#SMACCUS: A Trainee Perspective

3Amigos
If you’re reading this blog then I am sure you are aware that last week Chicago played host to the super-galactic conference that is SMACC. Equally, I am sure you have read summary upon summary and a number of the some 84,655 tweets relating to the conference. This post is a small and humble offering of the opinions of a triumvirate of (often clueless) trainees from the UK. Richard Lowe, Tristan Banks and myself, Richard Carden, all set out to the Windy City to see what all the fuss was about with suitcases packed full of optimism and enthusiasm. During and after the conference the three of us discussed our key learning points and share them with you here.

 

SPOILER: IT WAS AWESOME. EVERYONE SHOULD GO TO DUBLIN.

 

1) Sepsis is WAY more confusing and complicated than the three of us had ever imagined/realised.

We’d all read the Rivers paper, and then we all read the troika of ARISE, PROCESS and PROMISE; we all knew the sepsis 6 guidelines; we all knew the definitions of sepsis, severe sepsis and sepsis shock, and then POW. Now we know nothing! A fascinating and lively debate amongst some of the worlds authorities on sepsis management left us somewhat bewildered. There was disagreement over the diagnosis; there was disagreement over the treatment and role of fluids (if any!). Our take home message was that if they look like s**t then they probably are very sick! There was and is on-going discussion on whether you sepsis is a fluid-deplete state (in the absence of over GI losses) and that there may be benefit in withholding fluids and going straight for the vasopressors (a little punchy for an ST2!). There seemed a good consensus that in the presence of a decent peripheral cannula in a big vein it is ok to administer noradrenaline as interim measure before central access is gained. Overall sepsis is clearly a continuum and it is probably too broad a subject to treat one and all homogenously. The global burden of sepsis is not in the developed world, it lies in impoverished countries and the biggest atrocity is the lack of any new medicine to tackle the endemic diseases of such countries.

Will it change anything that the three of us do….probably not. It just highlighted how little we actually know and how much we have to learn. Cue frantic reading of every sepsis paper ever. Once we know the arguments and the evidence and the physiology inside out, then we will be in a position to operate outside the guidance, but not before then. Which leads me on to the next key lesson…

 

2) Twitter does not replace knowing the evidence and primary literature.

It’s easy to get caught up in the debates and discussions that take place in the ‘Twittersphere’ but it is so vitally important that you understand and read the primary literature. The ‘Twitterati’ that keep us so preoccupied are often experts and have expert insight; be inspired and go and read the literature.

 

3) Do the simple things well and master the basics.

For all the chat that we hear about REBOA, ketamine, thoracotomy, and surgical cricothyroidotomy, there is nothing that can replace doing the simple things well. There is a disproportionate amount of attention given to these subjects when compared to the basics. It is easy to get carried away with it all. There was some ATLS-bashing going on that was both appropriate and inappropriate; appropriate in the sense that it still advocates some pretty controversial treatments i.e. 2L crystalloid, airway before massive haemorrhage etc., omission of conditions such as impact brain apnoea. However, it is worth mentioning the things it does do well, such as provide a common language of trauma, give the non-expert an approach to managing the trauma patient and most of all stir an interest in the management of trauma. It is not the ideal way to treat a trauma patient if you are an expert with years of experience, but it is appropriate for juniors who are lacking the knowledge and expertise. It needs an update but it is not to be written off completely just yet.

That being said, if some suffers a traumatic cardiac arrest from penetrating thoracic trauma then you should do a thoracotomy…

 

4) Give Tranexamic Acid to bleeding trauma patients.

Crash-2 is sufficient argument. However, there are those who don’t believe despite the evidence.

 

5) Share the mental model

This was a recurring theme that makes so much sense and cannot be understated. Share your thought processes with your team, let them know what you are thinking and what your anticipated course of action is. A choir sings so much better if everyone knows the words…

 

6) Build Resilience

Prepare for the worst. It will come and when it does it can either destroy you are help you grow. Building resilience will help achieve the latter. Especially as juniors with our careers ahead of us, it makes so much sense to nurture these characteristics early so that we can weather whatever storms may lie ahead.  With this comes the concept of mindfulness.  This promotes resilience and also gives you an opportunity to reflect and destress.  Read about it and do it.

 

7) Read

Read a lot. Read about anything and everything you can get your hands on. The speakers at SMACC were there because they know the evidence; there because they have read widely and variedly. If you want to be awesome then it takes commitment and hard work. Regurgitating the opinions of those who have been through all the evidence and have vast clinical experience will not cut it.

 

8) Make a presentation interesting

Not only is the content of SMACC incredible, but it is also a masterclass in giving a presentation.  The presentation style varied at times, but for the most part they were excellent.  The slides were simple and did not contain endless prose or impossible-to-read tables.  The presenters told a story, made you laugh and more importantly, made you think.  The vast majority of presentations were a breath of fresh air, and a welcome deviation from the kinds of presentation you can (unfortunately) become used to.  In summary, make a presentation interesting…..and read this book:

TED

Having written this and been back through and read it, this article sounds rather negative. This is was not my/our intent! SMACCUS challenged and inspired us in unimaginable ways. It has challenged us to read everything, question everything, work better in teams, work better at looking after our own health, think about how we think about things and generally gave us a huge injection of the contagious passion that runs rife at the conference.

For those of you who are unsure about social media and FOAM, I challenge you get involved. Let it push you to read the evidence. If you disagree with ‘dogmalysis’ then look at the literature and form your own evidence-based opinions. Immerse yourself and it will change you for the better.

 

See you in Dublin. You will not regret it.

 

Cheers, and thank you SMACCUS

 

 

Rich, Rich, Tristan

Posted by Richard Carden

Dr Richard Carden MBChB MSc BSc (Hons) PGCert FHEA MAcadMEd RAMC(V) Dr Richard Carden MBChB MSc BSc (Hons) PGCert FHEA MAcadMEd RAMC(V) is an Emergency Medicine Trainee in London. He is currently a PhD Candidate in Trauma Sciences at the Centre for Trauma Sciences. He is a Major in the British Army with 335 Medical Evacuation Regiment. He is a Co-Founder of the National Trauma Research and Innovation Collaborative and Module Lead for the MSc in Emergency and Resuscitation Medicine at QMUL. You can find him on twitter as @richcarden

  1. But don’t forget that the three Sepsis mega-trials failed to show that expert, nuanced, tailored care was superior to amateur, protocolised, cook-book care.

    Reply

    1. Indeed. Lack of any meaningful clinical difference was really interesting. You could easily argue that if you don’t have an exert on hand then EGDT would do the job.

      Not a popular view I’m sure.

      S

      Reply

  2. That’s a great point, Derek, thanks. I completely agree, my point was simply that as a trainee (not an expert) it is probably more appropriate to go by the book until sufficiently experienced with enough knowledge to deliver expert care. Thanks for reading!

    Reply

    1. There are multiple ways of interpreting the EGDT trials:

      1) Once you get the basics right, how you tweak the haemodynamics makes little difference to hard outcomes
      2) There is a small subset of very sick patients which benefit from careful manipulation of circulatory parameters
      3) Experts possess an attribution fallacy that because they ‘think’ about the issues more, they actually have a better control over the eventual result

      On point 2, this group must be so vanishingly small you wonder if it is worth paying experts (and associated equipment) the big $$$ when you achieve an equivalent outcome for the overall population with less expertise and technology.

      Reply

  3. Great Rich and team for the summary

    Reply

Thanks so much for following. Viva la #FOAMed

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