Podcasts about smaccdub

Country-fiedMD interviews DasSMACC volunteer, @thenursealyx, about her introduction into FOAMed (Free Open Access Medical Education) and SMACC  (Social Media and Critical Care) as well as her experience at 2016 SMACCDUB.  We also get a little preview of the 2017 DasSMACC in Berlin, Germany!!  The source of #INFOAMATION

Rapid Sequence Airway (RSA) involves the same preparation and pharmacology as RSI with the immediate planned placement of an extraglottic device (EGD) instead of intubation. Like DSI, RSA is an alternative airway management strategy that may be ideal for preoxygenation of hypoxemic patients as well for prehospital and in-flight use. Depending on the chosen EGD, RSA can facilitate gastric decompression, positive pressure ventilation with PEEP delivered by a ventilator and endoscopic intubation. The speaker presents the evolution of this novel concept in New Mexico, reviews their clinical experience with RSA in both the prehospital and hospital settings and assesses the available literature.

Airway management is a fundamental responsibility and skill of all involved e.g. emergency physicians , anaesthetists and critical care physicians. We need airway algorithms because there is still severe morbidity and mortality related to airway management. (NAP 4 study, ASA Closed claims series) The 2015 Difficult Airway Society guidelines, published in the British Journal of Anaesthesia in December 2015, provide a sequential series of plans (A to D) to be used when tracheal intubation fails. They are designed to promote patient safety by prioritising oxygenation and minimising trauma and they highlight the role of neuromuscular blockade in making airway management easier. The guidelines recognise the difficulties in decision making during an emergency and stress importance of human factor training. The guidelines include steps to assist the anaesthetic team by providing a common stem of options (a simple algorithm) for maintaining oxygenation, limiting the number of airway intervention attempts, encouraging declaration of failure by placing a Supraglottic Airway Device and overtly recommending a time for stopping and thinking. They emphasise the importance of considering discontinuing anaesthesia and waking the patient up (if appropriate) when tracheal intubation has failed. Videolaryngoscopy and second generation Supraglottic Airway Devices are recommended and all anaesthetists, intensivists and emergency medicine physicians, should be trained to use them. There is however limited evidence available relating to the management of the can’t intubate can’t oxygenate situation (CICO) PLAN D. However it is strongly recommended that all anaesthetists must be trained to perform a surgical cricothyroidotomy and a standard operating procedure for Front of Neck Access to the airway is described using a “scalpel bougie tube” technique. Learning Objectives • Importance of optimal preoxygenation. • Best technique at laryngoscopy. • Maximum of 3 attempts at laryngoscopy / intubation. • Maximum of 3 attempts at placing a Supraglottic Airway Device. • When tracheal intubation fails, waking the patient up is almost always the safest option. • All practitioners involved in airway management need to learn the “scalpel bougie tube” method of cricothyroidotomy.

In the past two decades, airway management has been revolutionized by the development of video laryngoscopy, hyperangulated blade geometry, optical stylets, laryngeal masks, and a host of advances in airway pharmacology and technique. The core skill of airway management, however, remains laryngoscopy, whether or not the operator uses a blade with a camera at the end. In this presentation, we break down laryngoscopy into its discrete components and describe best practice technique at each step. We will start by describing common mistakes made in patient positioning; proposing a set of parameters the provider can use to guide positioning that is optimal for laryngoscopy, including the configuration of the patient in the bed, the bed height and head elevation, as well as provider stance. We then move into the effect of laryngoscope grip on operator catecholamine management and describe the optimal laryngoscope grip for emergency airway management. We next confront one of the core principles of RSI, the delay between medication administration and commencement of laryngoscopy, and propose an alternative approach that emphasizes early laryngoscopy with deliberate slowness. We turn our attention to the value of the jaw thrust–as performed by an assistant–during airway management, and then move into a step by step analysis of laryngoscopy as the blade moves into the mouth, down the tongue and ultimately to the glottis. We espouse suction as an underutilized device by emergency providers, and describe the two most important intra-laryngoscopy optimization maneuvers: optimization of the position of the head, and optimization of the position of the larynx. We discuss the value of using the gum elastic bougie for both difficult and routine intubations and describe pitfalls encountered when using the bougie (and how to manage them). We conclude by describing the 3-finger tracheal palpation method of endotracheal tube depth confirmation.

We accept that knowledge translation is critical to the practice of emergency medicine, yet when it comes to the practice of BEING an emergency physician, we do always practice evidence-based medicine. We realized that the experiences of many female emergency physicians were similar but not shared, so we created an open access resource to address that. FemInEM was born out of the real but unfortunate truth that the gender pay gap is alive and well, and promotion of women through the academic pipeline is slow and women still experience unconscious bias at all levels of development. Malignant behavior runs rampant within medical training, and women are disproportionately affected by this reality. In addition, balancing work life and home life can pose extra challenges, especially for women. Numerous studies have shown even when working full time, women often carry more of the “care based” workload for home and family, compounding the “work-life conflict” felt by physicians regardless of gender. We will share the journey of how FemInEM began as a blog but evolved quickly into a centralized resource for women needing advocates and champions. We will tell stories of how we are helping to change the conversation related to gender and equity in EM by highlighting the successful practices and programs in an open access format. By using the principles of FOAM and the power of social media, we are trying to move the needle on gender and medicine in a way that hasn’t been done before.

More than a hundred years ago Osler moved medical education to the bedside. Somehow today, most medical education still takes place in the lecture hall far away from patients. Medical education is often thought of as a top to bottom process where experienced professors and clinicians provide information and feedback to novice learners, with the goal of increasing knowledge and adjusting behavior. This approach to medical education can be effective, but may also only provide situational learning making what is learned in school today, outdated tomorrow. Creating an environment where students can learn reflective practice that can evolve with them as they move from novices to experts may prevent situational experts and facilitate expert performance. The continuous changing nature of modern healthcare also demands that students from an early educational age are provided with the skills needed to learn, work and adapt within a continuously evolving environment. These skills aren’t traditionally taught in medical school as learning in context is limited. Therefore, the future of medical education should focus on helping students develop the skills needed to become their own learning choreographers who take responsibility for their own education, not only as students but also as lifelong learners as part of their continuous medical education. The purpose of the talk is to answer some of the question that may arise when you allow medical students to choreograph their own education. How this process can be started with you as the educator, and can be done without compromising patient safety and maybe even improve patient outcome.

Caring for the critically unwell is an important and difficult task. So preparing our people to meet this challenge should be all about excellence. Too often, the structures and pressures that define medical training focus on competence rather than excellence. Competence is measurable. It can logged, assessed, and can be applied to across big organisations. But aspiring only to competence limits us - our patients need more. So can we learn from how other high-performance organisations train? For Olympic teams, aiming for competence just isn’t good enough. These organisations develop their athletes over many years - equipping them, ready to deliver an excellent performance under pressure. Successful coaching relationships operate on an individual level. They are long-term. They are flexible. And they are measured not by exams or assessments, but by whether the person being coached can perform in the real world. Should you be thinking about being a coach rather than a trainer? And how can we move our focus from competence to excellence? This talk will explore three aspects of high-performance coaching which have relevance for clinical educators: ⁃ Goal setting and commitment ⁃ The value and limitations of marginal gains theory ⁃ Self-compassion as a tool for achieving excellence.

This will be a panel discussion with a focus on the different styles of training and education in prehospital care.

Wilderness and expedition medicine is the epitome of practical, pragmatic, minimalist and thoughtful care. Austere and extreme environments require special knowledge, critical thinking, innovative practice and sometimes cunning improvisation. Diagnosis in the wilderness relies heavily on clinical examination skills, monitoring and special investigations are very limited, and treatment options are determined by the breadth and depth of the individual practitioner’s hands-on skills. The implications of extreme environments – high pressures and altitude, frigid and sweltering temperatures, hypoxia and high-intensity endurance exercise – can provide us with great insight into the physiology of humans responding and adapting to critical illness. In this presentation, Ross shares trials and tribulations and draws on experiences from wilderness rescue, and expeditions around the world, which provide lessons for wilderness medics. Many of these lessons can be translated to insights into practicing better acute and critical care medicine in our day-to-day settings.

After five months working in the ICU and ED of the Médecins Sans Frontières run Kunduz Trauma Centre (KTC) in northern Afghanistan, I found myself caught up in an eruption of war as the Taliban forcibly took control of Kunduz from the US backed Afghan Military. This marked the beginning of a challenging week of heavy conflict in which our hospital was the only facility providing impartial medical care to war wounded civilians and soldiers from both sides of the conflict. Despite the proximity of the rapidly changing front line, we believed the hospital was the safest place to be, as both warring parties had agreed to respect the protection provided to us under International Humanitarian law. My work in KTC came to a grinding halt when a US Gunship fired over 200 missiles into our hospital, destroying the main building and killing 42 people including 14 of my colleagues. It was a scene of nightmarish horror that will forever be etched in my memory. Since returning from Afghanistan, I have watched in shock as hospital after hospital in both Syria and Yemen has been bombed. Over 250 hospitals in Syria and 130 in Yemen have been attacked since the beginning of their respective conflicts, cataloguing a growing disregard for the rules of war. Despite the condemnation by the UN, the attacks on medical facilities continue, unabated. Following an eye witness account of the attack on KTC, I will look more globally at the trend in hospital bombings, asking some important questions: Is international humanitarian law no longer respected by warring parties? Are we entering into a new paradigm of war where hospital attacks are a legitimate military tactic? What does this mean for the future of critical care delivery in war zones across the world?

The World Health Organization notes that 80-90% of all diagnostic problems could potentially be solved by basic radiograph (x-ray) and ultrasound (US) examinations; however, the problem is that two-thirds of the world’s population currently has no access to imaging technologies (1). From refugee camps in Greece, to rural clinics in Australia, to Everest Base Camp, point-of-care ultrasound is one of the most powerful diagnostic and procedural tools in any austere clinical setting. This transformative technology allows front line providers who have direct responsibility for patient care to rule in or rule out diagnoses rapidly, and to ensure safety in performing procedures with real-time image guidance. For example, POCUS training just allowed a midwife to identify a massive amount of free intra-abdominal fluid in the 30 year-old Ugandan mother presenting to gynecology clinic with her third pregnancy and new abdominal pain. She notified the surgeon of her concern for a ruptured ectopic pregnancy and the patient was immediately taken to the operating theatre, and she survived. She related that before her ultrasound training, her practice of sending this patient to town for an ultrasound evaluation by the only radiologist in the district would have delayed definitive care, and may have resulted in death. When I worked in an Ebola treatment unit one of my favorite patients who had been doing well suddenly spiked a fever to 40 degrees Celsius. His abdomen became rigid and I had no idea why. In a setting where no other imaging was possible, POCUS allowed me to see that there was an unexpected issue with his bowels. That knowledge led me to start him on antibiotics, and adjust care plans after I found similar in several other patients. Ultrasound machines have become increasingly portable, user-friendly, and less expensive over the last decade. This is resulting in a growing presence in otherwise austere environments. POCUS trained clinicians can afford imaging capacity to health facilities that may have very limited on-site diagnostics. There is no ionizing radiation, nothing invasive, and it is cost-efficient (2,3). Human resources are consolidated; the clinician is the diagnostician. POCUS provides the potential to quickly narrow differential diagnoses by facilitating a look inside the body during the patient encounter, and research studies support its use to solve information gaps in resource-limited settings (4-10). Moreover, the potential for this digital technology to be shared – and to leverage global expertise and consultation – increases the range of application beyond one individual’s knowledge base. References 1. World Health Organization Medical Devices: Managing the Mismatch, 2010. Accessed March 20, 2016. Available at: http://apps.who.int/iris/bitstream/10665/44407/1/9789241564045_eng.pdf 2. Mercaldi CJ, Lanes SF. Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis. Chest 2013;143(2):532–8. 3. Adhikari S, Amini R, Stolz L, Blaivas M. Impact of point-of-care ultrasound on quality of care in clinical practice. Reports in Medical Imaging 2014; 7: 81-93. 4. Sippel S, Muruganandan K et al. Review article: use of ultrasound in the developing world. International Journal of Emergency Medicine 2011; 4:72 5. Henwood PC, Beversluis D et al. Characterizing the limited use of point-of-care ultrasound in Colombian emergency medicine residencies. International Journal of Emergency Medicine 2014; 7:7 6. Deng D, Mingsong L et al. Ultrasonographic applications after mass casualty incident caused by Wenchuan earthquake. Journal of Trauma 2010; 68: 1417-20 7. Fagenholz P, Gutman JA et al. Chest ultrasonography for the diagnosis and monitoring of high-altitude pulmonary edema. Chest 2007;131(4):1013-8 8. Shah SP, Epino H et al. Impact of the introduction of ultrasound services in a limited resource setting: rural Rwanda 2008. BMC International Health and Human Rights 2009; 9:4 9. Kotlyar S, Moore CL: Assessing the utility of ultrasound in Liberia. J Emerg Trauma Shock 2008; 1(1): 10-14 10. Stein W, Katunda I, Butoto C: A two-level ultrasonographic service in a maternity care unit of a rural district hospital in Tanzania. Trop Doct 2008; 38(2): 125-6

The talk focuses on why clinicians miss the diagnosis on aortic dissection. It breaks down the key pearls on history and physical exam that guide you into correctly suspecting a dissection. Aortic dissection is a challenging diagnosis that you can not afford to miss. The talk aims to give you the framework to avoid missing the diagnosis. I want to raise the bar so that the standard of care is not to miss a dissection when it presents atypically. The talk will also highlight strategies on what to do when you suspect the diagnosis. It will guide you to order the right imaging tests and begin the treatment promptly. Sit back and be ready to see dissections in a different light.

The sick and the dead from SMACCdub

This talk will look at current and previous pre oxygenation practices and some of the current research. It will also discuss the notion of commitment to evolution of practice, the breakdown of cognitive biases and how to move forward with adequate self reflected practice.

Modern acute care medicine is eye-wateringly complex and potentially dangerous. It really can't be delivered safely without deliberately addressing our teamwork (in both acute and chronic situations). Unfortunately, historically, human factors were commonly left to chance, and recently have been threatened by decerebrate checklists and meaningless psychobabble. Practical strategies exist (thank goodness!) and will be reviewed. We have much to learn, but must also avoid overly simple answers to exceedingly complex problems. It's time to get back to basics and away from the BS. Come be part of a practical revolution

Richard will cover the rationale and evidence for prehospital blood product transfusion in trauma, look at the available current and future options, suggest best clinical practice and highlight areas of future research.

Patients with TBI (traumatic brain injury) often have concomitant systemic injuries that complicate the management of the TBI. How does the practitioner balance the needs of the hypotensive resuscitation with CPP? How does ICP affect emergent operative needs? Thoracic injuries complicate cerebral oxygenation - are there effective management strategies? Where is the best place to care for these patients?

Rory Staunton was a healthy 12-year old boy, known for his smile and his work standing up for others. A simple fall during basketball practice caused an abrasion on his arm, which is the suspected beginning of a cascade of events that led to his death from sepsis. Rory was seen by both his pediatrician and a local emergency department, and was sent home with a diagnosis of a viral illness. He returned the next day in septic shock and died shortly thereafter. A review of the medical records revealed that there were errors that occurred during his emergency department visit. These errors were the focus of a controversial article in the New York Times, that included both details of the case, as well as the name of the physician that provided care. A backlash from the medical community occurred leading to multiple physician-written op-ed pieces, as well as over 1600 comments on the online version of the article. This talk will attempt to move away from the controversy of the actual article and instead focus on how these common errors could have occurred during any busy shift and what we can do to prevent them in the future. My intention in giving this talk is to continue to use this case to raise awareness of both pediatric sepsis and common medical error and hopefully lead to fewer outcomes like Rory’s.

Describing the importance of patient handover and the critical time when the pre-hospital practitioner will give this information to the receiving hospital staff. Using an analogy of the characters that appear in cowboy films, the preacher stands out as one who usually plays a small but significant role in getting his message across. We will compare this to the modern day practitioner and how they should achieve the objective of giving a good handover to the receivers, who may or may not be believers

To cool or not to cool. Traumatic brain injury is a major cause of mortality and long term morbidity. Hypothermia has been suggested as a potential treatment to limit secondary brain injury and improve outcomes. However, this currently remains controversial. Despite many small studies and meta-analyses suggesting benefit this has not been reflected in the recent larger studies. This may have been due to significant methodological limitations. The Eurotheum study completed last year which examine hypothermia as a rescue therapy suggested that we should abandon hypothermia in our traumatically brain injured patients. Before our community discards this potentially beneficial treatment after almost 50 years of investigation it is important to understand the limitations of the previous studies and the opportunities that currently ongoing studies have to address this question.

It’s been two decades since NINDS and MAST and ECASS and the other clot-busting lore cluttering up your brain. Have we learned anything in the interim? Are we using tPA more safely, more appropriately – or just more? And, what now, of endovascular therapy, CT perfusion, and patient-level predictive modeling – are you ready for the next decade of evolution in stroke care? In this talk, we’ll go into the most recent trial evidence relating to saving neurons, and whether we should be suspicious or celebratory of their outcomes. On one hand, we have clinicians putting the low-tech non-contrast CT in a mobile stroke unit to treat more patients, while other clinicians are using rapid MRI and CT perfusion to precisely target treatment. We’ve also seen endovascular treatment finally hit prime-time after years of false starts, and systems of stroke care re-organized around its delivery. The pace of practice change – and the reliability of the evidence – is enough to give you a stroke! Finally, we’ll look at the clinical trials underway, which may produce zero, subtle, or huge changes in practice. At the minimum, we’ll at least get a handful of new acronyms to file away.

Undertaking a decompressive crainectomy is perhaps one of the most challenging decisions we face within critical care, we don't know if we should do the operation, and even if we think we should we don't know when, or even how. Perhaps more importantly we don't do the operation, the neurosurgeons do, but we frequently put them in the position of doing the operation when we are at our wits end, or they do the operation without asking us when we still feel we have space to play. How can we resolve this, in a workplace environment which is already fraught with competing interests, beliefs, values and approaches? Evidence based medicine isn't going to provide an answer soon and it is unlikely that a superficial approach to improving teamwork will either. An important component will be the future structure of clinical training, our current systems reflect the way hospitals worked decades ago and the specialties we now have exist almost independently of the training which leads to consultant posts. Training should involve exposure to collegiate decision making and consensus building but this will be difficult to achieve within our current nationally co-ordinated training schemes.

Almost fifty years since the concept of brain death was first introduced, some individuals and whole nations still struggle with its concept and justification. Many controversies continue to surround brain death, although there is broad consensus that human death is ultimately death of the brain. This crucially involves the irreversible loss of the capacity for consciousness combined with the irreversible loss of the capacity to breathe since, taken together, these elements represent the most basic manner in which a human being can interact with their environment. Confusingly brain death is defined in two different ways based on ‘whole’ brain and ‘brainstem’ formulations, although the clinical determination of both is identical. It is not widely appreciated that death is a process, and this leads to misunderstanding by both the public and professionals; reports of brain dead patients ‘being kept alive’ on a ventilator are familiar. Pragmatically, once a threshold of irreversibility in the dying process has been reached, and brain death is such a point, it is not necessary to wait for the death of the whole organism for the inevitable consequence of its biological death to be certain. The majority of countries specify that a clinical diagnosis of brain death is sufficient for the determination of death in adults, but there are major international differences in the criteria for the determination of brain death. There is unanimity that confirmation of absent brainstem reflexes is fundamental, but wide variations in requirements for the apnoea test. The diagnosis of brain death is robust when established diagnostic criteria are strictly applied but, somewhat worryingly, deviation from jurisdiction-specific diagnostic guidance is relatively common. This lecture will discuss the history and development of the concepts and diagnosis of brain death internationally, examine current challenges and controversies, and make the case for an international consensus.

Hazel Talbot provides an insightful look at neonatal and paediatric retrieval in her talk "Small Packages, Big Lessons"

Myths persist because they are essential to the human experience and our development as a society. They fill the gap between what we know and what we think we know. Where does this gap hurt us the most? In our vulnerable populations, for example, in our care of children. The “myth incarnate” in medicine: defective dogma. Not all dogma is bad – after all, dogma means “that which is believed universally to be true”. The problem with medical dogma is that our critical thought processes are curtailed by wholesale acceptance. Medical dogma is a special kind of myth, because it’s difficult to define. We repeat defective dogma for three reasons: “It is known”. Sometimes the dogma is all that is known on the subject, or it is simply the majority consensus. Be careful with this one – because there may be a reason for this specific teaching – not all dogma is bad. Dogma is sentimental. We learned from our teachers who learned from their teachers. We want to honor those who taught us, and we get attached to some ideas. Sometimes – even subconsciously – we allow our attachment to an idea to give it more credence than it deserves. The third driver of dogma is insecurity. “I know what I know”. In other words, “don’t make me reveal my limitations.” Myth: “They’re all fine” Remedy: Remember to look for the subtleties in children. Early warning signs are there, in the history or in the physical exam. If it doesn’t add up, investigate. Myth: “Only pediatricians are experts” Remedy: Don’t delegate decisions. You can do this. You sometimes are the only one that can. Myth: “I will break them” Remedy: Children are not another species. Use all of your skills for all of your patients” Powered by #FOAMed – Tim Horeczko, MD, MSCR, FACEP, FAAP

As patients becomes more complex, the tribal systems we use to look after them remain stuck in the 18th Century when the treatment for everything was amputation and, if you survived, leeches. The large modern hospital is becoming a battleground of competing SODs* and SONs** practising their art in a multi-organ (failure) world. Many staff lack acute medical skills; those with such expertise are siloed far away from the ward in emergency departments, operating theatres and ICUs. Despite disease not knowing or caring what time it is, all hospitals remain solar powered with minimal nocturnal on-site expertise. As nursing & medical staff move more towards rotating rosters where no-one knows more than a single-sentence-summary of their patient’s complex physiological, pathological & pharmacological needs, an ever-present vigilant family member may become the only hope of surviving any acute admission. The two most dangerous words in healthcare may well be ‘_my_ patient’. Come listen to a middle-aged intensivist rant about how things were so much better ‘back in the day’*** and bask in the utopian dream of a healthcare system that provides better, safer, patient-centred care. *Single Organ Doctor **Single Organ Nurse ***they weren’t

Cops and robbers, cowboy and Indians, and military movies have filled the minds of generations of healthcare providers with a vision of what gun fights and combat look like. Unfortunately, real violence looks nothing like any of these. As emergency and critical care providers, we forge additional perspectives as we care for the victims of violence. Yet, views of violence aftermath only scratch the surface of first-hand experience during the brutal, scary, gritty, and dirty realities of real world in-progress violence. It is horrible, and It is quick… really quick. In this focused discussion, we will talk about prehospital critical care team response to the mass shooting. We will explore how emotional and physiological barriers run amok making the simplest logistical and clinical decisions extremely difficult. We will discuss the importance of staying” left of bang”, incident recognition, initial confusion, and the critical nature of incident acceptance. Next we will review staff and patient safety priorities and basic concepts of tactical combat casualty care (TCCC). Finally, we will conclude with thoughts about your role as care provider when on duty as part of a pre-formed team, and what to do if off duty facing an active shooter. Today is the day to ponder actions you must take the moment an active shooter begins taking lives at an astonishing rate; THAT moment when the choices you make next will be the most important of your career. The choices you make today will affect the milliseconds and millimeters that determine survival… patient survival, your survival, and the survival of those waiting at home for you to walk back through the door.

Scott Weingart discusses Post-Intubation Sedation.

All biomarkers are awesome predictors of badness. Elevated hS-troponins after non-cardiac surgery or an acute exacerbation of COPD are associated with increased mortality. In seemingly healthy people elevated D-dimer levels are associated with increased mortality, just like NT-proBNP levels predict mortality in patients with end-stage renal disease. A biomarker, in its broadest sense, is defined as ” a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention” (NIH Biomarkers Definitions Working group, 2001). This definition includes everything from laboratory tests to blood pressure measurements or an ultrasound scan. The clinical assessment in the emergency department is based on the subjective history of the patient in combination with all available biomarkers and their change over time. Yet the notion that biomarkers are ”objectively measured” can lead to an overestimation of their individual importance in the bigger clinical picture. Overtesting and overdiagnosis have serious consequences not only for patients, but also for the health care system. In a clinical context the ease of getting a laboratory test leads to a lower threshold for testing, which has been shown to increase testing without affecting relevant clinical endpoints. Also, when a biomarker becomes part of the standardized workup for a certain symptom, primary care centers and emergency telephone services will refer patients to the emergency department for testing, even when the pretest probability is low. This bias is not an inherent problem of biomarkers themselves, but of the decision making process of clinicians. The human brain fears uncertainty, and anything that adds to the feeling of knowing is rewarding, which is the most probable explanation of overtesting in settings where medico-legal risks for the clinicians are low. The ever increasing numbers of patients seeking emergency care to rule out serious conditions is a development driven by medical professionals and is fueled by the perceived increased certainty provided by biomarker testing.

The vocabulary of elite teams is changing. Understanding the roots of grit, resilience and poise under pressure requires a deep dive into the challenging, sometimes ugly world of our emotions, fear, anxiety and expectations. This is the good news: the science of human performance has evolved as well, and offers insight on how to train for a focused and enlightened team mindset. Emotional regulation, environmental manipulation, stress inoculation, mental preparation -- these are the concepts that define the new resuscitative collective unconscious. In this session, we will discuss how the science of human performance and psychology can inform the development of expert teams, from heart rate and tactical breathing to emotional valence and cortisol surges.

Is there a specific time during our shift when we are too fatigued to safety practice? That was the question that led to a research project comparing the clinical performance of providers during the first hour of a day shift and the final hour of a string of night shifts. These providers were pulled out of their real-time clinical duties and video-taped while performing simulated critical care cases. The hypothesis was that the day shift providers would out-perform the night shift, but the opposite proved true. Blinded reviewers assigned the day shift providers lower performance scores and noticed some surprising medical errors committed during these simulated cases. So are we “awake” when we come to work? Should some type of case-based warm up exercise be encouraged just prior to a shift? Also, upon reviewing the data, it was found that the majority of the providers studied had been off the day prior to their morning shift. Jan Paderewski, a famous pianist said, “If I miss one day of practice, I notice it. If I miss two days, the critics notice it. If I miss three days, the audience notices it.” Perhaps clinicians, similar to others who are elite in their field, truly need daily practice or some type of deliberate exercise prior to a shift to perform at the highest levels of care. How can we determine when we are not at our maximum level of mental sharpness during a shift? Can anything be done to improve our abilities in real time? This lecture will review the available literature surrounding mental fatigue and critical care based shift work and focus on techniques both before and during shifts to recognize and potentially mitigate any clinical sluggishness and improve patient care.

Ah, but you don't look like a professor! A recent statement from a (female) patient says it all, doesn't it? Since the first women were admitted to medical schools – quite a while ago in most countries, the participation of women in clinical and academic medicine has increased steadily. Overall, women represent the majority of health care workers and also medical students in most countries of the world today. SMACC audience is almost 50% female. However, only few women make it to the top, and with each step up the career ladder, the proportion of women decreases substantially, a phenomenon called the “glass ceiling” or the „leaky pipeline“. This is particularly true for some medical specialties such as critical care or trauma surgery, as opposed to specialties like endocrinology, pediatrics or gynecology. Although often subtle, gender discrimination against women continues to be a problem – for instance, it has been shown that a ficticious student named “John” would receive a higher salary and find a mentor easier than “Jennifer”. A manuscript written by “John” is judged more favourably than one that is authored by “Joan”, and female grant applicants with the same scientific productivity are given substantially lower scores than male applicants by reviewers (men and women). Sheryl Sandberg’s statements are as true in clinical and academic medicine as in other areas. This talk will definitely raise your awareness for the topic.

Motorcycle Trauma Simulation and discussion

Time tested rules and myths explored in a real life adventure, meant to honor and display the courage, commitment and sacrifice made by emergency medicine and critical care professionals around the globe. In a painfully honest reflection, Ashley crushes stigma and leaves us acutely aware of how our words and actions affect our colleagues and those that we love.

What paradigms should take precedence during a humanitarian emergency when the needs may overwhelm the resources, particularly in the early phase ? Is it possible to resolve the tension between quality and quantity in a resource constrained situation ? How has a changing geopolitical climate affected humanitarian medical action ? Is there a rôle for a critical care specialist at all, when medical resources are simple and finite ? What are the particular challenges of living and working together with a group of colleagues in an unfamiliar and stressful remote environment ? What can be learned for critical care practice in resource rich settings from our colleagues working in resource constrained emergency situations ? These, amongst other complex questions will be explored.

Darren Braude and Karim Brohi battle it out in the #SMACCDub Cage Match 'It is time to throw away the hard cervical collar'.

Martin -PRO- : The management of severe traumatic brain injury (TBI) has undergone extensive revision following evidence that longstanding and established practices are not as efficacious or innocuous as previously believed. Very few specific interventions have been shown to improve outcome in large randomized controlled trials and, with the possible exception of avoidance of hypotension and hypoxaemia, most are based on observational studies or analysis of physiology and pathophysiology. Further, the substantial temporal and regional pathophysiological heterogeneity after TBI means that some interventions may be ineffective, unnecessary or even harmful in certain patients at certain times. Improved understanding of pathophysiology and advances in neuromonitoring and imaging techniques have led to the introduction of more effective and individualised treatment strategies that have translated into improved outcomes for patients. In particular, the sole goal of identifying and treating intracranial hypertension has been superseded by a focus on the prevention of secondary brain insults using a systematic, stepwise approach to maintenance of adequate cerebral perfusion and oxygenation. As well as being used to guide treatment interventions, multimodal neuromonitoring also gives clinicians confidence to withhold potentially dangerous therapy in those with no evidence of brain ischemia/hypoxia or metabolic disturbance. The days of blind adherence to generic physiological targets in the management of severe TBI have been replaced by an individualised approach to optimisation of physiology which has translated into improved outcomes for patients.   Mark -CON- : The New England Journal of Medicine has published a number of articles recently that demonstrate no benefit from classic neurotrauma interventions (ICP monitoring, cooling, decompression). This is because factors such as ICP and CPP are associated with bad outcome by association rather than causation. This debate will demonstrate that critical care just complicates things and it is high time for the randomised trial between the very best Neurocritical care and NOB therapy (Naso-pharyngeal, Oxygen and a Blanket).

Resuscitation of the critically ill trauma patient involves a myriad of high-stakes, time-sensitive management decisions. The landscape is shifting rapidly: new evidence on hemostatic resuscitation and component therapy in hemorrhagic shock, peri-arrest point-of-care ultrasound, novel approaches to resuscitative thoracotomy and trauma RSI have at once clarified and muddied the waters. In this rapid-fire, case-based session, Petro and Hicks will debate some of the recent and potentially practice changing literature to assist with key inflection points in the care of the sickest -- and sometimes deadest -- trauma patients, and engage in some trauma dogmalysis in the process.

In a 2 min rant about medical tribalism, Dr. van der Velde questions which medical specialty, if any, owns prehospital physician response. What is more important: skillset or specialty? Is there a role for tiers of physician response? Is there a future in a stand-alone specialty?

Critical care practice in and out of hospital is a demanding field of medicine. It attracts a certain type of personality - the warrior: Those who want to do more, be more, work harder, evolve, innovate, be there for the big jobs, the complicated challenges. In a life that is becoming 24/7 and technology that can provide interventions and care in the this field of medicine that was only dreamt off a few years ago has become a reality, but also led to incredible high demands on our time, energy and dedication. We are dedicated to our cause, to our patients, to our services, but in the process, we are working longer hours, dealing with more complicated cases, higher demands and having more difficult advance care conversations. We work long shifts, live on caffeine but preach "first do no harm". We neglect quality sleep, good diets and in the process of trying to save others, might be killing ourselves. Fatigue is a killer and it is sneaking up on us like an enemy unseen. Whether you know if or not, you are in a battle for your own life.

Fight, Flight and (more commonly) Freeze are common reactions when faced with the critically ill child. In this talk i will discuss recognising these states and developing techniques to prevent and recover from them

Flavia Machado and Paul Young present the top 10 ICU trials of the recent past SMACC style. Their list of trials includes a number that challenge dogma and establish interesting new lines of scientific enquiry. In addition, they also include all the recent clinical trials that should change your practice. If you want to know what’s new in critical care then this is the talk for you.

The development of Helicopter EMS (HEMS, or as the Federal Aviation Administration recently coined it: “Helicopter Air Ambulance” or “HAA”) services in the United States has taken a decidedly different path in recent years compared to those in other countries. The wide spread use of single engine, VFR only aircraft, owned and operated by for profit companies is a uniquely American phenomena; at odds with most other countries who have developed HEMS programs around the world. This has resulted in significant direct competition between HEMS programs, as well as highly questionable billing practices that have started to garner attention. The origins of this development, including the use of the US “Airline Deregulation Act” to prevent states from regulating HEMS programs will be examined. More recent efforts in the US to tie reimbursement and program accreditation to the levels of care provided and minimum standards of equipment are still nascent at this time. Efforts by the US National Transportation Safety Board (NTSB) to mandate improved safety equipment standards have been met with resistance by the industry and the FAA. This has resulted in wide variability in US HEMS programs and the adoption of IFR standards, mandating NVG use, twin-engine aircraft and risk assessment strategies. There is also increasing scrutiny being placed on appropriate utilization criteria in the face of skyrocketing bills and questionable billing practices by for-profit companies.