I find clinicians are quick to consider sepsis and hypoperfusion/ischaemia as causes of a raised lactate, but slow to include other causes in their differential.
Although an elevated lactate has been shown to be associated with worse outcomes in numerous studies, not all causes of a raised lactate are sinister. It’s therefore important to diagnose the cause both to allow the right treatment and to avoid assuming an inappropriately poor prognosis.
This 12 minute video offers an approach to diagnosing the cause of elevated lactate based on an understanding of lactate physiology using a simple visual aid – a ‘lactate map’ and a memorable acronym.
I think all healthcare providers would do well to read this from time to time, and ask themselves where in their work they or their colleagues might be deviating from these principles, and what they could or should be doing to more closely adhere to them.
The Physician’s Pledge
AS A MEMBER OF THE MEDICAL PROFESSION:
I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
I WILL RESPECT the autonomy and dignity of my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient;
I WILL RESPECT the secrets that are confided in me, even after the patient has died;
I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice;
I WILL FOSTER the honour and noble traditions of the medical profession;
I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;
I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;
I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
I MAKE THESE PROMISES solemnly, freely, and upon my honour.
Have you deviated from any of the above?
Can you resolve not to in future?
What help do you need from your employer or your colleagues to allow you to adhere to them?
Can you think of colleagues who might benefit from being shown this pledge?
Please reflect on this line:
I will attend to my own health, well-being, and abilities in order to provide care of the highest standard
It is ABSOLUTELY RIGHT to prioritise these so you can be maximally effective for your patients.
If there are changes you need to make in this area, make them.
“What’s your leadership style Cliff? How do you like to run the emergency department?”
Our new fellow had asked a reasonable question. Although I’d never had to summarise it before, my reply came immediately: “I see my role as doing the most for the most by reducing the sum total of human suffering in the ED – both patients and staff”.
I hadn’t really reflected on this before. Obviously my clinical priority is resuscitation, but the reality is that resuscitation only contributes to a small proportion of ED workload. And when our resources and attention are prioritised to the resus room, the department fills with other patients in pain or distress, and their anxious relatives and parents(1).
Examples of the suffering, in patients, relatives, and staff, include:
Emergency departments really can be melting pots of human suffering, but there is so much we can do to reduce or relieve that suffering. We just need to expand our view of our role from ‘diagnose and treat illness’ to ‘care for patients and their families’.
I believe an emergency physician can do much to reduce the ‘area under the curve’ – from listening to the nurses, buying a round of coffee, making sure rest breaks happen; to relieving pain, thirst and cold; to trying to prevent illness and injury from claiming someone’s loved ones; to being understanding to an admitting specialty colleague; to taking the time to explain to parents and relatives what is going on, and that you are taking their presentation seriously.
How I believe we can influence human suffering in the ED.
This is a graphic to illustrate a concept, not a graph based on data.
I also believe this approach provides some protection from burnout. It is easy to be concerned with the difficult aspects of our job that are outside our control, which can result in stress and a sense of powerlessness. But there are so many things WITHIN our control that can make such a difference, that this is where our attention should focus. This is the ‘Circle of Influence’ described by Steven Covey in “The 7 Habits of Highly Effective People”, in which he argues that the first habit, Proactivity, is demonstrated by people who work on problems within their circle of influence, rather than wasting time on those things outside it. Not only will this provide us with more satisfaction and sustainability in our career, it should also make us happier people, since expressing kindness for other people is a key component in the recipe for human happiness (which I describe here).
Of course, the other staff can also make a massive difference. However as the emergency physician clinically in charge of the floor, I have a responsibility to lead by example, and can exert far greater influence than more junior staff. As summarised recently by Liz Crowe and colleagues(2):
“EM doctors as the leads of the ED often set the ‘tone’ for the interdisciplinary staff within the team. Each EM doctor can choose to actively contribute to building a safe and supportive culture of collegial
support, professional development and learning through high quality communication, humour and creating a sense of team within their departments.”
So let’s ALL set the tone. Support our teams, and show kindness to them and our patients. We can all help reduce the Area Under the Suffering Curve.
1. Body R, Kaide E, Kendal S, Foëx B. Not all suffering is pain: sources of patients’ suffering in the emergency department call for improvements in communication from practitioners. Emerg Med J. 2015 Jan;32(1):15–20.
This guest post from a fellow retrieval clinician contains a powerful message for us all. We have a responsibility to recognise the inevitability of clinician error, and to develop systems within our organisations to support those involved to avoid the ‘second victim’ phenomenon.
– 0:01: Error – Noun – A mistake
I was the picture perfect hire, I had tailored most of my career for our line of work: retrieval.
I was a senior FRU Paramedic with a background including the hottest terms: “clinical development”, “ultrasound”, “research”, “educator” and the useless alphabet soup that one inevitably acquires through enough time in healthcare. My CV was mint, printed on subtly thick paper to give a subliminal message of “excellence” – calculated moves for a calculated outcome.
I knew the protocols, policies, procedures before stepping through the door. With a fantastic orientation behind me, I was fucking awesome. I was in the stratosphere of awesome. Flightsuit, the smell of Jet A, podcasts blaring. I approached the one-year mark in retrieval feeling at home. Being granted complete clinical autonomy, I found my work deeply rewarding, stimulating. Nitric Oxide, ECMO, Ketamine, DSI/RSI, TXAblahblahblah. The buzz of Twitter was my daily work.
“Error” was a word, a noun. Error was a picture of crashed airplanes or derailed trains. Droning Powerpoints featured the Swiss cheese model and non-sequitur diagrams with abstract buzz-words. If you sucked, you crashed and burned. If you were good, you landed on the goddamn Hudson River.
+ 0:01: I am Error
Through an error in medication transitions, a young girl died under my care. Regardless of the slew of contributing factors, the latent errors – I am Proximate Cause. That is a title that is hard to shed. That is a title that follows you through day and night, wakefulness and sleep, at work, in the car, in the shower, in bed.
Having lost my desire to return to work, I drafted a curt letter of resignation and began the search for work elsewhere where I might be free of consequence. I was filled with dread waiting for my pager to go off, whispering a prayer for an easy tasking. I lacked the organizational or personal tools to process the slew of emotions I felt – incompetence, inadequacy and guilt. Just as easily as I had woven myself into who I was, I came undone.
+ 0:02: “Error-Free” – Adjective – Containing no mistakes
Despite our best attempts to adopt the lessons of aviation, aerospace and high-stakes systems into our craft, we in retrieval are primed for error throughout the work we do every day. We dive into the currents of diagnostic momentum, wading through the thoughts of others. The chaos swirling around us leads to erosion of situational awareness and the interruption of processes. The unforgiving physiology of the critically ill also force us to tread close to the edge. The margins are razor-thin, the consequences are great.
Just like we prepare for the risks involved with a complex machine such as the helicopter, we must train for the consequences of the complexities of medicine, such as error.
Our teams train for the very remote risk of over-water ditching through egress training yet little time is spent on a constant danger to our teams and our patients. The injection of simulated error through misdiagnoses, human factors and poorly labeled vials can not only prime the team for the capture of potential error but also the very real emotions that can result from mistakes – simulated or not. Much discussion has been had on resiliency training as of late, much of its focus on preparing teams for success in the midst of crisis. We must train for events such as an error like mine to prepare the individual clinician for the crisis that follows.
Yet the burden should not fall squarely on the individual clinician. As high performing organizations we have a duty to put in place transparent processes that can provide clinicians with support following a mistake as well as a clarity about “what comes next” following a mistake. As I consider my subsequent hardship following the death of this child, much of it took root in the lack of support from my organization and a lack of clarity about what would happen as a result of all this. More damaging than anything else is the solitude that comes with being unable to share one’s experience. A “second victim” left to their own devices to cope with their mistake is a victim of a system that has failed them.
We are equally primed for injury. One of your greatest strengths becomes your Achilles heel. We pursue our passions and find that resus and retrieval is the medicine that stimulates the cortex. This work inevitably becomes a fundamental part of who we are. The pursuit of excellence under the demanding conditions of our work is all-consuming, leading to this work become the very mesh of our being – “The Retrievalist” “The Resuscitationist.”
Following error, we experience an unraveling of who we are. The hard fall to the bottom is hard to recover from. I write this to let you know that it gets better and that you’re not alone. The resignation letter is deleted, the bottles stop emptying, the sleep comes more easily and you accept that in our craft, “error-free” is just a word, an adjective and that “error” is a noun and does not define you.
This is a guest post from Dr Per Bredmose, anaesthetist and retrieval medicine physician in Norway, also known as Viking One
I struggle to ventilate the patient in the resus room, airway pressures are high, the bag doesn’t empty properly. In my mind I plan ahead for the next step. Through my mind goes the thought – is this the one, the one that I cannot ventilate? Statistically it is not likely to be, but I am prepared to add two-person technique, airway adjuncts like nasopharyngeal or oropharyngeal, or supraglottic devices that I use frequently in theatre. I feel confident in the use of these methods, and (in the worst case) in cricothyroidotomy. I have practiced that numerous times on our live-tissue course on anaesthetised pigs. However – before I start any of these actions.. I routinely, almost as a reflex from theatre turn the patient’s head 45 degrees to the left, and then the bag suddenly empties easily – and I can ventilate the patient.
Some people think that time with TIVA in theatre has little value for emergency medicine and advanced prehospital care. I strongly disagree. This is some of the most relevant and valuable time I have for keeping and optimising my practical skills. Bag-valve-mask (BVM) ventilation is an essential core skill for any prehospital provider. In theatre this manoeuvre is well known and frequently practiced. It is my impression that this head rotation is less used, and even maybe less well known outside theatre, and especially in the prehospital field. Therefore this is a reminder of an old technique.
When to do it: When encountering difficulties in conventional BVM ventilation, either when you cannot ventilate or when it’s just difficult to ventilate.
How to do it: Keep a firm one hand grip and gently rotate the head 45 degrees towards the side of the hand with the jaw grip. At the same time, one can try to optimise the one-hand-jaw thrust that goes along with BVM ventilation. Occasionally one needs to extend (dorsiflex) the neck a bit further to fully open the airway. The technique can also be used as a two-person technique, although this is rarely needed.
Opposition: Frequently I hear that I cannot transfer practice from theatre to the prehospital field. Well, this seems to work well in theatre, in ICU and in the field – airways are airways!!
Recently an article in European Journal of Anaesthesiology by Itagaki et al(1) with a cross over design showed an increase in tidal volume when the patients were ventilated in a head rotated position compared to neutral position with the same airway pressure. Their conclusion was as follows: Head rotation of 45° in anaesthetised apnoeic adults significantly increases the efficiency of mask ventilation compared with the neutral head position. Head rotation is an effective alternative to improve mask ventilation if airway obstruction is encountered. Therefore – this is a useful tool that one always should have in the “practical toolbox”. It is not always the solution, but occasionally it saves you (and the patient) a lot of trouble.
Thoughts from Dr Cliff Reid
I haven’t used this approach and wasn’t aware of previous research showing an increase in the retroglossal (but not retropalatine) spaces in (awake) patients with head rotation(2).
The mechanism is thought to be gravitational. It is also possible that neck rotation increases upper airway wall tension that reduces collapsibility of the lumen.
In this elegantly designed new study, a two handed BMV technique was used, similar to that advocated in my prehospital & emergency medicine environments. The rotation was always to the right, although the authors comment that they would expect the same results on the left. The increased tidal volume effect with head rotation occurred mostly in younger patients and patients with Mallampati classification I. Such patients are unlikely to be difficult to mask-ventilate, limiting the applicability of these findings to patients who are difficult to ventilate. However having one more option to employ to improve BMV efficacy (after two person technique, optimising ear-to-sternal-notch positioning, and inserting oro- and/or nasopharyngeal airways) may be useful, and the experience and perspective of my anaesthetic colleague Viking One is definitely food for thought. Obviously one should avoid this if there is potential neck injury so I won’t be trying it my trauma patients.
They say emergency medicine and critical care are no picnic, but I’ve been trying to change that. There’s something about sitting down on a blanket and sharing protected time for conversation that makes for good team building and effective communication. If you have snacks, it’s even better.
In the emergency department or intensive care unit one sometimes has to be opportunistic regarding finding time for teaching, debriefing a resuscitation case, or even eating. We end up doing these things (if at all) on the fly, in a rushed manner, and often standing up. Do we really have to? All you need for a picnic is a blanket, a floor, and some people. Hospitals have these. If you don’t want to be seen, pop outside or use a bed space with a curtain round it.
Here’s an example of an impromptu picnic. It was late in the evening, early 2013. After two busy resus cases, my senior registrar and I debrief picnic-style, with potato chips from a vending machine and a nice pot of tea. We’re still in the ED and available to our team, but anyone can clearly see we’re in the ‘picnic zone’ and so we’re left alone for ten minutes to gather our thoughts and identify any learning points. The ED is usually a factory of interruption, but no-one wants to interrupt a picnic.
Here’s resident teaching. We don’t have time to leave the ED, but there’s always time for a picnic, during which we cover a surprising number of critical care topics. People won’t fall asleep while picnicking.
And here’s a picnic with the intensive care trainees outside the unit. This is actually lunch, but why shouldn’t lunch be a picnic once in a while?
We’re encouraged to practice mindfulness and take mental time out as a way to prevent or manage stress in the critical care environment. I think this is enhanced with an accompanying brief physical time out too. One person sitting on a blanket on the floor might be a weirdo. Get two or more people, and you have a picnic. Everyone loves a picnic.
Syncope is a common ED presentation. An ECG is a critical investigation in syncope to identify the cause, including rare conditions associated with risk of sudden cardiac death.
So we should be really grateful when we are invited to interpret an ECG while we’re in the middle of six other tasks.
The problem with syncope is that some of the important life-threatening causes have fairly obscure ECG features that might be hard to remember. Some of these disorders and their ECG features are not entirely familiar to the clinicians who first screen the ECG.
When you’re busy and cognitively stretched you can save time and reduce the risk of missing important findings by having a structured, memorable checklist. I use the acronym WOBBLER, because I don’t want these people to wobble and kiss the dirt again.
The nice thing about WOBBLER is that it uses the sequence that you follow when you look at an ECG, ie from left to right, or from P wave to T wave.
The key is that this is for ECGs without obvious ischaemia or dysrhythmia. If you see something like this (STEMI):
or this (VT):
you don’t need WOBBLER, you need to be treating that patient. So here goes:
W is Wolff-Parkinson-White syndrome – look for a short PR interval or delta wave:
O is obstructed AV pathway – look for 2nd or 3rd degree block:
or axis deviation:
…which is the first step in looking for B bifascicular block, or the combination of axis deviation and right bundle branch block:
the second B is Brugada, looking for characteristic morphology of the ST segment, so called coved ST elevation:
Now syncope, especially exertional syncope, can be caused by left ventricular outflow tract obstruction. Two conditions not to be missed associated with this (and exertional syncope) are hypertrophic cardiomyopathy and aortic stenosis. These both characteristically cause L– left ventricular hypertrophy:
So WOBBLER may help you find the important and rare abnormalities not to be missed in the syncope patient, going from left to right from P wave through to T wave, in the patient that does not have obvious dysrhythmia or ischaemia. Try it and let me know if it helps!
‘Do what you said you were going to do – the high performance culture of excellence under pressure’ is the title of a talk by General John Jansen, organised by my friend A/Prof Brian Burns on behalf of Sydney University.
It will be held on 20 December at 18.00 hrs at the Royal Prince Alfred Hospital in Sydney.
Free Registration available here, and refreshments are provided.
Don’t miss your chance to register for the best emergency/prehospital/critical care conference out there
Tickets will be released on the following dates:
Here are a few ‘rules of the game’ from the course organisers:
There will be 3 separate ticket releases: the major release will be as above on Wednesday, 26th October, a smaller allocation will be released on Wednesday, 7th December and a final limited release on Wednesday, 1st February
Your best chance will be with the first release, but if you really need to wait until you have leave confirmed then you can chance your hand on the February release
All prior delegates will receive an email reminder the week before tickets go on sale, but there is no other preference (first in best dressed!)
Owing to the limited number of spots there will be no DAY ONLY registrations issue
Workshop registration also opens on Wednesday, 26th October and like last year will be on a first come first served basis
If you miss out on a ticket there will be a waiting list
If you miss your preferred workshop there will also be a waiting list
You can check out the program here and registration fees here
Don’t worry if you can’t make it – all smacc talks are published free on line and you’ll find talks from the last four conferences at the smacc site
You ultrasound the chest of your shocked patient in resus with fluid refractory hypotension. You see fluid around the heart. The right ventricle keeps bowing inwards, which you recall being described as ‘a little invisible man jumping up and down using the RV as a trampoline’, and you know this is in fact a sign of right ventricular diastolic collapse.
The collapse of the right side of the heart during diastole is the mechanism for shock and cardiac arrest due to tamponade, because the high pericardial pressures prevent the right heart from filling in diastole. This patient therefore has ‘tamponade physiology’ on ultrasound. A quick scan of the IVC shows it is dilated and does not collapse with respiration. This confirms a high central venous pressure (as do the patient’s distended neck veins), also consistent with tamponade physiology.
A formal echo done in resus confirms your suspicion of a dliated aortic root and visible dissection flap, so the diagnosis is now clear. This is type A aortic dissection with tamponade. The patient remains hypotensive and mottled with increasing drowsiness. Cardiothoracic surgery is based at another hospital site 30 minutes away by ambulance.
As the critical care clinician responsible for, or assisting with this patient’s care (emergency physician, intensivist, anaesthetist, rural GP, physician’s assistant, etc.), how do we get this patient to definitive care and mitigate the risk of deterioration en route? Let’s discuss the options using real life case examples, and consider the physiology, the evidence, and the dogma.
Here are four key questions to consider:
1. To drain or not to drain the pericardium?
2. To intubate or not to intubate?
3. If they arrest – CPR or no CPR?
4. How to transfer – physician escort or just send in an ambulance on lights and sirens?
The patient is obtunded with profound shock and too unstable for transfer. The resus team undertakes pericardiocentesis and aspirates 30 ml of blood. The patient becomes conscious and cooperative and the systolic blood pressure (SBP) is 95 mmHg. The patient is transferred by paramedic ambulance to the cardothoracic centre where he is successfully operated on, resulting in a full recovery.
As the patient is unconscious and requires interhospital transfer, the decision is made to intubate him for airway protection. He undergoes rapid sequence induction with ketamine, fentanyl, and rocuronium in the resus room. After capnographic confirmation of tracheal intubation he is manually ventilated via a self-inflating bag. The ED nurse reports a loss of palpable pulse and CPR is started. A team member suggests pericardiocentesis but a senior critical care physician says there is no point because ‘it won’t fix the underlying problem of aortic dissection’ and ’the blood will be clotted anyway’. After a brief attempt at standard ACLS, resuscitation efforts are discontinued and the patient is declared dead.
The patient is hypotensive with a SBP of 90mmHg and drowsy but cooperative. The receiving centre has accepted the referral and an ambulance has been requested. The critical care physician responsible for patient transfers is requested to accompany the patient but declines, on the basis that ‘these cases are just like abdominal aortic aneurysms – they just need to get there asap. If they deteriorate en route we’re not going to do anything.’
The patient is transferred but 15 minutes into the journey he becomes unresponsive and loses his cardiac output. The transporting paramedics provide chest compressions and adrenaline/epinephrine but are unable to resuscitate him.
These cases illustrate some of the pitfalls and fallacies associated with tamponade due to type A dissection.
Pericardiocentesis can definitely be life-saving, restoring vital organ perfusion and buying time to get the patient to definitive surgery. Numerous case reports and case series provide evidence of its utility, even in patients in PEA cardiac arrest(1). The authors of the two largest cases series both used 8F pigtail drainage catheters(1,2).
One key component of procedural success was controlled pericardial drainage, removing small volumes and reassessing the blood pressure, aiming for a SBP of 90 mmHg. The danger is overshooting, resulting in hypertension and extending the underlying aortic dissection which can be fatal (3).
“In the setting of aortic dissection with haemopericardium and suspicion of cardiac tamponade, emergency transthoracic echocardiography or a CT scan should be performed to confirm the diagnosis. In such a scenario, controlled pericardial drainage of very small amounts of the haemopericardium can be attempted to temporarily stabilize the patient in order to maintain blood pressure at 90 mmHg. (Class IIa, Level C)”
Deterioration of tamponade patients following intubation is well described in the literature and the risk is well appreciated by cardiothoracic anaesthetists(5). Once positive pressure ventilation is started, positive pleural pressure is transmitted to the pericardium, where pressures can exceed right ventricular diastolic pressure and prevent cardiac filling. The result is a fall in and possible loss of cardiac output. This is further exacerbated by the addition of PEEP(6). One suggested approach if the patient must be intubated for airway protection but is not yet in the operating room with a surgeon ready to cut, is to consider intubation under local anaesthesia and allow the patient to breathe spontaneously (maintaining negative pleural pressure) through the tube until the surgeon is ready to open the chest(5). Alternatively preload with fluid, use cautious doses of induction agent, and ventilate with low tidal volumes and zero PEEP. However the patient can still crash, so remember that these effects of ventilation on cardiac output in tamponade can be mitigated by the removal of a relatively small volume of pericardial fluid(6).
In cardiac arrest, external chest compressions are unlikely to be of benefit. In a study on baboons subjected to cardiac tamponade, closed chest massage resulted in an increase in intrapericardial pressure. There was an increase in systolic pressure, but a marked decrease in diastolic pressure, with an overall decrease in mean arterial pressure(7).
This would lead to impaired coronary perfusion and would be very unlikely to result in return of spontaneous circulation (ROSC). In the clinical situation described above, it is only relief of tamponade that is going to provide an arrested patient with a chance of recovery.
For patients with cardiac tamponade requiring interhospital (or intrahospital) transfer, it would seem vital therefore that the patient is accompanied by a clinician willing and capable to perform pericardiocentesis in the event of severe deterioriation or arrest en route. This simple life-saving intervention to deliver the patient alive to the operating room should be made available should the need arise.
Patients presenting in shock from cardiac tamponade often have treatable underlying causes and represent a situation where the planning and actions of the resuscitationist can be truly life-saving.
Pericardiocentesis is recommended in profound shock to buy time for definitive intervention. Controlled pericardiocentesis should be performed paying strict attention to SBP to avoid ‘overshooting’ to a hypertensive state in type A aortic dissection. In cardiac arrest, chest compressions are likely to be ineffective and pericardiocentesis is mandatory for ROSC.
The institution of positive pressure ventilation often results in worsened shock or cardiac arrest, and this is exacerbated by PEEP. Where possible, avoid intubation until the patient is in the operating room, or use low tidal volumes and no PEEP. Even then pericardiocentesis may be necessary to maintain or restore cardiac output.
Patients requiring transport who have tamponade should be accompanied by a clinician able to perform pericardiocentesis in the event of en route deterioration.