Smacc

Katrin Hruska discusses the usefulness of biomarkers in Emergency Medicine. All biomarkers are awesome predictors of badness. Elevated hS-troponins after non-cardiac surgery or an acute exacerbation of COPD are associated with increased mortality. In seemingly healthy people, elevated D-dimer levels are associated with increased mortality. Similarly, NT-proBNP levels predict mortality in patients with end-stage renal disease. A biomarker, in its broadest sense, is defined as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention” (NIH Biomarkers Definitions Working group, 2001). This definition includes everything from laboratory tests to blood pressure measurements or an ultrasound scan. The clinical assessment in the Emergency Department is based on the subjective history of the patient and all available biomarkers (and their change over time). If we assume that biomarkers are

Chris Hicks delves in to how to optimise performance in a team environment in emergency medicine and critical care. When teams fail and fall apart, we are quick to analyse the performance. We pick it apart and see what went wrong, and why. Chris suggests that we should do the same thing for over-performing teams. We should analyse how and why they perform at optimum levels. In doing this, in reaching a higher understanding of elite performance, we can harness the techniques used, simulate and train them, and thus improve performance across the board. This is not a new concept. High performance in elite sport is driven by athletes searching to push themselves in new and more extreme ways during training. They do this so when they are faced with stressful situations in competition, they have seen it all before. High performers talk about being ‘in the zone’. This is a state of body and mind where optimum performance comes naturally and easily. Research suggests that when an individual is ‘in the zone’, areas of

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Jo Anna Leuck discusses fatigue in critical care. Is there a specific time during our shift when we are too fatigued to safely practice? That was the question that led to Jo Anna’s research project comparing the clinical performance of providers during the first hour of a day shift and the final hour of a string of night shifts. The providers were pulled out of their real-time clinical duties and video-taped while performing simulated critical care cases. The hypothesis was that the day shift providers would out-perform the night shift, but surprisingly the opposite proved true. Blinded reviewers assigned the day shift providers lower performance scores. Furthermore, they noticed some surprising medical errors committed during these simulated cases. Jo Anna examines how performance is impacted by practise, or lack thereof. She raises examples such as coming in to work after a few days off, or after an extended break and posits that performance will be negatively affected in these circumstances. Perhaps clinic

Karin Amrein talks about the challenges for women working in the critical care world. Incredibly, despite female prevalence, Critical Care is considered a man’s world. We've all heard the notion, “big boys with big toys.” The false assumption is that men are more interested in the latest equipment and technology. However, Karin thinks that the “soft factors” like love, care and teamwork are what will make the biggest difference in the future. Moreover, women are judged by their appearance and not their accomplishments. They are subject to questions like “Are you really a doctor?” or comments like “But you don’t look like a professor.” Patients and their families are often insecure when a woman oversees their treatment. Tragically, women are lost on their way to the top, captured by the “Glass ceiling.” One review showed that women have to be 2.5 times more productive to be given the same score in peer review. Another study showed that papers received better reviews when authored by a man. Karin presents stati

Motorcycle Trauma Simulation and discussion

Ashley Liebig is a senior flight nurse and helicopter rescue specialist with STAR Flight. She talks with passion about her job, her vocation. Ashley divulges a deeply personal and deeply traumatic story from the SMACC stage. Pre-hospital medicine, emergency medicine and critical care are difficult jobs. There is a human toll to be paid when working in these areas. Ashley wonders if the stress, the emotion and the trauma torments all listeners. She believes it does not matter. Because it affects some. And it has affected Ashley. Ashley implores you to be nice. She wants her colleagues to understand her, communicate with her, and respect her. She explores the physiological maladaptive response when humans experience trauma and relates this to her experience. Ashley goes on to share how she has, and is, dealing with the chronic stress she is experiencing. It involved adaptation and behaviour changes. She educated herself on the effects of chronic stress and engaged strategies such as exercise, laughter, and huma

Nikki Blackwell provides an insight into critical care in humanitarian emergencies. Through her experiences in hunger emergencies, epidemics, natural disasters and conflict zones, Nikki has gained a wealth of wisdom and lessons. She shares these from the SMACC stage. Nikki talks about some of the practical things she does when working in resource poor settings. It starts with hospital hygiene to reduce nosocomial infections, and often entails Nikki working alongside the cleaners due to resource limitations. Hand hygiene is difficult without running water and Nikki champions using the WHO Handrub Formulation. Other challenges include cold chain storage, blood donations, limited monitoring and food and nutrition. Nikki also discusses the challenges of working in different environments. Invariable the environment will be too hot… or too cold! On top of this, working in remote locations often entails living with the other medical professionals you are working alongside. This presents interpersonal challenges. Mor

Kathryn Maitland describes the challenges faced with oxygen therapy as an emergency intervention in critical illness in African children. Where Kathryn works, in East Africa, there is no access to intensive care. Caring for critically ill children is all done in the Emergency Department. 70% of the global burden of disease and deaths from pneumonia occurs in Southeast Asia and Sub-Saharan Africa. The WHO has published guidelines as to what classifies as pneumonia, severe pneumonia, and very severe pneumonia. These classifications rely on clinical signs. However, Kathryn in her research has discovered that these classifications are rarely correlated with the actual underlying disease process. Clinical signs are non-specific for the diagnosis of pneumonia. Oxygen is recommended for severe and very severe pneumonia. This has led to calls to prioritise oxygen delivery in African hospitals. However, it has not led to change from a health department or funding viewpoint. There are also oxygen delivery practicalitie

Francesca Rubulotta argues in favour of the ICU being no place for the elderly. She describes the ICU as a horrible monster, a very dangerous place. Furthermore, she suggests the ICU is on par with climbing a mountain in terms of risk and exposure to catastrophise. She continues to make the point that once a person reaches adulthood, the healthcare system is a one size fits all model. This extends to the type of treatment required – whether it be for an acute or chronic condition. Whilst hospitals, and ICU specifically, may be suited to assist those with acute conditions, it is perhaps less appropriate to deal with chronic conditions that avail the elderly. Francesca concludes that for the elderly, there needs to be a new model. One reliable, dedicated to the older patient population and able to provide the dignity they deserve. Karin Amrein provides a counter argument. She bases this initially through a personal story of her grandmother. This provides the basis for her argument that advanced age does not pre

Darren Braude and Karim Brohi debate over the utility of hard cervical collars. Darren argues that it is time to do away with hard cervical collars. He raises some assumptions. The first being that movement of the spine is bad. As he explains, movement is not the problem. Rather, energy deposition in the spine causes injury, not simply movement. With that being said, the problem is that the hard collar does not prevent movement! Surely, the benefits of the hard collar outweigh the risks. Darren argues otherwise. He discusses the effects of the hard collar on ICP and venous drainage of the brain. The issue here is that the patients with the highest risk of cervical injuries also carry the highest risk of concomitant brain injuries – and we as clinicians should not tolerate any increased risk to the brain. Finally, Darren argues that the hard cervical collar impairs airway management which is the priority for any emergency situation. Cervical collars are unlikely to help and can cause harm! Karim argues in favo

PRO: Medicine is a complex craft. Acute medicine is more complex. Excellence is delivering effective acute care depends on recognising the broad base of basic sciences, clinical experience, and results of clinical trials. Central to all decisions has to be how these will benefit the patient – both in the short term as well and longer term so that survivors of acute illness are left with the best possible outcome for that patient, their caregivers and the community at large. This is a daunting concept under time-limited, information-limited conditions. Clinicians are often left with uncertainty about the impact of decisions and rely on short-term surrogate measurements to justify treatment options. Consequently, assessing outcomes are invariably confounded by associations that bear little relationship to causation or biological plausibility. Such confounders are often demonstrated in observational studies and RCTs with low levels of internal validity, particularly those conducted in single centres and/or dri

Martin Smith and Mark Wilson debate whether neurocritical care improves outcomes in severe TBI. Martin argues in favour of neurocritical care. He concedes that longstanding and established practices are not as efficacious or innocuous as previously believed. Very few specific interventions have been shown to improve outcomes in large randomised controlled trials. With the possible exception of avoidance of hypotension and hypoxaemia, most are based on analysis of physiology and pathophysiology. Further, the substantial temporal and regional pathophysiological heterogeneity after TBI means that some interventions may be ineffective, unnecessary, or even harmful in certain patients at certain times. Martin however, contends that improved understanding of pathophysiology and advances in neuromonitoring and imaging techniques have led to more effective and individualised treatment strategies. Ultimately, this has led to improved outcomes for patients. In particular, the sole goal of identifying and treating intra

Anthony Holley and Marietjie ‘MJ’ Slabbert debate the value of prehospital doctors in trauma. Anthony argues that doctors in the prehospital setting add little value. He does so with the upmost respect for prehospital doctors and having worked in this setting himself. He makes the point that across the globe, the employment of doctors in the prehospital setting is a rarity. Working in this environment is diverse and every situation encountered requires a different skillset. This presents a logistical challenge. Anthony continues to discuss the evidence, or lack thereof, in this space. He raises the point of competing interests from paramedics, flight nurses and doctors themselves. This leads to apples being compared to oranges most of the time. Anthony goes on to suggest all the advanced clinical interventions that are necessary in prehospital situations can be competently undertaken by paramedics. MJ argues for the negative. In doing so, she concedes that the evidence base for prehospital medicine is scarce.

Resuscitation of the critically ill trauma patient involves a myriad of high-stakes, time-sensitive management decisions. The landscape is shifting rapidly: new evidence on hemostatic resuscitation and component therapy in hemorrhagic shock, peri-arrest point-of-care ultrasound, novel approaches to resuscitative thoracotomy and trauma RSI have at once clarified and muddied the waters. In this rapid-fire, case-based session, Petro and Hicks will debate some of the recent and potentially practice changing literature to assist with key inflection points in the care of the sickest -- and sometimes deadest -- trauma patients, and engage in some trauma dogmalysis in the process.

Alex Psirides and Sara Gray debate over whether ‘Do Not Resuscitate’ (DNR) should be the default choice for all patients. Alex contends that application of ‘CPR-for-all’ is the ultimate evidence drift. A treatment that is completely appropriate for dropping dead whilst running a marathon has almost no place in acute healthcare facilities where chronic irreversible complex co-morbidities abound. 90% of doctors would not choose CPR for themselves, yet 100% are trained in how to administer it to patients. Defaulting to ‘CPR-for-all’ removes a patients’ ability to provide informed consent for assault whilst they die from another disease. Remember – 2 weeks in ICU can spare you 5 minutes of difficult conversation. Sara on the other hand argues that DNR should not be the default position. Across the globe, patients are assumed to be full code to allow for prompt resuscitation, until code status can be discussed and clarified. There are numerous excellent reasons for this. Can you imagine if our systems decreed that

In a 2 min rant about medical tribalism, Dr. van der Velde questions which medical specialty, if any, owns prehospital physician response. What is more important: skillset or specialty? Is there a role for tiers of physician response? Is there a future in a stand-alone specialty?

Marietjie (MJ) Slabbert describes the unseen enemy, fatigue in critical care medicine. MJ does 24 hour shifts every other day with just three to four hours of sleep. Though many would claim that this is more than enough, MJ thinks otherwise. Physicians are killing themselves while trying to save others because fatigue kills. MJ points out that sleep is one of the basic necessities in Maslow's hierarchy of needs. Fatigue often affects the go getters or type A personalities. Among doctors, the critical care and emergency doctors are at a higher risk of being fatigued. MJ points out the dangers of being fatigued. Driving while tired is as dangerous as drunk driving or speeding. Fatigue also puts patients at risk as it increases medical errors and safety compromising behaviour. Studies show that the response time of anaesthetists increased twenty times when they were sleep deprived. Fatigue is the number one problem faced by doctors and MJ wants us to wake up. Doctors are at a higher risk of getting cancer and th

James Tooley discusses the sheer terror that comes with the challenge of managing children in the pre-hospital environment. As James explains, although many clinicians may think that they do not need to (or may not want to) think about the paediatric population, it is something that every clinician would do well to mentally prepare for. James shows a video clip of a large-scale paediatric trauma and challenges you to consider being dispatched to the scene. How do you prepare for that? Simulation, as usual, is key. Through simulation one can discover knowledge gaps, limitations of equipment and guidelines, and coping strategies. James takes you through some specific pointers regarding equipment that one should carry when anticipating dealing with pre-hospital paediatric emergencies. Next, James discusses pressure and how it degrades performance. A clinician should be aware of where their pressure limit is. The importance lies in recognising when you reach your cognitive overload. Once you recognise this point

Flavia Machado and Paul Young present the top 10 ICU trials of the recent past SMACC style. Their list of trials includes a number that challenge dogma and establish interesting new lines of scientific enquiry. In addition, they also include all the recent clinical trials that should change your practice. If you want to know what’s new in critical care then this is the talk for you.