I’ve been in Melbourne for two days already, first for a day of ultrasound workshops and then the virtual PEM workshop yesterday. Both were excellent and I might share some reflections from those experiences in a separate post.
This post contains some of the learning and reflections from Day 1 of ICEM 2022 in Melbourne.
The day kicked off with a Welcome to Country from a Wurundjeri woman – if you’ve never heard of this before, it’s a really important part of gatherings in Australia. Welcome to Country can be performed by first nations people; in meetings where none are present, you can share an Acknowledgement of Country instead. The purpose is to recognise that the lands we meet on are lands of traditional custodians, the first nations people of Australia – recognised to be the longest continuous culture on earth – and to pay respects to elders past, present and emerging. First nations people welcome visitors to their lands through dance, song and symbolism. Incorporation of this welcome or acknowledgement is hugely important in the reconciliation of Australia’s people and in recognition of the damage caused to the First Nations people during colonialism and beyond. Today, we are meeting on Aboriginal land. You can find out more about Welcome to Country (and Acknowledgment of Country) here.
The first session of the day was focused on Global Health and Emergency Care; specifically, COVID-19 lessons for Emergency Care and the Public Health response.
Kamalini Lokuge brought an Australian perspective on the social determinants of health. The foundation of all successful public health, she says is trust – between governments and people. The social contract is not the same with those experiencing the most social disadvantage. During the peak of transmission in Melbourne, the most COVID affected regions were also those with the highest levels of social disadvantage. Early in the pandemic, this paper was published – and subsequent transmission followed its predictions very closely (to the apparent surprise of government). She spoke passionately about the role of healthcare providers as patient advocates in the context of public health – “my patients needed me to fight for them not to have gotten sick in the first place.”
Worldwide, with high-risk pathogen control we know all components of response rely heavily on community compliance and as such, lack of trust leads to public health failure. It is no surprise, then, that those people with uncertain employment, financial instability and structural disadvantage, who already have poor trust of government and societal authority figures, suffer worst. Surveillance, case investigation, contact tracing all rely on trust. Public health measures must be embedded in the provision of healthcare, rather than being perceived as surveillance instituted after the outbreak.
So what does she think this means for the health system? Firstly, we should increase preventing health budget and turn off the tap. Secondly, structurally disadvantaged communities must be part of leadership. However, many of the broader determinants of health lie outside the health system.
On a day-by-day basis, what does this mean for Emergency Medicine doctors? She urges us to use our power to provide care but also to address the drivers that cause disease. That might mean pausing when we see frequent attenders to consider the underlying structural determinants of health contributing to their attendance, and using our voices to speak out in politics.
Lee Wallis spoke about COVID’s impact on low and middle income countries. We already know that excess morbidity attributable to emergency conditions is the highest in low income countries. Even towards the end of 2021, COVID continued to disrupt health services in pretty much every country across the world. As COVID went on, access to Emergency Care became more disrupted. About twice as many countries reported service disruptions for ambulance services between Q1 and Q4 of 2021. When asked why, about 1/3 were related to disruption to resources (staff, funding etc), 1/3 related to policies to suspend or scale back services and about 1/4 was decreased care-seeking behaviour by patients. Six bottlenecks to scaling up access to COVID19 tools were identified; lack of funding, workforce challenges, supply and equipment shortages, lack of distribution capacity, lack of clear strategy/guidance/policy and lack of needed data and information. There is much overlap here with issues that need to be addressed for Emergency Care more broadly.
Armando Garcia Guerrero from Mexico discussed clinical tools for low resource environments. He made a beautiful analogy with rescue workers at scenes of earthquake related damage asking for quiet by raising their hands, in order to better listen for those in distress. He quoted Rudolf Virchow on one slide: “medicine is a social science, and politics is nothing else but medicine on a large scale.” He points out that very few people were expecting the pandemic and essentially nobody was prepared. He invites us to reflect on our own experiences and return to what we dreamed of becoming when we started medical school – how we aspired to take our place in the chain of survival – and to relearn our position in society. I loved the Mexican saying “if you are walking and you find yourself alone, come back” as an allegory for public health, which must be community focused. From here, he says, there is still much work to do.
Kang Hyun Lee shared South Korean lessons from the front line. The Korean response was essentially trace, triage, test and treat. The government actively tried to minimise time from first symptom onset to hospitalisation using mass testing, aiming for <72h. The problem was that the negative pressure rooms were rapidly filled with COVID19 positive patients, leading to long delays outside the hospital including in ambulances (a familiar sight in many nations). Demonstrably, after the COVID19 outbreak survival from out-of-hospital cardiac arrest fell. I wonder whether this was due to the disease itself, access block, reduction in willingness of bystanders to perform CPR, or perhaps a combination of all three, but it is certainly an interesting correlation. Similarly, injury surveillance data showed a fall in absolute numbers of serious injury but an increase in proportion of deaths – particularly in intentional injury (eg hangings).
How can we stop the next pandemic, he asks? Vaccination, cooperation and support were his answers. International cooperation must be at the heart of pandemic response, including ensuring equity of access to vaccination.
Maaret Castren was up first, with an update of cardiac arrest literature. Her whirlwind tour of the most recent papers included this one, on lactate for prediction of in-hospital cardiac arrest – which found that lactate >4 had and 18 fold increased risk of IHCA.
Ryan Radecki spoke mainly around airway management evidence in cardiac arrest. This paper found LMAs are probably a best approach, while this paper tried to determine the best time to manage the airway in out-of-hospital cardiac arrest, and didn’t really find an association with survival outcomes for any particular timing. He also flagged an interesting group in this paper, which was looking at BVM ventilation; the patients for whom BVM was a rescue device (as in, intubation was attempted but not successful and the patient was then ventilated with BVM) had good ROSC and survival to discharge, inadvertently validating the vortex approach to airway management. He finished up with a mention of this paper, which I won’t cover as Simon has already blogged about it.
Tori Stephens talked about resuscitation with limited resources, beginning with a scenario in south Africa in which there are six gunshot victims en route to a department, with only three doctors on shift. “Perfection,” she reminds us, “is the enemy of good.” She described how the LODOX scan is used at the entrance to resus to perform full body x-ray and identify life-threatening injuries and to begin resuscitation. She described the use of the ATLS approach in lower resource settings, along with innovations such as the use of a tight sheet in place of a pelvic binder, or foley catheter in a penetrating neck trauma (a practice used by us at Sydney HEMS in our prehospital work). Referencing her own experiences with organophosphate poisoning, she urged us to also look for ways to streamline the care we deliver and to work towards achieving them.
Peter Cameron talked about sepsis and the shift in management from Rivers’ groundbreaking research back in 2001 (now 20 years ago!). Many of Rivers’ recommendations – central access, transfusion, fluid boluses – have failed to stand the test of time and EBM. In fact, there’s little good quality evidence for anything in sepsis (despite what the campaigns might have us believe). I’ll also just leave this here…
His papers were predominantly concerning COVID19, particularly the effects on healthcare workers and especially around mental health. The other pandemic-related papers included one on skin injuries related to PPE usage and two around the effects of lockdown on attendances to the ED.
Non-COVID related papers looked at the impact of the coordinating nurse role on patient satisfaction in the ED, prehospital challenges in Iran and quality indicators in trauma.
Finally, Joe Nemeth encouraged more love for crisis resource management (CRM). This was less of an evidence-based talk than an impassioned call to CRM. I’m not sure that this is something that isn’t realised, at least in the UK and Australia – and certainly at Sydney HEMS we are very much concerned with CRM and related human factors topics. If you’re not familiar with CRM, here’s the LITFL page.
For the afternoon concurrent sessions, I headed to the Trauma session, which was kicked off by Mya Cubitt on the need to develop a new paradigm for geriatric trauma. In her excellent talk, she pointed out that pretty much everything we do in trauma is focused about maintaining momentum towards surgical intervention and it remains relevant in the military and in war zones. We’ve adapted it to our trauma patterns in Australia to a degree but older patients continue to be under-triaged. Even definitions of trauma need to be reviewed – they often inform funding, staffing allocation, management – and we should evolve our world view of trauma. Falls are the most common injury hospitalisation, the most common cause of trauma-related death, and patients aged over 65 are 11 times more likely to present with falls on the same level (as in, not falls from height but from standing). If we assume mortality is most important, the majority of deaths occur in those over 75 years of age (and most of those are from low falls). She reminded us that these older patients deserve the same expert-level primary, secondary and tertiary survey focused care and that we can rethink our trauma paradigm to include, not exclude, them.
Keihan Golshemi talked about trauma care performance indicators in Iran. He offered a wide variety of possible performance indicators, from prehospital to surgical, short and long-term outcome focused. In Iran, the average EMS response, on-scene EMS times and the wait in ED are used to evaluate prehospital performance but unfortunately Iran doesn’t have a national trauma registry; some local institutions have their own registries but they are not connected nationally. He called for establishment of a national registry as a matter of priority. Iran has engaged in a Delphi process towards identifying national key performance indicators is underway – focused on the fact that high quality trauma care has the potential to save lives.
Indranil Das from India spoke on trauma and geriatric emergency care in resource limited settings. In India, there is also a rapidly increasing ageing population, similar to much of the rest of the world. He urges us to triage patients aged >70yrs to trauma centres if they have significant mechanism of injuries but also to consider it without mechanistic triggers if they have significant comorbidities, as trauma is the 7th most common cause of death in this group.There’s evidence of better outcomes when care is coordinated between emergency physicians and geriatricians. Prehospital care is crucial to determining survival but less than 1% of overall LMIC population has access to dedicated EMS.
Whitney Bryant covered current evidence-based management of gunshot injuries. For anyone who is shot, she says, trauma is a naked disease – strip the patient, look for other injuries (I’d argue the same is true for stabbings, so probably any penetrating trauma). GSW to the head are particularly lethal but trauma priorities are the same. For GSW without hard neurological signs, collars aren’t necessary. Direct pressure is just as important in GSW and “works like magic!”.