applicable to real life. On the other hand, can students choreograph their own education? In educational psychology, these people are called humanists. In the humanistic approach students are active learners. The problem with this approach is that it is dependent on intrinsic motivation. Hence, it is important to realise when the student is intrinsically or extrinsically motivated. Sandra points out that both behaviouristic and humanist approaches fail to include the skill of reflection. While the humanist will expect the learner to self-realise refle

Tom Evans wants to bring lessons from elite sport development and training to medical education. Caring for the critically unwell is an important and difficult task. So, preparing our people to meet this challenge should be all about excellence. These are all true of sport – and Tom contends perhaps medical training! Nothing happens quickly in sport. It takes time, often many years. There are a number of challenging tests along the way for an athlete to reach the pinnacle of representation. So hard are the tests that not everyone will make it to the end. However, when one does make it, how the performance in those tests to get there has no bearing on how they will perform in the race or on game day. Standards are rigorous because there are no second chances. You do not get another go at the Olympic final. Elite athletes often only have a handful of coaches during their career. Coaches are accountable for the performance of their athlete and talent will not rise on its own. Tom contests the medical training sh

This will be a panel discussion with a focus on the different styles of training and education in prehospital care.

Ross Hofmeyr divulges some stories from his experience of wilderness and expedition medicine. In his words, wilderness and expedition medicine is the epitome of practical, pragmatic, minimalist and thoughtful care. Austere and extreme environments require special knowledge, critical thinking, innovative practice, and sometimes cunning improvisation. Moreover, diagnosis in the wilderness relies heavily on clinical examination skills. Monitoring is limited and treatment options are determined by the individual practitioner’s hands-on skills. Furthermore, the implications of extreme environments – high pressures and altitude, frigid and sweltering temperatures, hypoxia, and high-intensity endurance exercise – can provide us with great insight into the physiology of humans responding and adapting to critical illness. Join Ross as he displays his deep love of the wilderness and nature, and the lessons he has taken from the outdoors. These lessons, whilst useful for medical practice, transcend medicine. His stories

Kathleen Thomas describes her harrowing experience of a warzone whilst working in the ICU and ED of the Médecins Sans Frontières run Kunduz Trauma Centre (KTC) in northern Afghanistan. Kathleen describes her work during a week where she found herself caught up in an eruption of war. The Taliban forcibly took control of Kunduz from the US backed Afghan Military. This marked the beginning of a challenging week of heavy conflict in which the hospital was the only facility providing impartial medical care to war wounded civilians and soldiers from both sides of the conflict. Despite the proximity of the rapidly changing front line, Kathleen believes that the hospital is the safest place. Both warring parties had agreed to respect the protection provided to us under International Humanitarian law. Kathleen’s work in KTC came to a grinding halt when a US Gunship fired over 200 missiles into our hospital. This destroyed the main building and killed 42 people including 14 of her colleagues. It was a scene of nightmar

Trish Henwood talks on all things point of care ultrasound (POCUS) in resource limited environments. According to the World Health Organisation, 80-90% of all diagnostic problems can be solved by basic radiograph (x-ray) and ultrasound (US) examinations. However, the problem is that two-thirds of the world’s population currently has no access to imaging technologies. From refugee camps in Greece, to rural clinics in Australia, to Everest Base Camp, POCUS is one of the most powerful diagnostic and procedural tools in any austere clinical setting. This transformative technology allows front line providers who have direct responsibility for patient care to rule in or rule out diagnoses rapidly. Moreover, it ensures safety in performing procedures with real-time image guidance. For example, POCUS training can allow a midwife to identify a massive amount of free intra-abdominal fluid in a 30 year-old Ugandan mother presenting to gynaecology clinic with her third pregnancy and new abdominal pain. She can then notif

David Carr teaches you how not to miss the diagnosis of aortic dissection. David breaks down the key pearls on history and physical exam that guide you into correctly suspecting a dissection. Aortic dissection is a challenging diagnosis that you cannot afford to miss. The talk aims to give you the framework to avoid missing the diagnosis. Firstly, David begins by teaching you what questions to ask in the history to raise the suspicion of an aortic dissection. These include onset, quality, and radiation. As he explains, these simple three questions will raise the suspicion in the vast majority of cases. If you do not ask these three questions, you may as well be flipping a coin! Secondly, David goes on to an in-depth explanation of the pain patterns that can present in an aortic dissection. He describes the concept of chest pain plus one. David delves into what he sees as the questions and considerations only a ‘master clinician’ will think of. He implores you to join this group. Evidently, the physical exam p