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.
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:
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.
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 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:
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
Typed in the shadow of the Tempodrom here are some of my highlights from the second day of Das SMACC; a lot discussed in the podcast which will also be out in a bit. Sorry if this reads a bit like a stream of consciousness poem.
A MEETING OF THE TRIBES: INTER-PROFESSIONAL ISSUES IN CRITICAL CARE
What tribe are you? As you increase complexity you can increase the tribalism shown. If there a rite of passage you go through after which you know you belong? The flat culture is celebrated until it falls apart under conflict. The microaggression - 'just a nurse' needs to be avoided.
A common enemy (such as ITU) can help unite it encourages more tribalism. The consultant sets the tone of the shift but so does everyone in the team. Be aware of fundamental attribution bias and distinguish between behaviour and intention. We often criticise others based on their behaviour but praised ourselves for our intentions regardless of outcome or behaviour. Vulnerability and intention build teams. Be aware of your emotional intelligence and think who you want to be. Don't wage time fixing what doesn't work build on what does work. Think about your team reflexibility and how tribalism may affect your education culture. Beware of emotional contagion - how we behave transmits to others. Positive feedback is often vague whilst critical feedback is specific and we often forget the positive feedback compared to negative so more positive is needed so the student/colleague remembers.
Making Complex Problems Simple: Chris Hicks
A brilliant talk breaking down the management of a very complicated trauma call. A large process doesn't mean complex. Keeping it simple needs strategy. We make our habits and then our habits make us. We don't want any wild variances at the simple level. Four stages: Habit, Emergency Theory, Factor down problem, Limit variables.
Emergence theory creates complexity (this is how swallows appear to be flying in sequence - swarm behaviour). Three factors at play much like a swarm: Alignment. Separation. Cohesion - break you team down into sub teams: those dealing with airway, those on chest, those on pelvis etc.
Factor down from surface complexity e.g. look at airway problem, circulatory problem rather than whole massive problem.
Limit variables - eliminate steps, reduce team numbers, practice sim and increase engagement
Dream Big Plan Simple
The Future of Out-Of-Hospital Cardiac Arrest: Maaret Castren
50% of sudden cardiac risk had symptoms in preceding 4 weeks yet there is no risk prediction tool. Recommended the European Resus Academy - 10 steps to improve cardiac arrest survival.
Learning from Sim Part II: Critical Moments in the Emergency Department: Chris Hicks
Discussed emotional valence in simulation: if you feel an emotion in simulation you will better remember it when you feel that emotion for real i.e. anger or fear. Must practice good psychological health in simulation.
Finding the Needle in the Haystack: Paediatric Cardiac Disease: Michele Domico
Cardiac disease presents every other way than chest pain, murmur, cyanosis and hypoxia are obvious but far more common and vague are fatigue, failure to thrive, sepsis.
Children should not be fatigued, think if it adds up. Infection may unmask. Quiet tachypnoea can mean easily missed poor perfusion. Small children should not be quiet when you examine. Normal BP and HR does not mean good CO. Might have multiple presentations and have been given another diagnosis. Beware cognitive bias. Think heart in cases of repeat presentations.
Guts or Gadgets?… Prayers or Protocol?… Training or Tricks? - MJ Slabbert
Discussed the process of naturalistic decision making as she brilliantly went through a case of penetrative chest injury peri-arrest in the community. Do you go with protocol and RSI there knowing the BP will plummet and you'll have to do a thorocotomy in the community or scoop and run 5 minutes to hospital? Which is best?
16 Bits of Anaphylaxis - Daniel Cabrera
An outstanding presentation invoking Space Invaders.
Resuscitation for the Resuscitationist
Mass panel discussion here. No clear outcomes but some interesting areas of debate:
Vasoplegia e.g 130/7 - intravenous do not work
Preemptive CPR
? Use of Methylene blue
Refractory VF
Repositioning the pads
Or
Additional machine with 2nd set of pads with synchronized defib
Esmolol for refractory VF worth a try
Isoprenaline injection
Ketamine for semi-conscious patients during CPR
Encourage awake arrested patient to cough
When enough is enough-- close to 40 min of good quality CPR
Post resus temp control aiming 32-34C
Paralysis for temp control
Right, off to get the podcast out and then get to the party! Enjoy!
- Jamie
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
Take Aurally is off on holiday next week and this being Take Aurally it's going to be a FOAMed themed occasion!
SMACC (Social Media and Critical Care) is a health promotion charity. It is based on the philosophy of FOAM (Free Open Access Medical education – #FOAMed). DAS SMACC is being held at the Tempodrom, Berlin from 26th-29th June. For more information visit their website.
I'll be recording, photographing, blogging and tweeting from the conference and I'm looking forward to an inspirational few days! Hopefully see you there!
- Jamie
