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The Role of the Immediate Responder in Mass Casualty Trauma Christina Hernon describes a traumatic experience in gripping detail. In doing so, she shares her deeply personal insights into what it is to be an Immediate Responder. Christina suggests that the medical system must change to support these people. After a major formative experience at a life-threatening mass casualty incident, Christina felt incredibly unprepared despite over two decades of training in emergency and first response. Christina reflects that all the training that students undergo does not prepare them for every scenario. The standard approach to emergency care, is this scene safe? is completely inadequate for those present the very moment an incident occurs. These people are then amidst and surrounded by an unsecured and potentially unsafe scene. After her experience Christina had an acute stress reaction exactly like after rough calls in prehospital Emergency Medical Services. However, Christina wasn't offered the usual support given

Natalie May brings the lessons she has learnt from Sydney HEMS training and teaches you how to apply them to your practice. What can hospital specialties learn from teaching and training in prehospital and retrieval medicine? Natalie, a self-described medical education enthusiast, gives you her thoughts on the application of educational theory to the challenges of the prehospital environment. Evidently, Natalie will discuss three domains of medical education – Induction, Competence and Culture. Firstly, Induction How do you welcome new staff to your service? In Sydney HEMS there is a week-long full team training. This teaches new clinicians to contextualise pre-existing knowledge into their new environment. Here, they combine teaching tools including demonstration, simulation, discussion and debriefs. This is often in stark contrast to in-hospital inductions that can consist of a cursory department tour and online modules. Moreover, Natalie discusses the medical education principles that provide the basis of

Sara Gray tackles the controversial topic of disaster ethics in critical care. Most hospitals develop a disaster plan, but few jurisdictions develop a plan for triaging or rationing scarce resources when the existing supply is overwhelmed. Rather than leaving individual health care workers to make these decisions, we should work together as a community of experts to develop ethical, practical and appropriate policies for triaging scarce resources during a disaster. Healthcare resources are finite. In the case of large-scale trauma with large numbers of casualties, such as a disaster scenario, how do you decide who gets what? Sara discusses her guiding principles when thinking about disaster triage. First and foremost, avoid having to triage or ration scarce resources. Have a plan and make first part of the plan to be “Never use the plan”. Mitigate all the risks and possibilities that would see the plan being enacted. This involves sharing with partner hospitals, urgently reordering supplies and repurposing wh

Liz Crowe believes that love can revolutionise the way we approach critical care. She wants every doctor to become love ambassadors for their critical care community and share love like nothing is holding them back. Liz believes that work life balance does not exist because we spend most of our time at work. Therefore, it is essential to love and be passionate about the work we do. Liz compares the feeling of being a novice in critical care to first being in love. Initially, there is fear and excitement doing new procedures. However, as days go by, you lose the rhythm. This is how relationships evolve, both in life and in critical care. Relationships with critical care is all about hanging in there and, love. Love helps to sustain it. She discusses the role of love and leadership in critical care. Liz demonstrates that great leaders always lead with love and compassion. Leading with love does not make them weak or indecisive, instead it creates a climate of trust and intimacy that makes individuals and the te

For Ross Fisher there are things that scare him. And he knows there are things that scare you too. Ross discusses the purpose and effect of fear in medicine and surgery. Whoever you are and whatever you do, there are things that you are afraid of. It is not stress, it's fear, it's real and it affects us. Ross wants you to know, it is okay to be afraid. Being afraid is recognising a threat and realising that there is a limitation to your ability, and that you have reached that point. Ross describes three moments in his career that he has felt fear. Real fear, that was different to stress. Moments before operating on a preterm neonate of 29 weeks. Believing he had transected the common iliac artery in a haemorrhaging 9-year-old during a removal of a Wilm’s tumour. And being reported for malpractice by a colleague. In each situation, Ross felt fear. What does fear do to a person? It is different to stress. Stress in critical care medicine is part of the job. In fact, it is necessary to reach a performance state.

Resa Lewiss gives her insights into leadership. Through her experience training and working in Emergency Medicine and Critical Care, Resa has collated a series of pearls, pitfalls, and lessons shared by leaders. For Resa, there are leaders, and there are follows – more often than not, people know good leaders. Resa firmly believes that leaders look like leaders. She affirms that it is neither a male nor a female trait – despite what some may assume. Resa shares her lessons on leadership. 1) There is never a need to publicly embarrass someone Public embarrassment serves a purpose, however this purpose is often misguided and can be better achieved in other ways. Resa has experienced the embarrassment firsthand and knows of its detrimental impact. A good leader will give a person an out and speak to them in private. This is much more effective. 2) Make a decision Being indecisive can be perceived as worse than making the wrong decision. Leaders need to be confident in their decisions. 3) Know your strengths and

Medical journals have many possible functions, but the main one for most is publishing science. They are actually better at campaigning and agenda setting, rather like the mass media. Journals are now beset with problems, including failing to include data, publishing lots of poor quality material, being slow to publish, publishing research that is either not reproducible or fraudulent, encouraging waste in the system, failing to be transparent, and exploiting academics. New ways of publishing science are appearing, and a better system would be for the grant proposal, protocol, and full data to be published on a database with the whole process transparent.

Antibiotic Use for Sepsis in Critical Care: Steve McGloughlin Steve McGloughlin presents his thoughts on antibiotics and their use in sepsis and critical care. Steve discusses the ABC of sepsis… the trouble is after A for Antibiotics there is not a whole lot else! In sepsis and severe infection, the goal is to change the trajectory of the patient, away from death and to a more favourable outcome. The tools that are currently on offer in critical care are pretty simple. There are things to support the patient such as fluid and ventilators. In addition, we consider goal directed therapy. In terms of definitive therapy, the list is quite small. Perhaps only antibiotics and source control can be turned to. Antibiotics are a powerful tool. So much so that the number needed to treat is around four. They are also very commonly used. 70-80% of patients in the ICU will get antibiotics – far higher than nearly all other treatments. Steve has some basic advice for the use of antibiotics to enhance their effectiveness. G

Per Bredmose discusses the use of inhaled nitric oxide (iNO) in retrieval medicine and critical care. He explains why iNO is useful for retrieval and transport of the critical respiratory failure patient. iNO is not a magic bullet, but rather a bridge that will help you get to where you need to go when treating a patient. Furthermore, it can be useful in both pre-hospital and in hospital care. What is nitric oxide? It is an endothelial derived potent short acting vasodilator mainly found in the pulmonary system. It also exists in other areas of the body. When nitric oxide is delivered via the inhaled route it has local effects only, with no systemic effects. Most people will be familiar with the use of iNO in persistent pulmonary hypertension of the newborn. However, there are other uses which are more “off label”. For instance, take the case of severe ARDS lungs in pre-hospital settings. These patients present challenges in retrieval for several reasons, including the retrieval ventilation systems being infe

How do you diagnose death? In Critical Care we deal with death on a regular basis and although it seems black and white, that is often far from the truth. Patricia Gerritsen discusses what it means to be dead and how that knowledge can aid you in stopping a resuscitation effort. Patricia presents the degrees of death in her eyes as: Soon to be dead Reversibly dead Irreversibly dead Reversibly, irreversibly dead Changes occur following death that can be proof of death. But not always. Pallor mortis, algor mortis, rigor mortis, livor mortis and decomposition can all indicate someone has died. There are other clues that can indicate a person is either dead or will soon be dead – with minimal chance of any life saving intervention. The varying ways death presents itself poses a challenge for the clinician. This is especially true when deciding when to stop a resuscitation effort. Consider the reversibly, irreversibly dead – also known as the Lazarus phenomenon. These patients achieve return of spontaneous circu

Diagnostic medicine is not simple – Casey Parker discusses the finer points of the diagnostic process in critical care. Diagnosis is not black and white. The world is not black and white. It is all shades of grey and about probability. One tool that clinicians have to deal with probability is Bayes’ theorem. Since it was first described in 1763 Bayes’ theorem has been applied, rejected, and rediscovered in many fields. Its use in medical diagnostics is a relatively recent phenomenon. This talk will review the history of Bayes in medicine. Since 1763 the medical world has made dramatic leaps forward. However, Bayes’ theorem still has its place. It has been made more accessible with nomograms and more recently handy clinical decision-making tools in the form of smartphone apps. Casey helps you put all this together by elaborating on the diagnostic process. Firstly, is the pre-test probability – how likely is a disease in any given population. Not all populations are the same. Therefore, depending on where you w

Kate Prior conveys the lessons she has learnt working as a doctor as part of the Medical Emergency Response Team (MERT) in Afghanistan. “Unexpected survivors” are those patients who, according to their injury severity score, should die of their injuries but they survive against the odds. The years of conflict in Afghanistan saw increasing numbers of these grievously injured patients surviving to live a fulfilling life. How was this achieved? As Kate explains, it is sometimes necessary to reorder the ABCDE. In the case of a major trauma with catastrophic bleeding, stopping the bleeding needs to be prioritised above all else. Kate describes the methods she used. Secondly, she discusses the importance of taking the hospital to the patient. Kate talks about the capability of the Chinook helicopters she worked in. In her words ‘helicopters become flying Emergency Departments’. This enables advanced assessment and interventions to be delivered on scene. This includes IO access, blood transfusion, RSI and high-quali

Peer review is at the heart of science. Yet, as Richard Smith explains in this talk, there are many problems with peer reviewed research. As Richard argues, peer review is not an evidence-based process, but rather a faith-based process. Is it time for something different? Peer review has two main functions: 1) Quality assurance and 2) Improving what is published. However, with that in mind, there is no evidence of effectiveness of peer review, and lots of evidence of its ineffectiveness. This is along with peer review being slow, expensive, wasteful, inefficient, prone to bias and being largely irrelevant! Richard discusses a few of the main issues as he sees it. For example, studies in large journals are more likely to be wrong when compared to smaller journals. Some argue that the vast majority of research is a waste of time. Similarly, replication is also a major problem, as Richard explains. A huge number of studies cannot be replicated, raising questions about the initial research. What is published in j

The exposure of fabricated numbers in published papers by eagle-eyed readers has been due to sporadic serendipity. I am going to describe a semi-automated method that you can take away with you to do some sleuthing. I am going to describe what I found when I analysed over 4500 papers.

Jeff Drazen delivers a powerful message on the use of medical evidence in critical care. Medicine is powered by knowledge, but how do we know what is true and what is not? How do we deal with uncertainty in a setting where outcomes are not closely related to known variables? For example, although there are a few people who have survived jumping or falling from an airplane at high altitude, it is a rare event. Thus, a test to determine how to prevent death from such a disaster would only take a small number of participants to see if a particular method works. In contrast, when considering a medical condition where a large fraction of people might seemingly “recover” without treatment, such as tuberculosis, how does one determine if a treatment is effective? In this talk Jeff discusses the trials surrounding blood glucose control in the Intensive Care Unit (ICU). The way we have dealt with increased blood sugar levels in critical care has changed over time. Whereas once upon a time there was little thought give

Medicine is powered by knowledge, but how do we know what is true and what is not? How do we deal with uncertainty in a setting where outcomes are not closely related to known variables? For example, although there are a few people who have survived jumping or falling from an airplane at high altitude (http://zidbits.com/2010/12/can-you-survive-a-freefall-without-a-parachute/), it is a rare event. Thus, a test to determine how to prevent death from such a disaster would only take a small number of participants to see if a particular method works. In contrast, when considering a medical condition where a large fraction of people might seemingly "recover" without treatment, such as tuberculosis (http://www.who.int/mediacentre/factsheets/who104/en/print.html), how does one determine if a treatment is effective? In this talk, I will examine how we gained knowledge about tuberculosis as an example of a disease where a combination of observational scientific findings and clinical trial data are linked to advance k

Michael Perlmutter guides you through the prehospital diagnosis and treatment of sepsis. Sepsis is a difficult diagnosis to make. Even in the hospital, where a plethora of tests are available to assist the clinician. The diagnosis remains a challenging one, due to the very nature of sepsis. A shadowy shape-shifter notorious for its ability to hide in plain sight. For now, even in-hospital, there is no test with perfect sensitivity or specificity for sepsis. This is especially true in the prehospital environment, where we must rely on tools we can bring into the field: physical exam, point of care tests (lactate/venous gas), assessment of end-tidal CO2, and ultrasound. The aim of prehospital sepsis care is two-fold – early diagnosis and early treatment. First, early diagnosis of cases ranging from early sepsis to septic shock. Point of care testing is essential. Measurement of EtCO2 serves two purposes: as a reasonable surrogate for lactate and providing an accurate respiratory rate. A vital sign that is notor

Endothelium was once thought to be an inert organ. However, it plays an important role in multiple functions. These include coagulation, inflammation and determination of vascular permeability. He then gives a brief overview of the endothelial arrangement, function of the glycocalyx layer and how an injury causing a loss of the protective layer results in holes in the endothelium. The inflammatory cells enter via these holes and causes oedema in the affected organs leading to multiple pathologies. Danny then explains the role of endothelium in controlling cell barrier function. Activation of cortactin protein and the myosin light-chain kinase (MLCK) enzymes activate stress fibres resulting in pulling of endothelial cells thereby increasing its permeability. Danny discusses the role of endothelial dysfunction in acute respiratory distress syndrome (ARDS) at macrovascular, microvascular and molecular levels. Macrovascular thrombosis is related to an increase in severity of ARDS, pulmonary hypertension, and mort

Bill Knight explains the concept of death by neurological criteria and the complexities surrounding organ donation in such situations. Bill discusses the process of dying, the definition of death, how to approach the neurologically dead patient and how to consider organ donation. Death is a complex topic. Due to advancements in medical technology and processes, the definition of death is a challenging one. Bill talks at length about the definition of death by the neurological criteria. Dying is an active process, whereas death is an event. The acceptance of death by the neurological criteria is often challenging as Bill will highlight. Bill talks about the care of the dying or dead patient. There is a point at which care will transition from supporting the patient to supporting the organs. This is still good care. There is an alignment of parallel intentions – first and foremost resuscitation of patients and then failing that, proceeding to considering and actioning organ donation. This is important due to th

Greg Kelly focuses on transferable skills from adult practice applicable to the collapsed neonate, taking us first through a systematic approach to the common underlying causes and the physiology behind them. He outlines a comprehensive approach to the clapped out baby even when the underlying cause isn't immediately clear and reassures us that there are plenty of simple interventions we can undertake.