SMACC – Innovate, Explore, Connect, Belong, Inspire

 

2 weeks post SMACC and I have finally got around to sharing some thoughts. The first is to say that it is difficult to outline what I learnt during my 4 days in Dublin. To summarise, it was more about ‘how’ I practice medicine, than ‘what’ I do. But, here are some of my highlights.

The first session of day 1 was the John Hinds plenary. John Hinds was a prehospital doctor and anaesthetist who died shortly after SMACC last year in a motorbike crash. His lecture last year was one of my favourites – well worth a listen/watch.

HINDS: Crack the Chest. Get Crucified.

His partner, Janet, and colleague spoke wonderfully about the funny, committed and irreverent man they knew. One of the key messages from his talk last year was to ensure your intentions are always honourable, and they encouraged us to use the hashtag #whatwouldjohndo.

Feedback & developing performance

Victoria Brazil – so you think you are a resuscitationist?

Has there ever been a time when you were deluded about your performance? The Dunning-Kruger curve illustrates the relationship between experience and confidence and how we may think we are better than we are.

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This graph was taken from Sandra Viggars talk on Day 3

The counterbalance to this position is imposter syndrome: we don’t think we deserve to be in the position we are in.

So how do we close the gap? Victoria argued that it was through feedback, and described an incident from her early career when she had completely misread her performance at a prehospital incident and then demonstrated how to give good feedback.

She said the road to knowing how good we are (self-insight) lies with other people. And recommended the following top tips for giving and getting feedback:

  • be honest
  • do it often (get into the habit)
  • we need to actively seek feedback
  • Be a mirror, this is what I saw, this is what I thought, lets have a conversation….

She acknowledged that this can be quite hard as you become more senior (rather than trainees).

Kettlebells for the brain (Meditation)

Scott Weingart

Scott delivered a podcast live on stage about the role of meditation as a work out for your brain. It was really challenging and there were some interesting concepts which are best understood by listening to it yourself! It’s not out in full yet but here is the sneak preview:

EMCrit Wee – Vipassana Meditation

The case for HEMS

Gareth Davies

Started with admitting his bias! And acknowledged that evidence is scant. He emphasised that when we judge helicopters they should be delivering ‘full bore’ medicine – maximum commitment, maximum effort, uncompromising, full armourmentarium.

And encouraged the audience to ensure:

  • Do your best
  • Attention to the basics
  • Translation from other areas (require support of peers, delivering hospital care out of hospital eg REBOA)
  • Demonstrate a commitment to clinical excellence
  • The notes you write are beyond reproach
  • Governance package in ED/PHC that is second to none
  • Present at grand round, speak at cardiothoracic audit day (battle for credibility lies outside of the ED, outside of the EM journal)
  • Not just trauma

And to provide students with examples of exemplary care, inspirational clinicians and the best education experience of their training.

Elderly care

There were some themes from the Emergency Medicine stream which are relevant to PHEM – most notably, in my opinion, the growing population of older people requiring our care.

Suzanne Mason’s presentation was entitled ‘Acute Care of the Elderly’ and she advocated learning to love frailty!

Some idea of the numbers: patients in the over 65 age group represent approximately 25% of attendances to EDs; 90% of them are necessary and 60% are admitted. She shared the following video which is incredibly thought provoking:

http://www.hsj.co.uk/hsj-knowledge/commissions-and-inquiries/frail-older-people/video-what-went-wrong-with-mrs-andrews-care/5076842.fullarticle

We all have a role to play, and there is good evidence to support prehospital interventions. For example, paramedics trained to assess patients following falls – 25% reduction in ED attendances, and 6% reduction in subsequent admissions.

Adrenaline in cardiac arrest

Jim Manning reviewed progress in resuscitation and compared ‘artificial perfusion’ with the effective interventions of ‘artificial ventilation’ and defibrillation. He argued that artificial perfusion is where we are least successful and reviewed the evidence for adrenaline.

Adrenaline is given to try and improve coronary perfusion pressure, and research shows that coronary perfusion pressure > 15 mmHg is associated with ROSC. There is also a demonstrable improved ROSC rate and admission with adrenaline, but no difference in hospital discharge or neurological outcome vs placebo. Where does this leave us? Well, with quite a few questions!

  • Why doesn’t it work? Perhaps because we are giving it IV and in those with a poor coronary perfusion pressure it is sitting in the vein.
  • Should we give up?
  • How about intra-aortic/intra-arterial adrenaline?

Watch this space!

The Boston marathon bombing

Christina Hernon (@EMedTox) talked about her experience as an ‘Impromptu Immediate Responder’. She was already at the scene when the bombs went off but not in a formal immediate care role. It was an extremely powerful presentation and I would recommend listening to/watching it when it is released later in the year at http://intensivecarenetwork.com/smaccmedia/, but some of the things she talked about were:

  • Is the scene safe? – yes, no, I don’t know.
  • Shit can happen anywhere, you might be there.
  • How to be safe in an unsafe scene
  • Try not to move patients
  • Haemorrhage control and maybe airway opening manoeuvres are all you can do + set up some form of triage areas
  • Be very wary of your stress response

For those of us responding after an incident such as this, be kind to these Impromptu Immediate Responders.

From a bigger picture point of view, should we have some form of community preparedness? This might then have an impact then on recovery of those exposed.

Coaching for medicine

Tom Evens (@DocTomEvens) is a coach for British rowing and he talked about the similarities between medicine and sport, and what we can learn from the principles of coaching sport.

 Find your talented person and believe in them.

 As a senior clinician you are able to see what a trainee could become at the beginning of their career, when they are not. What is their goal? What is the standard required to reach that goal? Be humble in the face of that standard. Success comes from an aggregation of good choices – commit to a standard.

Marginal gains – questioning assumptions.

The reality of progress: increments, inches, persistence, progression. But there is a risk of concentrating on the small stuff at the expense of missing the big stuff – must focus on the basics.

Self compassion

Help people thrive in their training programme, not just survive. Athletes have to engage in their training. The danger of being a perfection driven person is if you don’t recognize your humanity. A negative response to a failure can impede your performance for days.

The Greatest Presentation in the World

Ross Fisher

As well as delivering a fabulous presentation entitled ‘Things that scare me’, Ross shared his presentation secrets in a very entertaining and inspiring talk. Rather than reading what I took home – have a look at his blog which covers everything you need to know about improving your presentations.

http://prezentationskills.blogspot.co.uk/2016/06/the-greatest-presentation-in-world.html

Further reading

For more reflections on the conference please see this St Emlyns post and their further reading list and the podcasts they recorded each day.

SMACCDUB – A Trainee’s Perspective. St.Emlyn’s

Episode 10: Stress Inoculation

Inoculation training

Big thanks to Anand Swaminathan @EMSwami, Chris Nickson @precordialthump, Jesse Spurr @Inject_Orange, Chris Hicks @HumanFact0rz, and Tom Evens @doctomevens

Their pre-workshop reading/listening recommendations:

http://stemlynsblog.org/englishman-south-africa-robert-lloyd-st-emlyns/

http://emcrit.org/podcasts/toughness-michael-lauria-i/

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Visualisation tips:

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Episode 9: Maternal Collapse

Mat collapse-2

Apologies for the quality of the sound – we recorded in a very echo-ey office!

The Royal College of Obstetricians and Gynaecologists (RCOG) green top guideline is accessible here:

https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_56.pdf

We have talked about ramping previously, in Episode 6: Oxygenation. This is how a pregnant patient should be positioned for airway manoeuvres and interventions, for example induction of anaesthesia and intubation.

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The ILCOR 2015 update pertaining to Cardiac Arrest Associated with Pregnancy is accessible here:

https://eccguidelines.heart.org/index.php/circulation/cpr-ecc-guidelines-2/part-10-special-circumstances-of-resuscitation/

Including this picture demonstrating manual displacement of the uterus:Manual displacement

The concept of deliberate practice is discussed in more details on these sites:

This is Cliff Reid (resus.me) talking about his lecture from the Royal College of Emergency Medicine Conference in 2015:

http://resus.me/rcem15/

And this is Simon Carley’s (St Emlyn’s) blogpost on the subject:

http://stemlynsblog.org/the-pursuit-of-mastery-through-deliberate-practice/

And last, but not least, Scott Weingart (EMCRIT) from SMACC 2013

http://emcrit.org/podcasts/path-to-insanity/

 

References

Advanced Life Support (7th Edition). Resuscitation Council UK. 2016.

Parry R, Asmussen T, Smith JE. Perimortem caesarean section. EMJ. 2016; 33: 224-229.

Clark SL, Cotton DB, Pivarnik JM et al. Position change and central hemodynamic profile during normal third trimester pregnancy and post partum. Am J Obstetrics & Gynaecology. 1991; 164: 883-887.

Bamber JH, Dresner M. Aortocaval compression in pregnancy: the effect of changing the degree and direction of lateral tilt on maternal cardiac output. Anaesthesia & Analgesia. 2003; 97: 256-258.

Lee SWY, Khaw KS, Kee WN, Leung TY, Critchley LAH. Haemodynamic effects from aortocaval compression at different angles of lateral tilt in non-labouring term pregnant women. British Journal of Anaesthesia. 2012; 109: 950-956.