SMACC

SMACC

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Podcasts and media from the Social Media and Critical Care Conference (SMACC)

Episodes

Don't DSI...Rapid Sequence Airway (RSA)! - Darren Braude  

Rapid Sequence Airway (RSA) involves the same preparation and pharmacology as RSI with the immediate planned placement of an extraglottic device (EGD) instead of intubation. Like DSI, RSA is an alternative airway management strategy that may be ideal for preoxygenation of hypoxemic patients as well for prehospital and in-flight use. Depending on the chosen EGD, RSA can facilitate gastric decompression, positive pressure ventilation with PEEP delivered by a ventilator and endoscopic intubation. The speaker presents the evolution of this novel concept in New Mexico, reviews their clinical experience with RSA in both the prehospital and hospital settings and assesses the available literature.

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DAS Guidelines Explained - Ellen O'Sullivan  

Airway management is a fundamental responsibility and skill of all involved e.g. emergency physicians , anaesthetists and critical care physicians. We need airway algorithms because there is still severe morbidity and mortality related to airway management. (NAP 4 study, ASA Closed claims series)

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 be used when tracheal intubation fails. They are designed to promote patient safety by prioritising oxygenation and minimising trauma and 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) for maintaining oxygenation, limiting the number of airway intervention attempts, encouraging declaration of failure by placing a Supraglottic Airway Device and overtly recommending a time for stopping and thinking. They emphasise the importance of considering discontinuing anaesthesia and waking the patient up (if appropriate) when tracheal intubation has failed.

Videolaryngoscopy and second generation Supraglottic Airway Devices are recommended and all anaesthetists, intensivists and emergency medicine physicians, should be trained to use them. There is however limited evidence available relating to the management of the can’t intubate can’t oxygenate situation (CICO) PLAN D. However it is strongly recommended that all anaesthetists must be trained to perform a surgical cricothyroidotomy and a standard operating procedure for Front of Neck Access to the airway is described using a “scalpel bougie tube” technique.


Learning Objectives
• Importance of optimal preoxygenation.
• Best technique at laryngoscopy.
• Maximum of 3 attempts at laryngoscopy / intubation.
• Maximum of 3 attempts at placing a Supraglottic Airway Device.
• When tracheal intubation fails, waking the patient up is almost always the safest option.
• All practitioners involved in airway management need to learn the “scalpel bougie tube” method of cricothyroidotomy.

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Leisurely Laryngoscopy: Best Practice Technique for Airway Success - Reuben Strayer  

In the past two decades, airway management has been revolutionized 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, whether or not the operator uses a blade with a camera at the end. In this presentation, we break down laryngoscopy into its discrete components and describe best practice technique at each step. We will start by describing common mistakes made in patient positioning; proposing a set of parameters the provider can use to guide positioning that is optimal for laryngoscopy, including the configuration of the patient in the bed, the bed height and head elevation, as well as provider stance. We then move into the effect of laryngoscope grip on operator catecholamine management and describe the optimal laryngoscope grip for emergency airway management. We next confront one of the core principles of RSI, the delay between medication administration and commencement of laryngoscopy, and propose an alternative approach that emphasizes early laryngoscopy with deliberate slowness. We turn our attention to the value of the jaw thrust–as performed by an assistant–during airway management, and then move into a step by step analysis of laryngoscopy as the blade moves into the mouth, down the tongue and ultimately to the glottis. We espouse suction as an underutilized device by emergency providers, and describe the two most important intra-laryngoscopy optimization maneuvers: optimization of the position of the head, and optimization of the position of the larynx. We discuss the value of using the gum elastic bougie for both difficult and routine intubations and describe pitfalls encountered when using the bougie (and how to manage them). We conclude by describing the 3-finger tracheal palpation method of endotracheal tube depth confirmation.

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The Greatest Presentation in the World… Tribute - Ross Fisher  

Delivering a presentation is a skill like any other yet few folk are actually develop this skill they merely copy those they observe and reach the same level of mediocrity. There is more to a presentation than your slides. The p cubed concept gives an understanding of presentation design that will change your presentations forever.

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Prick with a Needle - Suman Biswas  

Musical genius Suman Biswas (@amateursuman) gave one of the most popular talks at SMACCDUB: A Prick with a Needle. The Anaesthetist from London, probably more famous for his satirical songwriting career, gives a poignant talk about communication.

Punctuated with some classic songs and delivered with his stand-up comic timing and panache, this is what SMACC is all about: an important message that could change your practice, delivered in a unique and unforgettable way.

Language warning.

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The FemInEM Story - Dara Kass, Jenny Beck-Esmay and Stacey Poznansk  

We accept that knowledge translation is critical to the practice of emergency medicine, yet when it comes to the practice of BEING an emergency physician, we do always practice evidence-based medicine. We realized that the experiences of many female emergency physicians were similar but not shared, so we created an open access resource to address that. FemInEM was born out of the real but unfortunate truth that the gender pay gap is alive and well, and promotion of women through the academic pipeline is slow and women still experience unconscious bias at all levels of development. Malignant behavior runs rampant within medical training, and women are disproportionately affected by this reality. In addition, balancing work life and home life can pose extra challenges, especially for women. Numerous studies have shown even when working full time, women often carry more of the “care based” workload for home and family, compounding the “work-life conflict” felt by physicians regardless of gender.

We will share the journey of how FemInEM began as a blog but evolved quickly into a centralized resource for women needing advocates and champions. We will tell stories of how we are helping to change the conversation related to gender and equity in EM by highlighting the successful practices and programs in an open access format. By using the principles of FOAM and the power of social media, we are trying to move the needle on gender and medicine in a way that hasn’t been done before.

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How Medical Students Can Choreograph Their Own Education - Sandra Viggers  

More than a hundred years ago Osler moved medical education to the bedside. Somehow today, most medical education still takes place in the lecture hall far away from patients.

Medical education is often thought of as a top to bottom process where experienced professors and clinicians provide information and feedback to novice learners, with the goal of increasing knowledge and adjusting behavior.

This approach to medical education can be effective, but may also only provide situational learning making what is learned in school today, outdated tomorrow.
Creating an environment where students can learn reflective practice that can evolve with them as they move from novices to experts may prevent situational experts and facilitate expert performance.

The continuous changing nature of modern healthcare also demands that students from an early educational age are provided with the skills needed to learn, work and adapt within a continuously evolving environment. These skills aren’t traditionally taught in medical school as learning in context is limited.

Therefore, the future of medical education should focus on helping students develop the skills needed to become their own learning choreographers who take responsibility for their own education, not only as students but also as lifelong learners as part of their continuous medical education.

The purpose of the talk is to answer some of the question that may arise when you allow medical students to choreograph their own education. How this process can be started with you as the educator, and can be done without compromising patient safety and maybe even improve patient outcome.

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Playing the Long Game: Commitment, marginal gains and self-compassion - Tom Evens  

Caring for the critically unwell is an important and difficult task. So preparing our people to meet this challenge should be all about excellence.

Too often, the structures and pressures that define medical training focus on competence rather than excellence. Competence is measurable. It can logged, assessed, and can be applied to across big organisations. But aspiring only to competence limits us - our patients need more. So can we learn from how other high-performance organisations train?

For Olympic teams, aiming for competence just isn’t good enough. These organisations develop their athletes over many years - equipping them, ready to deliver an excellent performance under pressure.

Successful coaching relationships operate on an individual level. They are long-term. They are flexible. And they are measured not by exams or assessments, but by whether the person being coached can perform in the real world.

Should you be thinking about being a coach rather than a trainer? And how can we move our focus from competence to excellence?

This talk will explore three aspects of high-performance coaching which have relevance for clinical educators:
⁃ Goal setting and commitment
⁃ The value and limitations of marginal gains theory
⁃ Self-compassion as a tool for achieving excellence.

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Prehospital care, how do I get trained properly, panel discussion - Gareth Grier  

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

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Going Wild: Lessons from Wilderness Medicine - Ross Hofmeyr  

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. Diagnosis in the wilderness relies heavily on clinical examination skills, monitoring and special investigations are very limited, and treatment options are determined by the breadth and depth of the individual practitioner’s hands-on skills. 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. In this presentation, Ross shares trials and tribulations and draws on experiences from wilderness rescue, and expeditions around the world, which provide lessons for wilderness medics. Many of these lessons can be translated to insights into practicing better acute and critical care medicine in our day-to-day settings.

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Oh s**t, they’re bombing our hospital! Is this a new paradigm for war? - Kathleen Thomas  

After five months working in the ICU and ED of the Médecins Sans Frontières run Kunduz Trauma Centre (KTC) in northern Afghanistan, I found myself caught up in an eruption of war as 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 our 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, we believed the hospital was the safest place to be, as both warring parties had agreed to respect the protection provided to us under International Humanitarian law.

My work in KTC came to a grinding halt when a US Gunship fired over 200 missiles into our hospital, destroying the main building and killing 42 people including 14 of my colleagues. It was a scene of nightmarish horror that will forever be etched in my memory.

Since returning from Afghanistan, I have watched in shock as hospital after hospital in both Syria and Yemen has been bombed. Over 250 hospitals in Syria and 130 in Yemen have been attacked since the beginning of their respective conflicts, cataloguing a growing disregard for the rules of war. Despite the condemnation by the UN, the attacks on medical facilities continue, unabated.

Following an eye witness account of the attack on KTC, I will look more globally at the trend in hospital bombings, asking some important questions: Is international humanitarian law no longer respected by warring parties? Are we entering into a new paradigm of war where hospital attacks are a legitimate military tactic? What does this mean for the future of critical care delivery in war zones across the world?

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PURE: Point-of-Care Ultrasound in Resource-limited Environments - Trish Henwood  

The World Health Organization notes that 80-90% of all diagnostic problems could potentially 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 (1).

From refugee camps in Greece, to rural clinics in Australia, to Everest Base Camp, point-of-care ultrasound 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, and to ensure safety in performing procedures with real-time image guidance. For example, POCUS training just allowed a midwife to identify a massive amount of free intra-abdominal fluid in the 30 year-old Ugandan mother presenting to gynecology clinic with her third pregnancy and new abdominal pain. She notified the surgeon of her concern for a ruptured ectopic pregnancy and the patient was immediately taken to the operating theatre, and she survived. She related that before her ultrasound training, her practice of sending this patient to town for an ultrasound evaluation by the only radiologist in the district would have delayed definitive care, and may have resulted in death.

When I worked in an Ebola treatment unit one of my favorite patients who had been doing well suddenly spiked a fever to 40 degrees Celsius. His abdomen became rigid and I had no idea why. In a setting where no other imaging was possible, POCUS allowed me to see that there was an unexpected issue with his bowels. That knowledge led me to start him on antibiotics, and adjust care plans after I found similar in several other patients.

Ultrasound machines have become increasingly portable, user-friendly, and less expensive over the last decade. This is resulting in a growing presence in otherwise austere environments. POCUS trained clinicians can afford imaging capacity to health facilities that may have very limited on-site diagnostics. There is no ionizing radiation, nothing invasive, and it is cost-efficient (2,3). Human resources are consolidated; the clinician is the diagnostician. POCUS provides the potential to quickly narrow differential diagnoses by facilitating a look inside the body during the patient encounter, and research studies support its use to solve information gaps in resource-limited settings (4-10). Moreover, the potential for this digital technology to be shared – and to leverage global expertise and consultation – increases the range of application beyond one individual’s knowledge base.

References
1. World Health Organization Medical Devices: Managing the Mismatch, 2010. Accessed March 20, 2016. Available at:
http://apps.who.int/iris/bitstream/10665/44407/1/9789241564045_eng.pdf

2. Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest 2013;143(2):532–8.

3. Adhikari S, Amini R, Stolz L, Blaivas M. Impact of point-of-care ultrasound on quality of care in clinical practice. Reports in Medical Imaging 2014; 7: 81-93.

4. Sippel S, Muruganandan K et al. Review article: use of ultrasound in the
developing world. International Journal of Emergency Medicine 2011; 4:72

5. Henwood PC, Beversluis D et al. Characterizing the limited use of point-of-care
ultrasound in Colombian emergency medicine residencies. International Journal
of Emergency Medicine 2014; 7:7

6. Deng D, Mingsong L et al. Ultrasonographic applications after mass casualty
incident caused by Wenchuan earthquake. Journal of Trauma 2010; 68: 1417-20

7. Fagenholz P, Gutman JA et al. Chest ultrasonography for the diagnosis and monitoring of high-altitude pulmonary edema. Chest 2007;131(4):1013-8

8. Shah SP, Epino H et al. Impact of the introduction of ultrasound services in a
limited resource setting: rural Rwanda 2008. BMC International Health and
Human Rights 2009; 9:4

9. Kotlyar S, Moore CL: Assessing the utility of ultrasound in Liberia. J Emerg
Trauma Shock 2008; 1(1): 10-14

10. Stein W, Katunda I, Butoto C: A two-level ultrasonographic service in a
maternity care unit of a rural district hospital in Tanzania. Trop Doct
2008; 38(2): 125-6


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The Aorta Will %$#@!& You UO - David Carr  

The talk focuses on why clinicians miss the diagnosis on aortic dissection. It 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 can not afford to miss. The talk aims to give you the framework to avoid missing the diagnosis. I want to raise the bar so that the standard of care is not to miss a dissection when it presents atypically. The talk will also highlight strategies on what to do when you suspect the diagnosis. It will guide you to order the right imaging tests and begin the treatment promptly. Sit back and be ready to see dissections in a different light.

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Who should be intubated pre-hospital - Gareth Grier  

Gareth Grier discusses who should be intubated following severe trauma pre-hospital.

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Pre oxygenation, the powerful pawn in Prehospital RSI - Dr Geoff Healy  

This talk will look at current and previous pre oxygenation practices and some of the current research. It will also discuss the notion of commitment to evolution of practice, the breakdown of cognitive biases and how to move forward with adequate self reflected practice.

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Teamwork: The strongest drug in the hospital - Peter Brindley  

Modern acute care medicine is eye-wateringly complex and potentially dangerous. It really can't be delivered safely without deliberately addressing our teamwork (in both acute and chronic situations). Unfortunately, historically, human factors were commonly left to chance, and recently have been threatened by decerebrate checklists and meaningless psychobabble. Practical strategies exist (thank goodness!) and will be reviewed. We have much to learn, but must also avoid overly simple answers to exceedingly complex problems. It's time to get back to basics and away from the BS. Come be part of a practical revolution

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Prehospital red blood cell transfusion - is it enough? - Richard Lyon  

Richard will cover the rationale and evidence for prehospital blood product transfusion in trauma, look at the available current and future options, suggest best clinical practice and highlight areas of future research.

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Management of extra-cranial injuries in patients with TBI - William Knight  

Patients with TBI (traumatic brain injury) often have concomitant systemic injuries that complicate the management of the TBI. How does the practitioner balance the needs of the hypotensive resuscitation with CPP? How does ICP affect emergent operative needs? Thoracic injuries complicate cerebral oxygenation - are there effective management strategies? Where is the best place to care for these patients?

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Hospital Handover of Major Trauma - Make them Listen - Kieran Henry  

Describing the importance of patient handover and the critical time when the pre-hospital practitioner will give this information to the receiving hospital staff. Using an analogy of the characters that appear in cowboy films, the preacher stands out as one who usually plays a small but significant role in getting his message across. We will compare this to the modern day practitioner and how they should achieve the objective of giving a good handover to the receivers, who may or may not be believers

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