Focused Trauma Conference 2017: Deel Drie

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In the third part of the day we focused on balloons, namely REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) - the Life in the Fast Lane post can be found here.  The talk was by @emeddoc.  This procedure is intended for cases of non-compressible traumatic haemorrhage.  Before REBOA the best possible method to achieve haemostasis was through compressing the descending aorta via resuscitative thoracotomy (RT).  Data from the American Association for the Surgery of Trauma (AAST) in 2014 shows that REBOA is at least non-inferior to RT.  In trauma patients in LOST (ie not TCA yet) who required REBOA 92.6% survived their stay in ED and 22.2% survived to discharge.  Increasingly work has shown REBOA to be feasible in the pre-hospital setting and has the best survival rates if performed pre-hospital.  

However, a study from Japan showed that REBOA is associated with an increase of 16.5% in mortality.  However, the median door to surgery time was 97 minutes and further research has shown in animal studies that lactate clearance is intact 45-60 minutes post REBOA but after that the ischaemia distal to the balloon may be irreparable hence the poor date from Japan. This raises the possible of future research into partial inflation to not completely cut off distal flow and have some permissive hypotension.  

REBOA is not just for the pre-hospital medics to be concerned about; it requires clear handover to the hospital and theatre teams after it is used as it will alter physiology.  It it there to buy time for the definitive surgery and it was emphasised several times that any unit wanting to implement REBOA will require widespread organisation and culture change.  

Here is the Take Visually graphic for this podcast and blog:

It was a brilliant and interesting day; thank you to all the organisers.  Antwerp is a lovely city and the Belgian people were very welcoming; if you can visit do!

Focused Trauma Conference 2017: Deel Twee

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In the second part of the Focused Trauma Conference we were treated to a focus on the role of ultrasound and clam shell thoracostomy.

Dr Jim Connolly (@jiconnoly) kicked off the second part by imagining a post-stethoscope world (Stethxit) and instead where we all have hand held ultrasound devices - a reality that's closer than we think - he believes once they crack a cost of <£1000 (i.e. the cost of the new iPhone) a unit we will all have one! POCUS will help identify the majority of causes in cardiac arrest (pretty much all of 4Hs and 4Ts apart from hypothermia or toxins).  POCUS reduces the time to operation, the number of CT scans and even the length of stay in hospital.  It is time critical, helps with Bayesian reasoning and with answering Yes/No answers.  It is more sensitive than auscultation and x-ray in detecting pneumothorax and takes a quarter of the time that CXR does.  However it is important to remember its limits:

  • A FAST scan needs about 500ml blood in the abdomen to pick up - "you need blood to bleed" and so there may be false negatives
  • It changes nothing in penetrating TCA

However in blunt TCA it is useful to pick up cardiac standstill (a very poor prognosis) and also to distinguish pseudo from real PEA.

It was then onto thoracostomy with Professor Lockey and then Dr Connolly again.  The procedure was first performed in 1988 and provides better visualisation than the left lateral approach.  Professor Lockey talked about the approach in 'street thoracostomy' often performed in cases of stabbings and even terrorism:

  1. Open the pericardium
  2. Seal the hole (ideally a single hole in the right ventricle) - occlude with a finger, stitch or staple it or use foley catheter
  3. Restart the heart - flick it, volume load, 2 handed massage, ventricular adrenaline, given bicarbonate (usually young people getting stabbed so should be fine) and calcium
  4. Clip the internal mammary arteries and clamp aorta and hilar
  5. If the patient wakes during anaesthetise with Midazolam 1mg and Ketamine 30mg
  6. Forensic awareness is also important in cases of stabbings 

The whole procedure should take less than 2 minutes.  It is not to be performed in cases of shootings/high energy transfer, if the heart is empty or if the TCA has been prolonged.

Dr Connolly reinforced many of these messages as well as emphasising that the biggest barrier to before the clamshell is the fear of being criticised.  It is a procedure not an operation designed to achieve damage control and restore physiology NOT anatomy.  It is to be performed in witnessed TCA or if there were very recent signs of life or if the systolic BP is <70mmHg despite fluid resuscitation.  The wound most likely to survive is a wound to the right ventricle with a tamponade.  When suturing a horizontal mattress suture is least likely to occlude the coronaries.  He also emphasised the importance of training - at times of stress we revert to our lowest level of training.  There are other considerations to have - once output is restored the patient needs to go straight to theatre and can have only vertical sliding not horizontal.  

Here are the Take Visually graphics for this podcast:

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Focused Trauma Conference 2017: Deel Een

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It was great to attend the inaugural Focused Trauma Conference hosted at the University of Antwerp.  Although run with a Belgian slant on things there were a number of British speakers and the whole event was in English which was useful for my dotard ears as one of the few uni-linguists in the audience.  The venue was amazing.  

Thanks to the breaks the day roughly broke up into three sections with different topics explored.  So, like the aorta in REBOA, (more of that later) we will tackle the day in three parts.  

In the first part Professor Nijs began by exploring major trauma in Belgium.  Belgium has twice the mortality rate due to trauma of the UK and has no system of Quality Assurance.  I was really proud to be part of the NHS as he highlighted the improvements seen in the UK since the MTC network was set up.  Whilst he pointed out that all systems need a 5 year maturation period in the UK we had seen immediate improvements in outcomes which increased year on year.  Major Trauma is an area of constantly changing paradigms: we no longer consider traumatic cardiac arrest a futile endeavour and there are ever improving methods of haemorrhage control such as REBOA.  He feels Belgium should aspire to the UK model but they will need:

    1.    The resources

    2.    People who understand

    3.    People who have the skills

Dr Ed Barnard (@edbarn) then spoke about traumatic cardiac arrest (TCA).  There is no universal definition of traumatic cardiac arrest which makes research difficult but this is predominately a disease of young people. Whilst initial papers gave low survival rates recent Trauma Audit and Research Network (TARN) data from 2009-2015 shows a 7.5% survival to hospital discharge rate as well a 2/3 moderate to good neurological outcome post TCA.  He discussed methods of public engagement as well as distinguishing between low output states in trauma (LOST) and no output states in trauma (NOST).  Whilst the standard methods of controlling bleeding and IV filling may work in LOST the future of resuscitation in NOST may involve methods of controlling and providing flow such as selective aortic arch perfusion.

In the final talk of part one discussed the European Resus Council (ERC) algorithm for TCA,

Universal cardiac arrest algorithms are not suitable for TCA as they can result in delays of nearly 10 minutes whilst looking for a reversible cause such as tension pneumothorax.  The ERC algorithm places chest compressions at a lower priority in TCA than treating hypoxia, tension pneumothorax, tamponade and hypovolaemia.  Dr Truhlar (@TruhlarA) openly admitted that the role of CPR is unknown.

The only nation to reject the ERC guidelines was the UK (insert Brexit reference) with the UK Resus Council producing its own guidelines as above which keeps thoracostomy and needle decompression as considerations not standard practice for all TCA.  

Dr Monsieurs (@kmonsieurs) continued this debate of the role of chest compressions in TCA.  He felt that maybe chest compressions provide little benefit in TCA and get in the way of other things which provide much more benefit.  There was discussion about how hard it can be for a professional to stop CPR for other procedures once bystanders have been doing compressions after calling for help.  Dr. Barnard made the interesting point that chest compressions whilst improving systolic BP cause diastolic BP to drop and so reduce coronary perfusion.  

I think the role of chest compressions in TCA and the ERC and UK TCA algorithms will provide much more fuel for research in the years to come!  

Here's the Take Visually for this podcast: 

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We're All Going on a #FOAMed Holiday

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Take Aurally is once again on the move this time heading to the Belgian city of Antwerp to take in the refined air, culture and the Focused Trauma Conference  on 14th October. 

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For those not going worry not as we shall podcast from the conference (or a cafe near by) as well as present a Take Visually or three.  Remember to follow @takeaurally for all the goings on.  

Here's the full running order:

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UMEC, I MEC, We MEC

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It was an honour to be asked to present at the 4th annual Undergraduate Medical Education Conference (UMEC) at the University of Nottingham on 7th July.  It's a great opportunity to see the great work being done to improve the teaching of our students.  

I think we were all impressed by the work of WAMS (Widening Access to Medical School) a programme run by medical students in association with work by the university to widen access to students who might otherwise not go to medical school.  I was very lucky with the support from home I received; many are not so lucky. 

                                              The DREEAM team out in force for UMEC 2017.

It was great to hear from my fellow podcaster Charley Peal on her work 'Nifty Fifty' giving clinical students a booklet of 50 challenges such as escorting a patient to X-ray to help them orientate and stay on the ward.  Or as she and her fellow medical fellow Becca Noble put it ''avoid being a trip hazard''.  Not saying I actually caused people to trip up when I was a medical student but I certainly had some near misses.

There was a good discussion about the difficulties of sharing educational resources.  This is why I support FOAMed despite its detractors.  No paywall; no firewall.  The challenge is quality control of course but I've often thought that there's great work going on that just isn't celebrated enough.  I've regularly been in conferences and felt it just seems like some institutions are better than others at getting their message out there.  There must be reasons at the individual level to explain this but it must also be due to leadership and the culture of an institution.  

We also discussed the conundrum at the heart of medical education I feel.  Our students want to pass exams.  We want them to be safe doctors.  It's sad but understandable when in the past I've had to cancel sessions because they're near exams and whilst they'd help the students as doctors I know engagement would be poor if I put it on.  

My DREEAM colleague Matt Govan kindly filmed me.  It's actually hard to boil a subject down into 7 minutes and it took a lot of practice.  Looking at it I hope it shows a progression with using the P3 approach to presentation.  The last time I presented I was told I dance about a bit so here I'm routed to the spot by 'anchoring' against the podium.    

In my last blog at Das SMACC I mentioned how SMACC has helped change the approach to conferences at this philosophy was evident at UMEC; short presentations, workshops dotted amongst the schedule with social media being used throughout.  As someone who attends a lot of conferences it's a great development and one to be continued.  Thanks to everyone at the UMEC organising committee.  

Das SMACC Day Three

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And so Das SMACC ist fertig and I am sat in my office in Nottingham reflecting on an amazing three days.  Thank you to all who made Das SMACC happen and thank you to my colleagues for accompanying me on the ride, tolerating me and allowing me to convert their voices into MP3 format.

So, Day Three.  It's fair to say that I was not in the best of humours at the beginning of the day which may have had something to do with the Das SMACC party the night before.  Maybe.  

LIGHTING THE FLAME: CRITICAL CARE EDUCATION
Chair: Simon Carley
Panel: Jenny Rudolph, Walter Eppich, Chris Nickson, Victoria Brazil, Sandra Viggers, Daniel Cabrera

The morning however was worth the trek in.  An inspiration panel of educationalists (new word for me) on the future of education in Critical Care. There is a Storify thread which you can follow here as otherwise my succinct points below won't do it justice.

  • How do we train doctors now to deal with the future? - train the basics well and use these as the building blocks for the future, teach empathy and compassion as these will still be needed as automation increases
  • Interprofessional education should be the norm and used throughout medical school, teach the fundamentals (anatomy, pathology) together and then subspecialise later - I completely agree with this and think this should be the way all universities function, if I come to power...
  • We don't actually teach how to be a doctor at medical school, we teach students how to be a resident (F1) which is where they learn to be a doctor - Amen Walter!
  • Don't focus on learning from simulation, rather simulate to learn from work
  • The future will not be simulation centres but rather each hospital having a fluid, focused simulation team who will able to provide expertise to all departments within the hospital, we can't assume anyone can facilitate simulation, treat it as a skill like ECMO or REBOA
  • Look at your coaching conversations, tailor your approach, ask your students what they would like you to look out for at the beginning of the session - YES! Definitely going for this approach in the future, I regularly find it hard to discuss everything in a debrief
  • Always talk after simulation, whether good or bad or indifferent
  • Also a big discussion on the best time to give feedback and Work Based Assessments - a recurring problem I have!  
  • We don't train people to give or receive feedback - another recurring problem

How to Fail - Kevin Fong

Another new man crush!  Anaesthetist/Astronaut Kevin spoke about failure.  The old saying is true; it's not an option.  Failure will always happen.  We have to adapt to accept this and approach our safety mechanisms and responses to failure appropriately.  Hypercompetence is a myth.  Hubris is wrong.  We have to have 'graceful failure' otherwise human factors fails and we will let out patient down.  I also liked his point that maybe the only reason medical science began to see the heart as a pump was because mechanics had invented a pump and we had a frame of reference.  Makes me wonder what fundamental point we're currently missing because we don't have that frame today.  

Helping Without Harming - Jenny Rudolph

An inventive and entertaining talk.  Rather than being annoyed at someone and thinking WTF think another WTF (What's Their Frame?)  The hashtag #WTF2WTF is alive and kicking on Twitter and it will be interesting to see how this goes.  More about fundamental-attribution bias.  Thought provoking, something I will try.


The Global Refugee Crisis: Why it’s Critical that we Care - Vera Sistenich

The only talk to get a standing ovation.  I can't do it justice, watch it at the SMACC website.  The more people who watch the better.

How to Fail… Part Two - Martin Bromiley

We all know his late wife's story.  How he does it I don't know but another great talk.  A man with much to be angry about who actually chose to understand and help.  His thoughts were inspiring on human factors:

  • "I would't do what they did" - not helpful, next time you catch yourself thinking that think instead "Why did it make sense at the time?" 
  • Confident humility - no one is too senior to seek feedback
  • Look at our systems in place, do they make it hard to be right and easy to be wrong?

This isn't a cop out but I genuinely couldn't do the last session featuring Martin Bromiley and James Piercy justice so please check it out on the Das SMACC site.  Amazing human beings and it was a privilege to hear them.  I hope I don't have to go through what they did but I hope I could always be as kind.  

So that was Das SMACC.  Personally I love FOAMed and it was great to be with like minded people in an amazing city.  Berlin is an amazing mixture of beauty and horror and needs to be seen.  What about SMACC?  It is a bit cultish if I'm honest.  I can see the point of some of its detractors pointing out the swearing, the hashtags, how something is either great or sh*t.  And it has made 'celebrities' of medics - yes I know the irony as someone who blogs and records his voice in his spare time - which is something that may create challenges in the future.  But I loved it.  SMACC has challenged the old school.  Conferences where someone stands at the front and talks with no engagement are thankfully dying out.  It's been great to see the smart conferences adapt with workshops, social media and an open minded approach.  'Punk movements' like SMACC are the vehicle of such changes.  I hope I will always be so open minded. The focus on the next generation and innovation was a pleasure to see as well.  Danke Berlin.  Danke Das SMACC.

 - Jamie 

  

Das SMACC Day One

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Just a few initial thoughts whilst the first day of Das SMACC is still free in my head!

Pre-Hospital Medicine: The Future is Now: Brian Burns

Trauma is a silent killer with 14,000 killed every day or 5 million a year.  As a proud geek I fully approved of the demonstration of technology as a 'meerkat system' to predict severity, POCUS and point of care TEG with drones providing tailored blood products to the scene. Early day yes. Orwellian possibly. Exciting definitely. 

Jonathan's Story: Jessica Mason
 

I'm always looking for new ways of teaching and found the approach by Jess Mason of using a patient story inspiring. She said "remember the story, remember the medicine" as she used the story of a patient of hers with sickle cell anaemia to make an important point: it is a terminal disease and should be treated as such; be kind with analgesia - opioids are the best. 

Voices in my Head: Sarah Gray

Do you talk to yourself in the same way you would talk to a patient? Sarah talked about self compassion, an area of interest for me as my masters dissertation looks as mental health and resilience. This may be the subject of a future blog as she recommended the site selfcompassion.org as a window into our emotional health. Asked the audience to put their hand in the air and then lower it down if we knew someone who had died of suicide, suffered depression or self-harm. One hand out of 2500 was left in the air at the end... Don't burn out!


“Everything” at the End of Life: Alex Psirades

It's a fact that all medical students are trained in CPR but not in how to discuss DNAR. There were powerful reminders that as healthcare workers we all share the same ultimate fate of our patients: our mortality. Even with improvements in medicine the mortality rate in the 21st century remains the same as the 17th. Alex mentioned optimism bias and how as clinicians prognostication of terminally ill patients actually worsens as we know them more as people.  He highlighted the HHHHHMM scale used in veterinary medicine which I think actually has some transferability to human patients. 

The Problem with Physiology: Rinaldo Bellomo

"Today's medicine is tomorrow's derision" Rinaldo highlighted the problems of physiology with example discredited practices such as Early Goal Directed Therapy, replacing albumin, replacing Protein C or prophylactic craniotomy. More biases here - attribution bias & immediacy bias. That fluid bolus you gave to correct your patient's BP? In 20 minutes it will be back to baseline. Mad Physiology leads to Mad Medicine. 

Four Tragic Dog Deaths: Lessons in Program Design and Development: Resa Lewiss

A good look at programme design with the four pillars I recognised from DREEAM: Clinical Excellence, Education, Research and Administration.  Resa used the deaths of four of her childhood dogs as examples of how a project may die: Cancer - a slow, insidious killer such as a cultural or personnel issue, Homicide - someone outside comes along and pulls the plug, Suicide - something you do kills your project and Old Age - your project fails to adapt and grows old and gets passed by. Powerful and like all good presentations memorable. 


Endocarditis will also f&*k you up: David Carr


Endocarditis. There is a 1% risk per year of endocarditis for patients with valve replacement. The risk is 1-2% in intravenous drug users. There thrombotic non-bacterial endocarditis: marantic endocarditis seen in malignancy and anti-phospholipid syndrome related endocarditis seen in lupus. 95% will have fever. 90% will have a murmur. To think of it as 'fever plus one'. Fever plus stroke in the young - usually MCA infarct - should make us think endocarditis. Fever plus back pain (osteomyelitis suggest haematalogical spread of the organisms which can also cause endocarditis). Fever plus heart failure (especially if there is no history of CCF - 'virgin' heart failure. Failure plus arrhythmia. (First degree heart block may be boring but suggests pervalvular abscess). Only 5% will have peripheral stigmata such as Janeway lesions or Osler's nodes - I'm going to have to change my teaching. Far more important is to look in their mouth, dental work in the preceding fortnight is suggestive and easier to identify than Roth's spots.

Plenty to discuss in the future.  For now I hope you enjoy reading.  Off to upload the podcast!

 - Jamie