Tag Archives: Inspiration


How to Be a Hero

Kal-fly-iconI’m not a hero and don’t claim to be, but when I was given this talk to do for the SMACC 2013 conference I researched the topic and realised I’d worked with several of them.

The talk was the toughest I’ve ever given, because I cried while giving it, and knew that it wouldn’t just be the large audience in front of me who would know I was a wuss, but that it was being recorded for many others to find out too!

A full transcript of the talk, the slide set, and links to references from the talk can be found here.

Beherrsche die Reanimation

TLsm-icon The whole purpose behind my career and this blog is to save life. Like most emergency physicians I don’t see a huge number of resuscitation patients myself in a given week, so my best hope in making a difference is to develop my teaching skills so that I can motivate and inspire others to improve their ability to manage resuscitation.

The highlight of my week therefore has been the receipt of some email feedback from a colleague in Germany. An intensivist, internist, and prehospital doctor (I like him already) who tells me he found my ‘Own the Resus‘ talk helpful:


Dear Dr. Reid,

Few days ago, too tired too sleep after a long shift on my ICU (18 beds internal medicine ICU, I am specialist in internal medicine specialized in intensive care and prehospital emergency medicine in a major German city) I watched your talk via emcrit podcast. I was immediately caught, I soaked in every word, I was fascinated, watched it twice in the middle of the night and next afternoon I listened to it in my car driving to work.

At this very day I did some overdue crap beyond the end of my shift when I heard the ominous shuffling of feet and rolling of the emergency cart from the other end of the ward… “I think we need your help….”

There it was, difficult airway situation. Patient crashing.

Then what followed was a kind of “out of body experience”. I did what was necessary, made things happen like calling anesthesia difficult airway code, calling the surgeons, organizing fiber optics and meanwhile trying to secure that airway myself until i could dispatch anesthesia to the head and surgeons to the neck. Within few minutes there were 6 doctors and 5 nurses shuffling on 9 square meters…

I found myself 1 meter behind the foot end of the pts bed and with your talk in my head I found me consciously controlling the crowd. There was suddenly the messages of your talk and there was me. I don’t know how to put it into words, I wouldn’t have done something else in medical terms but thanks to your talk I had the vocabulary, the tools to reflect myself as the leader to be in charge of the situation somehow with more distance, and after a successful resus the 10 people involved in this code went off with a good feeling that everybody contributed in what they could and all for the pts benefit.

Your talk was a kind of transition to the next level for me: from the colleague who asks how to get out of trouble in many situations because he was often deeply in trouble, to the one who leads out of trouble.

With your talk many things suddenly became clear and I am looking forward to be able to work harder on this role of leading.

Thank you very much.

D

Save a life by watching telly?

BB2.055If you’re in the United Kingdom on Thursday 21st March please consider watching BBC’s Horizon program at 9pm on BBC2.

I’m in Australia so I’ll miss it, but I’m moved by the whole background to this endeavour and really want you to help me spread the word.

Many of you will be familiar with the tragic case of Mrs Elaine Bromiley, who died from hypoxic brain injury after clinicians lost control of her airway during an anaesthetic for elective surgery. Her husband Martin has heroically campaigned for a greater awareness of the need to understand human factors in healthcare so such disasters can be prevented in the future.

Mr Bromiley describes the program, which is hosted by intensivist and space medicine expert Dr Kevin Fong:


Kevin and the Horizon team have produced something inspirational yet scientific, and – just as importantly – it’s by a clinician, for clinicians. It’s written in a way that will appeal to both those in healthcare and the public. It uses a tragic death to highlight human factors that all of us are prone to, and looks at how we can learn from others both in and outside healthcare to make a real difference in the future.

The lessons of this programme are for everyone in healthcare.

It would be wonderful if you could pass on details of the programme to anyone you know who works in healthcare. My goal is that by the end of this week, every one of the 1 million or so people who work in healthcare in the UK will be able to watch it (whether on Thursday or on iPlayer).


From the Health Foundation blog

Please help us reach this 1000 000 viewer target by watching on Thursday or later on iPlayer. Tweet about it or forward this message to as many healthcare providers you know. Help Martin help the rest of us avoid the kind of tragedy that he and his children have so bravely endured.

For more information on Mrs Bromiley’s case, watch ‘Just a Routine Operation’:

Cliff

Dogmalysis

dogmaticI made up a word a while ago: “dogmalysis”. It refers to the dissolution of authoritative tenets held as established opinion without adequate grounds.

DOGMA: something held as an established opinion; a point of view or tenet put forth as authoritative without adequate grounds

LYSIS: a process of disintegration or dissolution (as of cells)

It’s my favourite thing in medicine. I don’t know why – perhaps because of my admiration since childhood for irreverent scientists who questioned authority, like Feynman and Sagan. Or perhaps it is because I think at times we physicians need to experience the humility of having our ignorance exposed. This is necessary to keep medicine science-based.

My undergraduate and much of my postgraduate training consisted of being taught medical certainties that I was required to regurgitate under exam conditions. The reality of clinical practice then revealed the awesome irreducible complexity of biology in our patients who ‘don’t read the textbooks’. As we learn in emergency medicine to navigate the perilous Bayesian jungle to a ‘very unlikely’ or ‘very likely’ life-threatening diagnosis, and when we have to weigh up the benefit:harm equation of an intervention that could either kill or cure, we begin to appreciate that certainty without evidence – dogma, or faith – can be lethal.

The problem is, however, that our human brains seem to thrive on it. We have evolved a whole senate of cognitive biases, which enable us to function well in everyday social situations, but which prevent us from conducting an impartial analysis of objective clinical data. An enlightening example of the degree to which our interpretation of the same information can vary is illustrated by a handful of trials on fibrinolytic therapy for stroke, producing a spectrum of reactions from aggressive promotion to skeptical opposition.

Being human, I have no doubt that I am occasionally dogmatic about topics to which I erroneously believe I have applied skepticism. I appreciate the courage of trainees who have the guts to challenge my assertions and who demand the evidence to justify them. Keep doing it. Keep asking. Keep challenging.

Keep lysing the dogma.

No-one said it better than Carl:

Dogmalytic posts

 

 

An inspiring demonstration of spirit

I can’t imagine what it was like to go through what Fred Ettish went through. I remember being stunned at the overwhelming failure of his Karate in one of the early UFC fights in the mid-nineties, and gave no thought to the man inside the gi. I may even have been one of the viewers who felt some Schadenfreude at the apparent humiliation of traditional karate by Western boxing.

Now I see this man in a different light. Someone who has lost almost almost everything, yet refused to give in. I have no idea how I would react to such adversity, and never want to be tested in such a way. For an inspiring demonstration of spirit, watch this video that brought a tear to my eye. At around two minutes in you will see this is not about martial arts. This is about courage and strength and there is something to learn here for all of us.

Confidential stuff – in hospital cardiac arrests

A new report describes room for improvement in the care of cardiac arrest patients in hospital1.

The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) aimed to describe variability and identify remediable factors in the process of care of adult patients who receive resuscitation in hospital, including factors which may affect the decision to initiate the resuscitation attempt, the outcome and the quality of care following the resuscitation attempt, and antecedents in the preceding 48 hours that may have offered opportunities for intervention to prevent cardiac arrest.

Data were captured over a 14 day study period in late 2010 from UK hospitals, and were reviewed by an expert panel.

The summary is available here. I have picked out some findings of interest:

  • An adequate history was not recorded in 70/489 cases (14%) and clinical examination was incomplete at first contact in 117/479 cases (24%).
  • Appreciation of the severity of the situation was lacking in 74/416 (18%).
  • Timely escalation to more senior doctors was lacking in 61/347 (18%).
  • Decisions about CPR status were documented in the admission notes in 44/435 cases (10%). This is despite the high incidence of chronic disease and almost one in four cases being expected to be rapidly fatal on admission.
  • Where time to first consultant review could be identified it was more than 12 hours in 95/198 cases (48%).
  • Appreciation of urgency, supervision of junior doctors and the seeking of advice from senior doctors were rated ‘poor’ by Advisors.
  • Physiological instability was noted in 322/444 (73%) of patients who subsequently had a cardiac arrest.
  • Advisors considered that warning signs for cardiac arrest were present in 344/462 (75%) of cases. These warning signs were recognised poorly, acted on infrequently, and escalated to more senior doctors infrequently.
  • There was no evidence of escalation to more senior staff in patients who had multiple reviews.
  • Advisors considered that the cardiac arrest was predictable in 289/454 (64%) and potentially avoidable in 156/413 (38%) of cases.
  • The Advisors reported problems during the resuscitation attempt in 91/526 cases (17%). Of these, 36/91 were associated with airway management.
  • Survival to discharge after in-hospital cardiac arrest was 14.6% (85/581).
  • Only 9/165 (5.5%) patients who had an arrest in asystole survived to hospital discharge.
  • Survival to discharge after a cardiac arrest at night was much lower than after a cardiac arrest during the day time (13/176; 7.4% v 44/218; 20.1%).

 

In the opinion of the treating clinicians, earlier treatment of the problem and better monitoring may have improved outcome:

Compare these findings with a smaller scale confidential enquiry into the care of patients who ended up in intensive care units, published exactly 14 years ago by McQuillan et al2:

“The main causes of suboptimal care were failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice.”

One of the co-authors of the McQuillan study, Professor Gary Smith , has spent years improving training in and awareness of the importance of recognition of critical illness, and pioneered the “ALERT” Course TM: Acute Life-threatening Emergencies, Recognition, and Treatment. Professor Smith provides commentary on the NCEPOD report and the slides are available here, including a reminder of the ‘Chain of Prevention’3.

It’s a shame these issues remain a problem but it is heartening to see NCEPOD tackle this important topic and provide recommendations that UK hospitals will have to act upon. It is further credit to the vision of Pete McQuillan, Gary Smith and their colleague Bruce Taylor (another co-author of the 1998 confidential inquiry). These guys opened my eyes to the world of critical care and trained me for 18 months on their ICU, which remains a beacon site for critical care expertise and training. Without their inspiration, I may not have ended up in emergency medicine-critical care and I doubt very much that Resus.ME would exist.

1. Cardiac Arrest Procedures: Time to Intervene? (2012)
National Confidential Enquiry into Patient Outcome and Death (NCEPOD)

2. Confidential inquiry into quality of care before admission to intensive care
BMJ 1998 Jun 20;316(7148):1853-8 Free Full Text


OBJECTIVE: To examine the prevalence, nature, causes, and consequences of suboptimal care before admission to intensive care units, and to suggest possible solutions.

DESIGN: Prospective confidential inquiry on the basis of structured interviews and questionnaires.

SETTING: A large district general hospital and a teaching hospital.

SUBJECTS: A cohort of 100 consecutive adult emergency admissions, 50 in each centre.

MAIN OUTCOME MEASURES: Opinions of two external assessors on quality of care especially recognition, investigation, monitoring, and management of abnormalities of airway, breathing, and circulation, and oxygen therapy and monitoring.

RESULTS: Assessors agreed that 20 patients were well managed (group 1) and 54 patients received suboptimal care (group 2). Assessors disagreed on quality of management of 26 patients (group 3). The casemix and severity of illness, defined by the acute physiology and chronic health evaluation (APACHE II) score, were similar between centres and the three groups. In groups 1, 2, and 3 intensive care mortalities were 5 (25%), 26 (48%), and 6 (23%) respectively (P=0.04) (group 1 versus group 2, P=0.07). Hospital mortalities were 7 (35%), 30 (56%), and 8 (31%) (P=0.07) and standardised hospital mortality ratios (95% confidence intervals) were 1.23 (0.49 to 2.54), 1.4 (0.94 to 2.0), and 1.26 (0.54 to 2.48) respectively. Admission to intensive care was considered late in 37 (69%) patients in group 2. Overall, a minimum of 4.5% and a maximum of 41% of admissions were considered potentially avoidable. Suboptimal care contributed to morbidity or mortality in most instances. The main causes of suboptimal care were failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice.

CONCLUSIONS: The management of airway, breathing, and circulation, and oxygen therapy and monitoring in severely ill patients before admissionto intensive care units may frequently be suboptimal. Major consequences may include increased morbidity and mortality and requirement forintensive care. Possible solutions include improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care.

3. In-hospital cardiac arrest: is it time for an in-hospital ‘chain of prevention’?
Resuscitation. 2010 Sep;81(9):1209-11


The ‘chain of survival’ has been a useful tool for improving the understanding of, and the quality of the response to, cardiac arrest for many years. In the 2005 European Resuscitation Council Guidelines the importance of recognising critical illness and preventing cardiac arrest was highlighted by their inclusion as the first link in a new four-ring ‘chain of survival’. However, recognising critical illness and preventing cardiac arrest are complex tasks, each requiring the presence of several essential steps to ensure clinical success. This article proposes the adoption of an additional chain for in-hospital settings–a ‘chain of prevention’–to assist hospitals in structuring their care processes to prevent and detect patient deterioration and cardiac arrest. The five rings of the chain represent ‘staff education’, ‘monitoring’, ‘recognition’, the ‘call for help’ and the ‘response’. It is believed that a ‘chain of prevention’ has the potential to be understood well by hospital clinical staff of all grades, disciplines and specialties, patients, and their families and friends. The chain provides a structure for research to identify the importance of each of the various components of rapid response systems.

Not a pin cushion

This is the daughter of my friend. Avery is only seven months old and has survived a critical illness and is thankfully now fully recovered. Her Dad has nothing but praise for the medical and nursing staff who cared for her. But one thing could have been better. Avery endured multiple attempts at vascular access without ultrasound guidance.

If you were her parent, and you were an emergency physician with galaxy-class expertise in emergency ultrasound, how would you react? Complaints? Incident forms? Outrage?

How about education? For free. Accompanied by lavish praise for the experts who treated Avery and made her better.

Avery’s Dad is ultrasound podcaster and gentleman Dr Matt Dawson. He is offering FREE ultrasound training to anyone who wants to improve their vascular access skills.

Are there nurses, physicians, or technicians in your ED or ICU that could improve their care with this training? Please consider sending them for this training. To register for the course, and to read Avery’s full story, go to notapincushion.com.

And if you’re already comfortable with ultrasound-guided vascular access, then visit the site anyway, as there is some education here for all of us: how to turn a gut-wrenchingly distressing experience into something positive that will benefit countless others. I am thoroughly inspired.

Best wishes to an amazing family.

Cliff

Mathematical Art of M.C. Escher

I am stunned by the beauty and brilliance of this video by Spanish filmmaker Cristóbal VilaInspirations: A Short Film Celebrating the Mathematical Art of M.C. Escher.

M.C. Escher (1898-1972) was the Dutch artist who explored a wide range of mathematical ideas with his woodcuts, lithographs, and mezzotints.

The cool bloggers at openculture.com write: Although Escher had no formal training in mathematics beyond secondary school, many mathematicians counted themselves as admirers of his work.

 

INSPIRATIONS from Cristóbal Vila on Vimeo.

 

 

 

If you want to well up further with rapturous contemplation of the beauty of mathematics in nature, check out his other video, Nature by Numbers

Nature by Numbers from Cristóbal Vila on Vimeo.

Training in prehospital and retrieval medicine

I’ve been too busy to blog literature updates for a couple of weeks since I and my colleagues have been flat out running a two week training course in prehospital and retrieval medicine.
Our Helicopter Emergency Medical Service physicians and paramedics care for a wide range of adult and paediatric trauma and critical care patients in some challenging environments. We therefore need to provide a fairly comprehensive induction course for new recruits.

The new guys did us proud. They just need to stay this awesome.