After a fabulous first day and a very good dinner at the Quay restaurant in Sydney we are back at the ICC for day 2.
The big announcement of the day was the news about CODA. We all knew that the end of SMACC was not a finality, but rather a change of direction. CODA is a colaboration between SMACC, the George Institute and the NEJM to use the power of social media, the innovation and community of SMACC to tackle major health issues. This is seriously ambitious stuff, but the collaboration of these groups can really do some amazing work beyond the critical care, anaesthetic, prehospital and emergency medicine communities. St Emlyn’s are keen to support this and to help promote it’s ideals. You can read more about CODA here https://codachange.org/
Session 1: Science and Innovation
We’re kicking off with science and innovation hosted by our good friend Peter Brindley.
The 80/20 rule, time horizons, circadian rhythms, productivity vs activity, breaks, rest, prioritisation, distractions, and more were all addressed to try and makes us more productive. I’ve heard a lot of this before but it was very well presented by Phil Dobson from brain workshops http://www.brainworkshops.co.uk/phil-dobson/
Sara Nolet from AgThentic asked some difficult questions about the consumption, transport and safety of food. It’s alarming to hear about the way that food is going to have to change in future years as the world may not be able to keep up with consumption. What we have now is not enough.
As a HUEL fan, I was really interested in this talk as I’m increasingly aware of the impact of humans on the environment through the way that we create and distribute food. You might ask why this is relevant for a critical care conference. I think there are two reasons. Firstly that we can see examples of how a potential crisis can drive creativity, especially through the use of start ups and true innovation. We should try and do the same in medicine.
Glen Singleman returned to a theme that has run through all of the SMACC conferences, that of cognition, bias and risk. He’s a crit care doctor and thrill seeking free fall parachutist. Not necessarily a natural mix you might think, but perhaps it is. He talked about how we can manage a little more rationally than we do at the moment.
I covered a fair amount of this back at a previous SMACC on this Gestalt talk. https://www.smacc.net.au/2015/11/guess-or-gestalt-by-carley/
It was an interesting talk, but went a little over time so I’m not sure we really found a conclusion.
Simon Finfer, Hallie Prescott and Carol Hodgson addressed the issues of clinical triallists and the rationale and need for us to continue to pursue new evidence. This really links up with the CODA idea in that we need to integrate the teaching, learning and innovation of SMACC into primary clinical research. I know that’s an aim and I really hope it continues in that direction.
So the first session of the day was very much about looking forward as to how we might practice in the future. Some of it is clearly inspirational and aspirational, but is interesting to pause every so often and think about where we are going.
Session 2: Bedside Critical Care
Another ‘Road to Resus’ session that took the case from yesterday to the next level. Our seriously injured patient is now in the ED and there are more decisions to be made. Key decisions today were to use the bougie in ED intubations (as a general rule) and that Rocuronium is better than Sux.
We also had to decide whether to take a hypotensive and unstable patient to the OR or via CT. So the decision which I would agree with. The only safe place to be so long as you have a competent trauma surgeon.
Caroline Leech is a great friend of St Emlyn’s and previously trained in Virchester. Now she has forged an incredible career as prehospital lead for the Midlands in the UK, as a lead educator and researcher in the faculty of prehospital care, and as an emergency physician at the UK’s busiest trauma centre.
Today she spoke on hypotensive mimics in trauma. I think this is a great topic having been caught out myself in the past when we assume that all hypotension is a result of trauma. Caroline advocates a mental checklist to ensure that we don’t miss the mimics and to not assume that all hypotension is bleeding. Another way of thinking about this is that the physiology you see does not define a specific anatomical injury.
Haney Mallemat is another friend of the St Emlyn’s team and a great educator in the #FOAMed world and as a conference presenter. Today he took on the crashing asthmatic, a group of patients who can be absolutely terrifying when considering advanced airway management. Starting with a talk based on a real case where a patient died (many of us have seen this) it really focused our minds on how risky these patients can be, and that they are still dying in our EDs. Haney talked about the difference between the tired and the tight asthmatic, they require different management techniques.
There was a bit of controversy about some elements. Vent settings were probably more aggressive than we manage in Virchester and we are ECNO rather than ECMO so that’s not really an option for us here.
Hallie Prescott returned to the stage to talk about the uncertainty that exists in the centre of sepsis. In a similar theme to Caroline’s talk this was about using thought and wisdom to tailor and specify our interventions to the patient in front of us and not to just go with the flow chart.
I particularly like this graphic from Cliff Reid via Alex Psirides. It kind of sums up where we are in the balance between restrictive and punitive guidelines vs. nuanced and patient specific approaches to Sepsis.
So. Another great session. A good blend of aspirational and creative thinking in the morning and then a focused clinical session in the latter half of the morning.
The great fluid debate
Paul Young, John Myburgh and Todd Rice came together to discuss the management of fluids in critical care. These three are some of the leading researchers in the world on critical care, and especially fluid management in critical care.
Interesting to listen to the panel who really had a nuanced approach that again fitted a theme today that we cannot rely entirely on fancy tests. Clinical history and examination are still core elements of our practice. The decision on the use of USS was interesting. Neither panelist stating it to be that helpful at this stage, but that’s not what the twitter poll thought. Unsurprisingly twitter were USS positive, but twitter does not represent the real world!
There was consensus that balanced crystalloids are better in sepsis, but the evidence if not as yet perfect. John Myburgh points out that there are no great fluids, so caution is required.
Moving on when the patient is now on the ICU and getting heavier, but intravascularly depleted. The waterlogged patient in other words. John Myburgh still in the clinical camp. Get them awake and get them to pee it out!
Loved this from Dave, and I agree 😉