Smacc

Flavia Machado gives you the ins and outs of a day in the life of an ICU doctor working in Brazil. She addresses healthcare inequality, ethics, and the challenges she faces in a developing country. By sharing a blow-by-blow account of a day at work, Flavia demonstrates the challenges and inequality that exists. And whilst poverty is shocking, Flavia believes inequality is worse. Flavia’s day begins in the morning with a ward round. Critical bed shortages mean that the clinicians have to make impossible decisions – which patients will get allocated one of the scarce beds? At 07:00am every morning, Flavia and her colleagues in the ICU have to play God. Inequality is plain to see. It is graphically depicted when looking at a map of the distribution of ICU beds across Brazil. In the north, an area of greater disadvantage, there are far less ICU beds per capita. Flavia continues her day, but the challenges do not stop. She checks WhatsApp later in the morning and is inundated with issues pertaining to medication s

Dr Anne Creaton talks about the healthcare capacity building in Fiji. Fiji was struck by Cyclone Winston in 2016. It caused widespread devastation and the impact will be felt for a long time in the future. The most important thing that Fiji has taught her is faith, patience and persistence. Anne begins by talking about the three Rs that are essential in trainees who want to work in Fiji or similar situations. The three Rs being: Realistic, Resilient and Resourceful. Emotional intelligence is also very important. Most of the people are highly trained, but always in a high resource environment. Dysfunctional systems in places like Fiji, can impact the clinician’s welfare and performance. Critical care systems are made up of multiple building blocks with doctors playing a small part. Anne compares critical care systems in Fiji to a game of Jenga. This is because multiple blocks that are essential for critical care systems are non-existent.  Anne divides the Jenga blocks of a critical care system into three: a pr

The paediatric airway terrifies many of us: at the smaccMINI paediatric critical care workshop, Fran Lockie explores some real-life examples of airway challenges and considerations. He takes us through the concept of the "airway bundle" and how teamworking and communication is key to improving paediatric airway care, emphasising the concepts we can borrow from adult practice to offload some of our cognitive burden and outlining the key components of first-class post-intubation care, with pitfalls and pearls of wisdom from his experiences as a prehospital clinician. Phil Hyde follows on with the nuance of assessing paediatric ventilation, starting with simple interventions and exploring the factors that make big differences for children in respiratory distress.

Andrew Chow gives a rapid breakdown of malignant cerebral artery (MCA) infarction and the utility of decompressive craniectomy. An MCA infarction is an ischaemic stroke, affecting the total or subtotal area of the MCA. It involves the basal ganglia (at least partially) and may involve the adjacent territories. The incidence is 10-20 per 100 000 and there is a high mortality rate of up to 80%. Early clinical symptoms of MCA infarction are contralateral hemiparesis, gaze deviation and hemisensory neglect. A malignant infarction will then progress to severe headache, nausea and vomiting, papilloedema and reduced consciousness. The pathophysiology underlying these clinical signs is complex and involves a failure of sodium pumps, leading to cellular swelling, metabolic failure, tissue necrosis and breakdown of serum products. So, how do you predict who progresses to a malignant MCA infarction? Andrew will guide you through the three domains to consider: Radiological, clinical and pathological. From there, the mana

Natalie Thrutle educates on the critical issue of lead poisoning in developing countries. Critical care means different things to different people. In the context of lead poisoning, you may or may not think of developing countries such as Nigeria. The response to the Zamfara state, lead poisoning outbreak, in Northern Nigeria, is unprecedented and requires a nuanced interpretation of ‘critical care’. In 2010, 400 children died from lead encephalopathy in the largest lead poisoning outbreak ever recorded, affecting more than 5000 children in Zamfara. The outbreak is ongoing. Children were presenting with intractable seizure and coma, not responsive to treatment for malaria and meningitis. 50% of these children were dying. Environmental poisoning was considered early on, due to the high levels of artisanal gold mining in the area. This increase in mining was a major economic boom to a remote and rural population much in need. MSF had never dealt with a lead poisoning outbreak before… neither had the Nigerian g

Nikki Blackwell tells her story of the emergency response to the Ebola outbreak in Nzerekore, Guinea. She chronicles the enormous challenges of providing care to some of the most vulnerable people in the world, in one of the most under resourced and challenging environments. The Ebola virus was first isolated in 1976. Between then and 2013 there were twenty outbreaks of Ebola. However, the outbreaks, although vicious, were relatively small and in isolated areas. This outbreak was by far the most complex, with a mortality rate of up to 40%. The fruit bat is the natural host and reservoir of Ebola. They transmit it to other animals, and ultimately humans. Human to human transmission occurs from body fluids, mucous membranes, and sexual contacts. Nzerekore, Guinea has a terrible health service and infrastructure stemming from a long period of conflict. This is further exacerbated by the scarce number of doctors. Further, what compounded the problem even more was the delayed recognition and action from the intern

In this podcast, Mervyn Singer talks about the link between stress and multiple organ failure. Often, the organs involved in multi-organ failure show no signs of structural damage or cell damage that would indicate these organs might be under stress. Stress might cause functional damage rather than structural damage. Stress is a normal coping mechanism which helps to deal with the various stressors we encounter. These mechanisms include changes in behaviour, as well as autonomic and hormonal modulation of various systems. These include inflammatory, immune, cardiovascular, respiratory and metabolic systems. Human bodies are not designed to cope with the stresses of prolonged life. These stresses include old age, co-morbidities, prolonged critical illness, modern lifesaving drugs, and organ support. Mervyn discusses the evolution of various theories associated with stress. Walter Cannon discovered acute stress response in 1915 when he noticed the manifestation of nervous exhaustion as physical illness in soldi

Jon McCormack gives you what you need to know in the case of paediatric blunt traumatic cardiac arrest. This is a rare but deadly occurrence. Data shows that the population incidence for paediatric blunt traumatic arrest is 1 in 100 000. Of these, most are male, and most are involved in vehicle traffic accidents, along with falls and non-accidental injuries. The median age is 7 years old. The injuries are severe, and the survival numbers make for grim reading… around 1%. So, the numbers are low in both incidence and survival. However, the cases can be deeply personal and effect the clinician and bystanders for a long time. With that being the case, coupled with the enormous upside both socially and economically, surely emergency care should “go all in”. Jon explains why this is the wrong approach. He discusses the reality of the presentation of a paediatric blunt traumatic cardiac arrest. He advises to limit unnecessary treatments and risks to yourself and team. There are potential survivors. Children who mai

Stephen Bernard shares his thoughts and the current evidence for using oxygen for cardiac arrest patients. Oxygen is ubiquitous in society! You can buy it in bottles and there are even oxygen cafes. This is especially true in hospitals where oxygen is used frequently and often without much thought. Oxygen is a natural substance. So surely, a short time on 100% oxygen can’t be harmful, right? Stephen wants to challenge that idea. In this talk he presents the data on why oxygen might be harmful to your patients, particularly following a cardiac arrest. Out-of-hospital cardiac arrest (OHCA) is common and carries a high mortality rate. In Victoria, Australia, approximately 50% of patients with an initial cardiac rhythm of VF achieve a return of spontaneous circulation (ROSC) and 30% overall survive to hospital discharge. The outcome for patients is improving. This is due mainly to faster ambulance response times and increased rates of bystander CPR. What is done in the hospital has altered the patient’s outcomes

John Myburgh speaks passionately about the use of oxygen in resuscitation, and clinical outcomes in critical care. For the 30 years, clinical understanding of haemodynamic resuscitation has been based on physiological paradigms that focus on convective oxygen delivery. Most of these emphasise the role of cardiac output, haemoglobin and recommend interventions using synthetic agents such as dobutamine, synthetic colloids and blood transfusions. However, markedly influenced by industry, these interventions and strategies hijacked critical thinking creating a belief in the utility of attaining short-term physiological surrogates for resuscitation that have little relevance in improving patient-centred outcomes. This ‘physiological fallacy’ has been demonstrated in high-quality RCTs of fluids, goal-directed therapy and catecholamines, that paradoxically inform the interpretation of new insights in the physiological basis of health and disease. In this talk John presents two halves. In the first half, he discusses

Scott Weingart discusses the scientific aspects of meditation. He believes meditation is to the mind what exercise is to the body. There are two types of meditation: focussed attention meditation or vipassana, and contemplative meditation. Generally, people exist in a default mode network. This happens when we are not focussed on anything in particular and thoughts occur in our brain without us being aware of it. Spending a few minutes every day aware of what thoughts are occurring in our brain is highly beneficial. This helps with stress control, relaxation response control, slowing of telomere degradation, control over emotions and increased concentration. Scott, however, wants us to focus on a single objective benefit of meditation - controlling the stimulus-response gap. Viktor E. Frankl explains - “Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” Meditation helps to choose our responses to stimuli, both go

Paul Young discusses remote ischaemic preconditioning and along he delves into the pitfalls of clinical research. 2016 was the 30th anniversary of ischaemic preconditioning. Remote ischaemic preconditioning is the magical offspring of ischaemic preconditioning and refers to the phenomenon whereby brief periods of ischaemia in one organ can protect other organs from subsequent prolonged ischaemic insults. Ischaemic preconditioning rose to prominence after a seminal paper in 1986 that demonstrated the protective effects of ischaemic preconditioning in dogs who had coronary ischaemia. This effect had been appreciated in humans. For instance, pre-infarct angina leads to smaller infarcts that in heart attacks without preceding angina. Remote preconditioning is for more magical. Paul takes you through the basics. The idea is simple enough. Blockage to one site leading to ischaemia preconditions another site to subsequent ischaemia. This was first demonstrated by blocking the circumflex artery in the first instance

Marius Rehn examines the difficulties and importance of evidence based medicine in prehospital resuscitation. Notably, combining academic activity with pre- and in-hospital clinical practice is hard work. Being an academic in a flight suit can be quite lonely. Marius wants this to change and is passionate about increasing the quantity and quality of prehospital research. Prehospital research that examines patient pathophysiology should dictate care – as it does in the hospital environment. However, Evidence based practice pertaining to the prehospital environment is minimal. This needs to change. Evidence based medicine in the prehospital setting can dictate care, critically appraise practice and enable improvements in process and cost effectiveness whilst decreasing harms. Evidently, in-hospital evidence is different to the field application. Ultimately, prehospital research is critical, 5.8 million people die from injury every year – around 10% of the world’s deaths. Unfortunately, pre-hospital research is

Anand Swaminathan brings precision emergency medicine and outcomes in critical care into the light. He will convince you to start calling diseases for what they are and as a result start offering the proper treatments and care. All disease exists on a spectrum. You can’t treat one end of the spectrum the same way you treat the other end. This talk is inspired by a case of Anand’s. An older man presented to the ED with acute onset shortness of breath and crackles. He was treated with Lasix. More and more Lasix – even though he wasn’t improving. Anand knew this presentation was more than just an exacerbation of heart failure. This was acute pulmonary oedema and this man needed a different treatment. Disease is on a spectrum with ‘urgent’ on one end and ‘critical’ on the other. The umbrella term that identifies the disease needs to be spread out so that it can be placed on this spectrum by you and others around you. Calling a presentation an exacerbation of CHF when it is in fact acute pulmonary oedema is wrong

Sue Mason gives you her take on Geriatric Emergency Medicine. Sue’s bread and butter is managing the elderly in the Emergency Department. It is not a sexy topic and there are few gizmos and gadgets. Nevertheless, it is very important. How big is the problem? Patients over 65 years represent about a quarter of the patients that attend Sue’s Emergency Department. However, most of these patients arrive by ambulance and the vast majority of visits in this age group are deemed necessary. This culminates with 50% of these patients being admitted. Attendance and admissions in the elderly age group are both going up. What are we doing about it? Advances have been made in prehospital care. In Sue’s region, paramedics have been trained in assessing and managing elderly falls. This found a reduction in ED attendance by 25% and decreased admissions by 6%. Approaching the management of the elderly with a multidisciplinary team has proved to be effective in a ward setting. This has not been replicated in the Emergency Depa

Dr Michelle Johnston talks about dystopian futures and the relevance of emergency medicine in forming such futures. Literature can provide insights into the two types of future we can expect: an optimistic, technologically advanced future as showcased in the movie “Blade Runner” or a dystopian future as envisioned by George Orwell in the novel “1984”. She discusses how different authors have written along similar dystopian themes with government controlling all aspects of human life. Some examples are novels like “Brave New World” by Aldous Huxley and “The Handmaid’s Tale” by Margaret Atwood. Or, “The Hunger Games”, “The Maze Runner”, and movies like “Brazil”. The common theme of these stories is oppression of the individual, non-existence or illusion of freedom, poverty, and police societies. Michelle believes that dystopian literature is based on the tiny fears of individuals and how they react to it, shaping the future. Therefore, she asks the question: what are the things that we do today that might lead

Mike Abernethy runs you through the pitfalls and challenges of rural trauma resuscitation and prevention. The farm is a dangerous workplace. Accidents have an unusually high morbidity and mortality not only for the worker, but also his/her family members. The reasons are multi-factorial but are the result of a complex interaction of environment, equipment and human factors. The vast majority of agricultural deaths involve tractors. No other industry uses 70-year-old machinery operated by workers whose age ranges from 10 to 90. How can we prevent such incidents? Mike is a prehospital physician (who is a wannabe farmer & tractor mechanic) and long-time resident of an agricultural community. In this talk, he will examine the details of a life-threatening accident involving one of his neighbours which perfectly illustrates the multifaceted nature of agricultural trauma. He will then discuss agricultural trauma more broadly. The statistics are similar across the globe, from the United States to Australia, Camb

Dr Simon Carley discusses the future of emergency medicine. Simon begins by talking about how things have changed in emergency medicine since he started his career in the 1990s. He wants to shed some light on where we are going with emergency medicine, what is happening to us and what is shaping us. He believes that predictions about the future, as shown in movies like Back to the Future, might not always come true but they certainly provide clues as to what is possible. According to Simon, three major factors influence the future of emergency medicine. The first factor is the people. Population predictions show that life expectancy has gone up, leading to an increase in the number of elderly people. As the age of the population increases, the age of the people dying due to trauma becomes older. This changes the approach of emergency medicine. Moreover, the age of the workforce in medicine is also increasing. Simon believes that the rigid systems must change to encourage the next generation of healthcare work

A Tribute to Dr John Hinds, Dr Janet Acheson speaks about her life with Dr John Hinds and how unexpected his death was. John Hinds was known as the pioneer of pre-hospital trauma, a master educator and powerful orator. He was “son” to his mother Josephine, “John boy” to his father Dermot and “John” to his friends and family. John Hinds inherited his meticulousness from his mother and sense of adventure from his father. Janet speaks about different lectures given by John Hinds during which he coined the term #ResusWankers and spoke about cricoid pressure and Cricolol.  She speaks about “Johnisms”, thoughts that she and John shared; find your people and acquire memories of life; do not let wankers bring you down, learn from your mistakes and finally, make your intentions honourable - the patient is the centre of everything. She requests the audience to help trend #WhatWouldJohnDo. Dr Fred MacSorley, a good friend of John Hinds, talks about how promising and talented John Hinds was when he entered the field of a

Dr Ashley Shreves discuses palliative care and critical illness. She begins by talking about a case she feels she mishandled during the initial days of her career. How she was unprepared to handle an end-of-life case efficiently. She goes on to enumerate the multiple specific challenges, a knowledge of which would have helped her handle the case more competently. First - One must identify the dying trajectory i.e., use the background information to check the viability of the patient. Second - Undertake a capacity assessment of the patient to ensure how much of the current situation they understand. Third - Check for advance directives where a patient has already given instructions regarding their end-of-life care. Communicating to the relatives and/or the patient regarding the imminent death is another challenge in end-of-life care. Proper communication regarding the withholding or withdrawal of life sustaining treatment (LST) to the patient is also very important. Another crucial aspect is knowing the ri