After a rather spectacular SMACC party involving the usual mix of dancing, music and Karaoke we are back at the ICC for day 3.
Practitioners advocating for humanity.
You’ve probably heard of Esther Choo through her work in advocacy in health care across the US. She stepped up to campaign against the dissolution of the affordable health act in the US. She mobilised groups of clinicians who worked to prevent the removal of health care from ordinary citizens in the US. What she did matters.
She modestly claimed that it was not her that made a difference, but perhaps it did as it drove her to continue to advocate for health care.
She moved on to help found and then lead in healthcare for #TimesUp which I really hope that you already know about. If not you can and should visit the site https://www.timesupnow.com/
Rob Gore talked on rethinking trauma. He talked on how trauma is more than a physical disease, but rather a disease that is influenced by economics, society, psychology and more. Working in Brooklyn, the neighbourhood he grew up in, he has a very personal perspective of how society influences the pattern and epidemiology of trauma.
Rob has worked hard in the world of prevention. You can see more from Rob here, and it’s worth hearing. He’s asked the difficult questions about why violence is happening and then thinking about how to prevent it.
Listening to Rob I found myself thinking about the disconnect that we have between what we know are the precipitants of violence as compared to the level of funding and intervention available to influence it. That led him to start the acclaimed KAVI program in Brooklyn. Amazing work that you can read more about here https://kavibrooklyn.org/
Hugh Montgomery, ICU Professor from London talked to us about his work on climate change advocacy. Hugh also happens to be an amazing magician as demonstrated to us earlier in the week, but that’s not what he was speaking on. He even has his own wikipedia page and it’s a worth a look to explore his background in advocacy and medicine https://en.wikipedia.org/wiki/Hugh_Montgomery_(physician)
Although his message is about climate change this talk was more about how we advocate through understanding how the way that we craft our messages can affect how we can advocate and change the world.
Reframing the message of climate change from abstract concepts (for most people) to those that matter to people, in a sustained way are essential if we are to tackle what is arguably the most important challenge that the world will face in the next 100 years. Climate change is a health issue and therefore it’s our issue too.
Mulinda Nyirenda talked on the development of emergency medicine in Malawi, which if I think she said has only three qualified emergency physicians. Her story of using data to drive change and develop primary care in emergency care across Malawi is an amazing example of how her service worked around the needs of the population as constrained by a limited resource environment.
You can read more about her work here https://www.primarytraumacare.org/people/mulinda-nyirenda/
Mulinda showed that her actions and leadership have made a real difference to patient flow and care in Malawi. Quite an achievement considering the enormity of the task that faced her when she got into post. Really inspirational stuff and a reminder that our colleagues in LMICs still have major challenges in developing emergency care. Maybe something that CODA can take forward? I was also delighted to hear that she will be taking this forward on the basis of data and in the spirit of academic emergency medicine. We need that academic rigour everywhere.
Brian Owler is a neurosurgeon and a politician. A strange combination you might think, but he argues that this is vital. We often think that in health care we are independent of politics but that’s crazy. Politics and healthcare are always linked and they always will be.
Brian talked about the power of narrative, the need to find stories that can engage the public and media in order to sustain and spread your public health message. For many of us that can feel uncomfortable as we are bound by confidentiality issues. However, so long as that is balanced and legal the power of stories is so powerful that it would be crazy for us not to use it. Brian reminds us that this works at all levels, arguing that we can use those narratives to change our politics, but also closer to home in our departments for example.
The panel discussion showed the link between all the speakers despite the wide range of projects and ideas. It starts with you, me and everyone here. It requires persistence and a belief that we can make a change, and we can.
Looking inward., looking out. This session focused on the use of actors in medical education. Using a variety of scenarios it was really clear about how much a trained actor can offer in the adjustment and variation of scenarios depending on which type of person they choose to play. I think it was a really elegant demonstration of this in practice. Worth a watch when it comes out online.
Bedside Critical Care
Our friends Salim Rezzaie and Ken Milne kicked off the final critical care session with a boxing match based debate on critical care controversies. Using a boxing match format they ran through a variety of topics.
Round 1: Should we use mechanical CPR? See the St Emlyn’s blog post here.. It’s an area where the evidence and ease of practice are at loggerheads. Whilst patient orientated outcomes are lacking there are arguments for m-CPR in practical terms. The decision from the audience?
Round 2: Epinephrine in cardiac arrest? Another topical conundrum that we’ve covered on St Emlyn’s here. Again it’s an issue where the decision depends on what you consider the most important outcome. Epi gives you more healthy survivors but twice as many severely neurologically damaged patients. The bottom line is that it rather depends on what you think is a good population outcome is.
Round 3: Should we use stroke ambulances? A controversial question especially as we’ve not really convinced ourselves about stroke thrombolysis! Read more on the blog here.
Round 4: Should we always use a bougie for intubating our patients? Again we’ve seen this reviewed on the blog before and we came out in favour.
The answer is that there should not allow EBM to dictate care, but rather it should inform our care.
Tomorrow Today: Advances in USS technology
Despite being led by self professed ultrasound nerds this was a cautionary tale that we need to balance the improvement of USS tech with our ability to interpret it. We should arguably spend more of our efforts teaching and learning USS as opposed to just getting a better bit of kit.
Good to see the scepticism on this topic. It’s not just about the kit.
Although that is not the real graph from Dunning Kruger as Ross Fisher will happily tell you 🙂
Sara Gray talks on the management of a patient with significant hypothermia. A patient caught in a Canadian winter with a temperature of 28C, who then vomits blood in large quantities.
I’m thinking that this might be a great topic for one of our #ResusFridays back in #Virchester
Carol Hodgson returned to talk about surviving ECMO. There is a lot of activity about ECMO at the moment, but it’s also an invasive and potentially high morbidity procedure. Just because something appears pretty cool in practice does not mean that it is always safe. We also need to consider the health care costs and missed opportunities if we continue to increase the number of patients going onto ECMO and other similar technologies.
It was wonderful to meet Shannah, who is an ECMO survivor having going onto ECMO following a flu infection. Note – lots of speakers freak out about speaking at SMACC, Shannah just rocked her presentation with style and panache (basically WOW!).
She went onto ECMO at the Alfred hospital in Melbourne. This is an incredible and difficult story to listen too. Very emotional and a reminder that we don’t really understand the experience of ECMO as clinicians.
For me this has been one of the most important talks of the conference. Really important to hear the patient perspective. Incredible talk from Shannah and Carol.
Ashley Shreves has spoken at several SMACC conferences on the management of palliative patients in the ED. She talked on the complexity of making decisions together with patients, and in particular how we need to work with patients to come to what is a complex decision at the end of life.
There was also some surprising stats on the success of interventions in the very old. Even those in their 90s have a 14% return home rate after ED intervention!
Road to Resus part 3.
So our patient is now on ICU and septic. Question 1 was about the use of steroids in septic shock. The answer was no to vit C and thiamine, but yes to steroids.
The second question was much more controversial. Should your clinician be a woman or a man? The evidence is that outcomes are better if your clinician is a woman. So the decision was an emphatic yes to a female critical care clinician.
Another great morning with the juxtaposition of advocacy and clinical care. That’s a real feature of the conference and one that I will miss as I don’t think any other conference has managed to aster this. The conclusion was for steroids, but not for Vit C and Thiamine.