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Anand Swaminathan and Iain Beardsell debate the use of thrombolytics in the treatment of submassive pulmonary embolism (PE). PE is a spectrum of disease. Patients should be treated differently depending on where they are on the spectrum. Subsegmental PE may need no treatment at all, whereas massive PE is unlikely to improve without thrombolytics. Anand argues for the use of thrombolytics. Evidently, time is critical when dealing with patients and Anand posits that thrombolytics gives the physician control over time. Submassive PE can deteriorate, leading to massive pulmonary embolism. A proportion of these patients will die. The data is not conclusive for the use of thrombolytics in terms of mortality, however long term outcomes do improve. Finally, Anand concludes by suggesting that the decision to use thrombolytics relies on sound clinical reasoning and decision making, informed by the available data. He argues for nuanced treatments and use of these drugs. Iain takes a different approach in his reply. Some

Ryan Wubben discusses the standards in Helicopter HEMS. He asks the question, what standards? The development of Helicopter EMS (HEMS, or as the Federal Aviation Administration recently coined it: “Helicopter Air Ambulance” or “HAA”) services in the United States has taken a different path in recent years compared to other countries. The widespread use of single engine, VFR only aircraft, owned and operated by for profit companies is a uniquely American phenomena. This is at odds with most other countries who have developed HEMS programs around the world. This has resulted in significant direct competition between HEMS programs. Additionally, it has drawn attention to highly questionable billing practices. Ryan examines the origins of this development. This includes the use of the US “Airline Deregulation Act” to prevent states from regulating HEMS programs. More recent efforts in the US to tie reimbursement and program accreditation to the levels of care provided and minimum standards of equipment are still

Natalie May & Roisin McNamara discuss a young person’s experience of critical illness. They are joined by Ema, an 11-year-old girl who had a scary time when she was diagnosed with tracheitis. Experiencing critical illness is  scary for anyone. However, when you are a young person, this terrifying experience is amplified. Natalie and Roisin tell us what we as clinicians can do or think about differently to provide a better patient experience. Although she is young, Ema provides some salient points about what doctors and nurses do well and what they can do better. The main take away boils down to clear communication. Medical professionals often think they are explaining things thoroughly. However, the words they use, and the speed of the delivery of those words, leaves a patient feeling confused and scared. On top of that, a patient's experience of critical illness leaves them exhausted, in pain and unable to effectively communicate. Bringing one’s awareness to this can assist when we are deciding how and w

Maxime Valois and John Christian Fox argue the role of POCUS in critical care. Maxime makes the case for POCUS being a problem. POCUS changes everything. It has helped physicians throughout the world to make easier, more accurate and faster diagnoses. It has contributed to enhance the diagnostic possibilities in resource-scarce environments However, as it gains more widespread acceptance, its use is becoming more and more common. Maxime contests that this poses a problem. No longer is ultrasound only in the domain of specialists and technology-eager early adopters of the technology. He proposes that this will lead to difficulties as non-specialists take up the technology. Maxime warns against being hypnotised against the seductive nature of ultrasound. Research and use of fancier, new or more advanced applications are likely to help the global advancement of POCUS and even medicine in general. But as POCUS enters fully in its stage of normal science, this will inevitably induce some degree of scientific esote

Scott presents the argument that whilst Emergency Physicians are amazing, as it stands, Emergency Medicine is failing. Scott presents the system as it should be. This involves stabilising the critically ill before admission to the ICU, seeing sick patients in appropriate time and seeing the less sick patients as you can. The issue as it stands, is when this system breaks down. He talks about the ‘boxes’ which now includes the ‘not sick at all’ patient. This leads to Emergency Physician’s not doing what they are trained to do. Scott discusses the issues with the outcome measurements of Emergency Departments. Hospitals measure patient satisfaction and wait times. Moreover, Scott argues that a trip to the ED should be the worst day in a patient’s life and measuring their satisfaction is misleading. A good medical outcome should be the indication of success. Scott also discusses the issue of Emergency Physicians not dealing with emergencies for most of their practice. This, in Scott’s eyes, leads to cognitive dis

There are nearly 100 billion stars in the Milky Way – and almost that many articles published every year. Luckily for you, we read them all – or, at least, the ones in the domain of EM (Emergency Medicine). Catch up with where the new literature is leading you, leading you astray, or just plain bonkers. Sit back and let us inspire you to take your own deep dive into all the great foundational science. We'll swing through new stroke treatments, the ketamine blow-dart, the best medications for reanimating the dead, and many more! Ryan Radecki: It has been exciting and surprising year in the EM literature. We'll be hitting all the highlights and letting you know what's hot and what's not. Topics to be addressed include, but are not limited to, abscess management, medications for renal colic, imaging for subarachnoid, new anticoagulant reversal agents, use of opiates, and the diagnosis of PE

Ben Shippey discusses the important anaesthetic considerations in bariatric surgery. Obesity surgery can induce a strong response in healthcare professionals. These biases must be overcome to facilitate efficient and safe services. Evidently, Bariatric surgery provides many challenges. To begin with, healthcare professionals can associate negative thoughts with obesity. Secondly, these patients present complex respiratory and cardiovascular physiology that must be considered. Ben highlights three important considerations when preparing for, and delivery anaesthetics in the bariatric population. These are Attitude, Assessment and Act. Attitude - Encompasses the attitude of the physicians, theatre team and the patient themselves. One must recognise and change their thinking about the obese patient. Ben’s team does this by realising the complex psychological background these patients invariably have. Assessment - Furthermore, a multidisciplinary team must undertake a broad assessment. Specifically for the anaest

John Carlisle asks the big question – what is the risk of surgery? It is a big question that holds implications for everyone involved in caring for patients. Like John, patients want to live a long and happy life. They would like to know whether the chances of living a long and happy life are enhanced by having surgery or not. They do not generally care whether they will be alive in 30 days or not. John explored whether or not we can accurately answer the question – what are the risks of a given surgery? Prognostic models based on a single surgical cohort are very vulnerable to chance and variation. This is even the case with large cohorts. The reason is that mortality is not that common. Therefore, the range of uncertainty in any one model is big. John explores this concept in the context of surgical intervention for abdominal aortic aneurysms. He highlights the perils prognosticating by describing the trials that influences the treatment guidelines for abdominal aortic aneurysms. John describes the current

Karim Brohi gives an insight into his mindset as a trauma surgeon, drawing on lessons from Zen philosophy. During this talk he discusses how we can develop the self confidence that helps us cope with stressful clinical situations. The word confidence is often talked about in a negative context, in terms of overconfidence or arrogance. Karim however uses this talk to highlight the importance of self-confidence. Self-confidence is important for you, your team, your department, and your healthcare system. Karim will teach you how to use this confidence to handle whatever is thrown at you. Zen philosophy draws on the notion of water. Water, mind like water, heart like water and core like water. How do you adopt a heart, mind and core that is like water? Water takes the shape of whatever environment it is in. In a glass, a vase or a lake, the water fills the space. It mimics its environment. Extending this analogy, water in its resting state is calm and still. However, throw a stone into the water and you create r

Haney Mallemat discusses the treatment for PEA cardiac arrest. Patients who present with pulseless electrical activity (PEA) arrest have a high mortality. The treatment of PEA requires finding and reversing the underlying cause; therefore a simple and rapid approach is required. Traditionally we were taught to use the H’s and the T’s, but this diagnostic tool is cumbersome and of questionable utility overall. Haney discusses the problems with the traditional H’s and T’s as well as focusing on newer approaches to PEA arrest. Haney makes the point that PEA is not a diagnosis, but a ‘waste basket term’ for a lot of possible diagnoses. Rather than assisting a clinician in the assessment and treatment of a patient, it acts on to lead to pontification. To that end, Haney wants us to do away with the H’s and T’s. The problem with the algorithm of diagnosing a PEA, as Haney explains, is the reliance on feeling a pulse. It lacks sensitivity and specificity, largely linked to using fingers. They should not be used in r

John Greenwood takes a broad view on pulmonary hypertension and explores the heart-lung interactions that occur in this disease process. Pulmonary hypertension commonly occurs when managing a patient with an acute critical illness. Pulmonary hypertension has a devastating impact on cardiac function. Whilst we recognise the disease itself, we don't recognise the ‘upstream’ effects. John explains how it is these effects that may be causing the patient to crash. John, in this talk, helps you to understand the clinical heart-lung interactions affected by pulmonary hypertension and the effect on the right ventricle. He educates you on identifying patients at high risk for pulmonary hypertension, and finally he discusses critical management strategies for patients with pulmonary hypertension. In the ICU, causes of acute pulmonary hypertension are evident daily.  Microcirculatory of the lung has a strong impact on what the pulmonary pressures are. Therefore, conditions such as pneumonia, ARDS and pulmonary oedema wi

Michele Domico presents a talk on the pitfalls of common paediatric resuscitative manoeuvres in paediatric cardiac patients. Emergency and critical care physicians are all well accustomed to items such as oxygen, bolus adrenaline, intubation and cardioversion. However, as Michele explains, these ‘go to’ interventions may in fact be harmful for the paediatric cardiac patient presenting to the emergency department in extremis. Due to the physiology of certain complex congenital heart diseases, the usual resuscitation manoeuvres may in fact kill the patient instead of helping. Supplemental oxygen can worsen the pulmonary to systemic blood flow ratio in single ventricle patients and cause them to have rising lactate levels and cardiac arrest from low systemic cardiac output. Intubation and positive pressure ventilation may impede pulmonary blood flow in patients with a Glenn shunt and the patient can become more desaturated. With increasing PEEP and higher respiratory rates, the patients will continue to deterior

Deirdre Murphy presents everything that can go wrong in cardiac surgery. Deirdre will impress on you that cardiac surgery is by no means a safe procedure! Murphy’s Law stipulates everything that can go wrong, will go wrong. Subsequently, Finagle’s corollary will tell us, it will be at the worst possible moment. In this talk Deirdre attempts to prove these theories in the world of cardiac surgery. Cardiac surgery can vary from being routine elective surgery to time-critical emergency surgery. The term encompasses a broad range of procedures carried out on patients from neonates to nonagenarians. In the 63 years since the first open heart surgery was performed using cardiopulmonary bypass enormous advances have been made in the field such that an average person presenting for coronary bypass grafting in 2016 can expect a very low chance of peri-operative morbidity or mortality. When things go wrong however, they can go badly wrong and at the worst possible moment. The list of problems that occur is extensive. D

Peter Brindley explains how burnout affects us all. It affects the cost, quality of care, organisational culture, performance and patient outcomes. Burnout is fatigue, loss of ideals, purposelessness, presentism and the sense of being under-appreciated. It is not tiredness, exhaustion, boredom, mid-life crisis, depression, PTSD, perfectionism or narcissism. Moreover, burnout involves the 4 C's: cutting corners, cynicism, callousness, and contempt. Peter explains when and why, and to whom a burnout occurs. A major reason for burnout is the difference between expectations and reality. This drives the thought, “this is not what I signed up for.” Furthermore, he presents the 12 steps which lead to a burnout. It begins by the need to prove yourself by working harder, neglecting your needs, avoiding issues, and losing friends or hobbies. This leads to denial, withdrawal, behavioural changes, depersonalisation, inner emptiness, depression and finally burnout. Peter suggests a few things that we can do to prevent bur

Francesca Rubulotta talks about disproportionate care in ICU. Disproportionate care is disproportionate in relation to the expected prognosis. Moreover, this can lead to moral distress among clinicians who think they are offering inappropriate care. There is mounting research and evidence pointing to the existence of disproportionate care. Furthermore, stress and burnout cause increased miscommunication and lead to low performance and concentration. Stress leads to absenteeism or in many cases, presenteeism. Presenteeism is when someone just shows up for work but does the bare minimum. Francesca shows the financial burden caused by absenteeism across various countries. Francesca points out that only 14% of employees feel engaged in their jobs. Moreover, data shows that companies which keep their employees engaged have higher rates of performance. Such companies have managers who are more engaged and approachable. Francesca discusses various studies that look at the appropriateness of care in ICU. She talks ab

Karin Amrein highlights the importance of bone health in ICU. Karin asks – do fractures matter? If the presentation is a hip fracture for elderly patients, then the answer is obviously, yes! However, Karin will describe why this answer should be a resounding yes for all patients who are admitted to the ICU. Critical illness affects bone. It is not a stretch to conceptualise this. However, Karin wants to impress on you that bone affects critical illness also! Bone is an endocrine organ, the largest endocrine organ. Fragility fractures are associated with substantially increased mortality and morbidity. One year post hip fracture, 50% of the patients are either dead or in a nursing home. Prevention is crucial! After an ICU stay, patients have a largely elevated risk of fractures – up to 65%. However, this risk factor is not recognised in the literature. If you survive critical illness and get home, you have done well. If you then sustain a fracture, you are almost back to square one! Karin attempts to explain

Natalie May gives you the break down of paediatric trauma. Paediatric trauma is relatively rare but terrifying. However, there are many ways we can think about paediatric trauma to make these challenging situations easier to face. Children are inherently portable. This means that they often turn up at peripheral, non-paediatric centres that are not major trauma centres. This highlights the importance of all physicians knowing how to deal with these cases. Anatomy and physiology of children is different to adults. Their ability to compensate is remarkable. This means the index of suspicion of serious injury should be higher. For instance, their ribs are a lot more pliable than those of adults, meaning hollow viscous organ injuries are more common following trauma. Similarly, their vital signs can be more confounding. Tachycardia could simply mean fear or pain. On the other hand, it could indicate a major internal bleed. This leads to children being under and over triaged at a high rate. Teenagers also present

Confined Space Airway Management in Emergency and Critical Care by Ross Hofmeyr Ross Hofmeyr discusses the ins and outs of managing an airway in a confined space. He details the challenges, the potential solutions and his top tips when faced with an airway in a less than ideal setting. Ross defines confined space airway management as airway management in an environment where access to the patient, normal positioning, and use of airway equipment is limited by physical constraints. Ultimately, these situations are endless. An icy crevasse or on a mountain top. Inside a cave. Motor vehicle crash scenes. War zones with bullets flying overhead. The inside of a helicopter or the back of an ambulance. Even inside tight Emergency Departments, cath labs or operating rooms that are full of advanced equipment. These are all scenarios in which one may find themselves faced with confined space airway management. Ross contends that all airway clinicians have the possibility to have to handle these situations. In this prese