Redthread Part One

It was great when Freya, David and Richard from the Redthread team at the QMC Emergency Department came down to record the first of three podcasts with us.  

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Redthread is a charity working with young people to help them lead happy, healthy and safe lives.  Key to this is the teachable moment, the moment a young person is in an Emergency Department and can be shown the way to turn their life around.  Since starting in London over 20 years ago they have since expanded into Nottingham and now Birmingham too!

In this episode the team tell us about their own backgrounds, how they came to Redthread and how Redthread came up to Nottingham.  They then take us through their day-to-day work and the help they can offer vulnerable young people.  There's advice along the way as well as chat about Curlywurlies!  

For more information visit the Redthread website 

ACPs in ED

In this special episode Senior ACP James Pratt joined the podcast to talk about Advanced Clinical Practitioners in ED.  This is a topic he's talked about before at various conferences and meetings.  At EM2C 2018 he started his talk rather impressively:

James and Jamie talk about:

  • What is an ACP and what their job role entails
  • James' own career and the development of the ACP team at the QMC Nottingham
  • What the Nottingham ACP course consists of and the course entry criteria
  • Issues in the development of the ACP team and how these were approached
  • Potential areas of future development
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There's an emphasis on the education and time required to create the ACP service and how this is not a short term solution to staffing issues but rather a long term investment in our staff

For more information on the ACP course at the University of Nottingham you can visit the course page here

For more information on Advanced Clinical Practitioner Educators you can visit the Association of Advanced Clinical Practitioner Educators website here

We're looking make more podcasts on advanced practice in the future so please get in touch with any suggestions!

P Cubed (How to do a Presentation) - #wewillgiveDREEAMpresentations

In a previous blog post I've already sung the praises of Ross Fisher and the p cubed approach to presentations.

In this live recording at the latest DREEAM educators' meeting I talk a bit more about p cubed, how to present information in a way that's not just nice to look but has science behind it.

Here are the slides.  As ever just click to scroll through them.

Topics covered:

  • Why bullet points are bad (irony)
  • How to storyboard - spark points and lightning slides
  • The science of presentations - cognitive overload, the three second rule, the rule of thirds and dual coding
  • How to present data

Here is the Take Visually for this episode: 

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I hope you enjoy this talk and feel inspired.  That's the purpose of this talk and as a team at DREEAM we have made a Twitter pledge #wewillgiveDREEAMpresentations.

For more information on learning theories (and why it's wrong to think about 'types' of learners) check out Learning Scientists.

Good luck telling people of the amazing things you've seen.

                 - Jamie

 

ABCDE of Chest X-Ray - Use the RIPE Approach!

In this podcast Dr. Harry Pick, Respiratory Registrar and Clinical Research Fellow at Nottingham University Hospitals NHS Trust came down to talk us through Chest X-ray Interpretation; a key skill in the Emergency Department!

Harry very kindly gave us a copy of the Powerpoint he uses when he teaches this topic; due to confidentiality reasons these slides don't have X-rays on them but great resources can be found at Radiology Masterclass. Click either side of the pictures to move through them.  

Remember the step by step approach:

Right patient; day and time? - this is key for all investigations.

Is the film AP (anterior to posterior) or PA (posterior to anterior).  This matters for two reasons.  Firstly, an AP film tends to be an portable CXR and so tells you that the patient was sick when it was taken, this may be confirmed by the presence of chest leads, O2 tubes and central lines on the film.  Secondly AP films exaggerate the size of the heart and so you cannot comment on cardiomegaly.  You can on a PA film.  In a healthy individual the heart should be no more than 50% of the thoracic width on a PA film.  If the scapulae are not projected into the chest assume it is a PA film.  It should always say if it is an AP film.   

'RIPE' - Rotation (equal space between medial aspects of clavicles to spinous processes), Inspiration (>7 anterior and 9 posterior ribs, Picture (can you see everything you want to see?) and Exposure (can you see vertebral bodies behind the heart).

Then remember ABCDE - this varies - the Take Visually below follows Airway, Breathing, Circulation, Diaphragm and Everything else.

Harry's ABCDE covers the same things but in a different order - Apices, Behind the heart, Cardiophrenic and Costophrenic angles, Diaphragms - above and below and Everything else. 

Don't forget to compare the chest x-ray with any previous ones (very easy on most programmes) - this is very useful to assess any acute changes.  Older x-rays should also have been reported which will help your interpretation!  

As you can see there's a subtle variation, make sure you find a method that works for you!  

Here is the Take Visually for this podcast.  

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Geeky Medics have a great page on the subject as well.

Focused Trauma Conference 2017: Deel Drie

In the third part of the day we focused on balloons, namely REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) - the Life in the Fast Lane post can be found here.  The talk was by @emeddoc.  This procedure is intended for cases of non-compressible traumatic haemorrhage.  Before REBOA the best possible method to achieve haemostasis was through compressing the descending aorta via resuscitative thoracotomy (RT).  Data from the American Association for the Surgery of Trauma (AAST) in 2014 shows that REBOA is at least non-inferior to RT.  In trauma patients in LOST (ie not TCA yet) who required REBOA 92.6% survived their stay in ED and 22.2% survived to discharge.  Increasingly work has shown REBOA to be feasible in the pre-hospital setting and has the best survival rates if performed pre-hospital.  

However, a study from Japan showed that REBOA is associated with an increase of 16.5% in mortality.  However, the median door to surgery time was 97 minutes and further research has shown in animal studies that lactate clearance is intact 45-60 minutes post REBOA but after that the ischaemia distal to the balloon may be irreparable hence the poor date from Japan. This raises the possible of future research into partial inflation to not completely cut off distal flow and have some permissive hypotension.  

REBOA is not just for the pre-hospital medics to be concerned about; it requires clear handover to the hospital and theatre teams after it is used as it will alter physiology.  It it there to buy time for the definitive surgery and it was emphasised several times that any unit wanting to implement REBOA will require widespread organisation and culture change.  

Here is the Take Visually graphic for this podcast and blog:

It was a brilliant and interesting day; thank you to all the organisers.  Antwerp is a lovely city and the Belgian people were very welcoming; if you can visit do!

Focused Trauma Conference 2017: Deel Twee

In the second part of the Focused Trauma Conference we were treated to a focus on the role of ultrasound and clam shell thoracostomy.

Dr Jim Connolly (@jiconnoly) kicked off the second part by imagining a post-stethoscope world (Stethxit) and instead where we all have hand held ultrasound devices - a reality that's closer than we think - he believes once they crack a cost of <£1000 (i.e. the cost of the new iPhone) a unit we will all have one! POCUS will help identify the majority of causes in cardiac arrest (pretty much all of 4Hs and 4Ts apart from hypothermia or toxins).  POCUS reduces the time to operation, the number of CT scans and even the length of stay in hospital.  It is time critical, helps with Bayesian reasoning and with answering Yes/No answers.  It is more sensitive than auscultation and x-ray in detecting pneumothorax and takes a quarter of the time that CXR does.  However it is important to remember its limits:

  • A FAST scan needs about 500ml blood in the abdomen to pick up - "you need blood to bleed" and so there may be false negatives
  • It changes nothing in penetrating TCA

However in blunt TCA it is useful to pick up cardiac standstill (a very poor prognosis) and also to distinguish pseudo from real PEA.

It was then onto thoracostomy with Professor Lockey and then Dr Connolly again.  The procedure was first performed in 1988 and provides better visualisation than the left lateral approach.  Professor Lockey talked about the approach in 'street thoracostomy' often performed in cases of stabbings and even terrorism:

  1. Open the pericardium
  2. Seal the hole (ideally a single hole in the right ventricle) - occlude with a finger, stitch or staple it or use foley catheter
  3. Restart the heart - flick it, volume load, 2 handed massage, ventricular adrenaline, given bicarbonate (usually young people getting stabbed so should be fine) and calcium
  4. Clip the internal mammary arteries and clamp aorta and hilar
  5. If the patient wakes during anaesthetise with Midazolam 1mg and Ketamine 30mg
  6. Forensic awareness is also important in cases of stabbings 

The whole procedure should take less than 2 minutes.  It is not to be performed in cases of shootings/high energy transfer, if the heart is empty or if the TCA has been prolonged.

Dr Connolly reinforced many of these messages as well as emphasising that the biggest barrier to before the clamshell is the fear of being criticised.  It is a procedure not an operation designed to achieve damage control and restore physiology NOT anatomy.  It is to be performed in witnessed TCA or if there were very recent signs of life or if the systolic BP is <70mmHg despite fluid resuscitation.  The wound most likely to survive is a wound to the right ventricle with a tamponade.  When suturing a horizontal mattress suture is least likely to occlude the coronaries.  He also emphasised the importance of training - at times of stress we revert to our lowest level of training.  There are other considerations to have - once output is restored the patient needs to go straight to theatre and can have only vertical sliding not horizontal.  

Here are the Take Visually graphics for this podcast:

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Focused Trauma Conference 2017: Deel Een

It was great to attend the inaugural Focused Trauma Conference hosted at the University of Antwerp.  Although run with a Belgian slant on things there were a number of British speakers and the whole event was in English which was useful for my dotard ears as one of the few uni-linguists in the audience.  The venue was amazing.  

Thanks to the breaks the day roughly broke up into three sections with different topics explored.  So, like the aorta in REBOA, (more of that later) we will tackle the day in three parts.  

In the first part Professor Nijs began by exploring major trauma in Belgium.  Belgium has twice the mortality rate due to trauma of the UK and has no system of Quality Assurance.  I was really proud to be part of the NHS as he highlighted the improvements seen in the UK since the MTC network was set up.  Whilst he pointed out that all systems need a 5 year maturation period in the UK we had seen immediate improvements in outcomes which increased year on year.  Major Trauma is an area of constantly changing paradigms: we no longer consider traumatic cardiac arrest a futile endeavour and there are ever improving methods of haemorrhage control such as REBOA.  He feels Belgium should aspire to the UK model but they will need:

    1.    The resources

    2.    People who understand

    3.    People who have the skills

Dr Ed Barnard (@edbarn) then spoke about traumatic cardiac arrest (TCA).  There is no universal definition of traumatic cardiac arrest which makes research difficult but this is predominately a disease of young people. Whilst initial papers gave low survival rates recent Trauma Audit and Research Network (TARN) data from 2009-2015 shows a 7.5% survival to hospital discharge rate as well a 2/3 moderate to good neurological outcome post TCA.  He discussed methods of public engagement as well as distinguishing between low output states in trauma (LOST) and no output states in trauma (NOST).  Whilst the standard methods of controlling bleeding and IV filling may work in LOST the future of resuscitation in NOST may involve methods of controlling and providing flow such as selective aortic arch perfusion.

In the final talk of part one discussed the European Resus Council (ERC) algorithm for TCA,

Universal cardiac arrest algorithms are not suitable for TCA as they can result in delays of nearly 10 minutes whilst looking for a reversible cause such as tension pneumothorax.  The ERC algorithm places chest compressions at a lower priority in TCA than treating hypoxia, tension pneumothorax, tamponade and hypovolaemia.  Dr Truhlar (@TruhlarA) openly admitted that the role of CPR is unknown.

The only nation to reject the ERC guidelines was the UK (insert Brexit reference) with the UK Resus Council producing its own guidelines as above which keeps thoracostomy and needle decompression as considerations not standard practice for all TCA.  

Dr Monsieurs (@kmonsieurs) continued this debate of the role of chest compressions in TCA.  He felt that maybe chest compressions provide little benefit in TCA and get in the way of other things which provide much more benefit.  There was discussion about how hard it can be for a professional to stop CPR for other procedures once bystanders have been doing compressions after calling for help.  Dr. Barnard made the interesting point that chest compressions whilst improving systolic BP cause diastolic BP to drop and so reduce coronary perfusion.  

I think the role of chest compressions in TCA and the ERC and UK TCA algorithms will provide much more fuel for research in the years to come!  

Here's the Take Visually for this podcast: 

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We're All Going on a #FOAMed Holiday

Take Aurally is once again on the move this time heading to the Belgian city of Antwerp to take in the refined air, culture and the Focused Trauma Conference  on 14th October. 

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For those not going worry not as we shall podcast from the conference (or a cafe near by) as well as present a Take Visually or three.  Remember to follow @takeaurally for all the goings on.  

Here's the full running order:

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The ED Pharmacist

Kunal Gohil, the ED Pharmacist at the QMC came down to discuss his role, the benefits, challenges and further developments. 

We talked about:

  • The training of a pharmacist in the UK
  • Kunal's background and how he came to work in the Emergency Department
  • His role and how it has developed
  • A normal day in the life of an ED Pharmacist 
  • The benefits to the department and trust
  • His work on time critical medication such as anti-Parkinson's 
  • Advice for other pharmacists and trusts interested in the role

Here is our Take Visually on the ED Pharmacist: 

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Wear Sunscreen: Tips for New Doctors

It's that time of year again; the medical new year where 5 years of medical school comes to fruition and students become F1 doctors.  I've thought back to my time as an F1 and here's 50 tips.  If you don't get the Sunscreen reference then I'm officially old...

  1. Medicine is a noble art dating back throughout humanity.  We will outlive any government or Health Secretary.  I've never not experienced anything other than respect from lay people when I've told them I'm a doctor.  We get cynical in our bubble but what we do is amazing.  Don't forget that.
  2. Make your intentions noble.
  3. Chocolate will always go down well with your new colleagues.  Tea and coffee or at least the offer of them will go down well with your patients and relatives.  
  4. Chest pain always needs an ECG.  Regardless of description.
  5. Abdominal pain and trauma rarely present in a straightforward way in the elderly.  Have a low threshold to CT scan and always discuss with a senior.
  6. Beware posterior STEMIs.  If you see regional ST depression look for ST elevation in other leads.  Make sure you check if any LBBB is old or new.
  7. Know your trust's PCI, Stroke and Upper GI Bleeding protocols early.  Don't wait until it's 0300 and you're with a poorly patient to find out.
  8. Back pain + Collapse = AAA until proven otherwise.  
  9. 'Nurse' is not a first name.  Learn the names of your colleagues.
  10. All women are pregnant until you prove otherwise. 
  11. Don't forget the aorta.
  12. If you think it's a PE it probably is.
  13. 'Senior Review' is not a plan.
  14. 'C?C' is not a diagnosis.
  15. 'Acopia' does not exist.
  16. It's never alcohol until you rule out everything else.  If it is alcohol consider Chlordiazepoxide and Pabrinex.  
  17. Gastritis is not an F1 diagnosis to make.  I'd argue it's not an Emergency Department diagnosis to make.  Rule out more serious causes first.
  18. Know the head injury guidelines.
  19. You can't always cure but you can always be nice.
  20. Be judicious with requesting D Dimers.
  21. Analgese often and early.  Document it.  If your patient declines then document that too.
  22. Always listen to your gut - whether it's telling you your patient is ill or that you're hungry.
  23. Your nursing colleagues won't kiss you backside but will certainly save it.  Be kind to them. 
  24. Monitor your urine output and urine colour and hydrate accordingly.
  25. Don't just write ''ECG nil acute'' in the notes.  Write your findings even if it's just ''Normal Sinus Rhythm.''  Your colleagues later on will thank you.
  26. Remember to prescribe time critical medications - Anti-Epileptics, Anti-Parkinsons, Antibiotics and Insulin.
  27. Respiratory rate is often the first observation to go off.
  28. Remember mean arterial pressure.  Your patients brain (GCS) and kidneys (U&E/Urine output) need monitoring.
  29. Remember that amazing 360 degree human being you were on your application to medical school?  Who sang, played instruments, played sports, danced, had dreams and passions?  Don't forget that person.  Use your free time.
  30. Take annual leave. Travel.
  31. Not every patient is nice but they still deserve your best.
  32. Mental health and serious organic disease are not mutually exclusive.  Don't be biased.
  33. Don't say 'unresponsive'.  Use GCS.
  34. Migraine and epilepsy don't start in later life.  Rule out sinister causes first for new headaches and seizures in the elderly.  
  35. Don't wear suede to work.  
  36. How to SBAR: 1). Say who you are and where you are calling from. 2). Say the reason you are calling. 3). Then start your SBAR.
  37. Don't judge others with different values that you judge yourself with.  
  38. See the bigger picture.  This is one of my favourite pictures taken from the edge of our solar system showing Earth.  It reminds me to see the bigger picture, a very valuable lesson when there is a 10 hour bed wait or a 5 hour wait to be seen in the department.  Always see the bigger picture.  Remember the 18 year old you who was so excited to get into medical school.  

39. It's not OK to not be OK.  Talk to someone.                                                                                                   40. There is nothing more contagious in healthcare than emotions.  Smile.  Be positive and it will spread.  41. Doctors consistently are amongst the most respected professions.  Never abuse that trust.                    42. Remember #HelloMyNameIs.                                                                                                                          43. Always get your sleep.                                                                                                                                      44. Coffee is your friend.                                                                                                                                       45. You should always get more out of alcohol then it gets out of you.  If that changes get help.                  46. Pain and Urinary retention are two important causes of agitation.                                                              

47.  Be careful what you post on social media.                                                                                                                 

48. Not matter how hard breaking news is for you it is worse for the patient/family receiving it.                                                                                                                     

49. Chew your food.  Especially watermelon - trust me on this.                                                                          

50. Wear sunscreen.


How I Learned to Stop Worrying and Love the ECG

ECGs are an essential part of Medicine and unavoidable as a student and junior doctor.  I remember being bleeped as an F2 on call by an Orthopaedic surgeon to read the ECG of one of his patients as he had forgotten...ECGs are definitely a case of improving confidence and knowledge through repeated practice and exposure.

Once again I cannot recommend Life in the Fast Lane enough for incredible resources when it comes to ECG.

Here is our video on how to take an ECG:

In the latest Take Aurally podcast I discuss an approach to ECG interpretation and in this blog I've enlisted the help of Albert Einstein to help me through.  You can find the tool for making this meme here.

Remember, it doesn't matter how the patient describes their chest pain as an ''ache'', ''twinge'', 'indigestion''...whatever chest pain is chest pain and needs an ECG.   

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This step is vital, is the ECG in your hands from the right patient, right day and time?  Also, get an idea about the presentation behind the ECG, do they have pain, shortness of breath, collapse or palpitations?

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Only in certain BBC television dramas (cough, Casualty, cough) does a flat line on an ECG mean death.  In real life it means that the ECG lead in question is not connected properly and needs reattaching.  Make sure you can see electrical activity in all 12 leads.  

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Most ECGs will tell you this anyway but it is important to be able to work this out for yourself.  In a regular rhythm (equal distance between all R waves) you can count the number of large squares between each R wave and divide 300 by this number.  Alternatively you can count the number of beats on the rhythm strip and times this by 6.  

There's about 3.5 big squares between each R wave here.  Using 300/3.5 gives a heart rate of 86.

Alternatively, there are 15 beats on the rhythm strip,  15 x 6 = 90.

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This is all about looking at the R-R distance for successive beats.  This can be marked on a separate piece of paper and moved along to confirm.

If the rhythm is irregular you can then also see if it's regularly irregular or irregularly irregular 

By looking at successive R-R distances we can see that this ECG shows a regular rhythm.

The QRS complex should be 3 small squares wide.  This is important for two reasons.  In tachycardia the duration of QRS points to the diagnosis and management as shown in the Resus Council flowchart below.  In normal rates it also points to a bundle branch block.

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Taken from Resus Council UK

My method for working out LBBB or RBBB...without a William or Marrow in sight

P waves indicate sinus rhythm.  PR interval should be 3-5 small squares.  

First degree heart block: PR interval is prolonged and remains the same (occurs between SA and AV node)

Second degree heart block: Mobitz 1 - the PR interval gets longer and longer until there is a dropped QRS and the cycle starts again.  (Occurs in the AV node) Mobtiz 2 - the PR interval is long, stays the same length but there is a dropped QRS in a ratio: 3-1, 4-1 etc (occurs after AV node in bundle of His/Purkinje fibres)

Third (complete) heart block: No relationship between P waves and QRS (occurs anywhere from AV node down)

PR interval could also be shortened as seen in WPW.

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Axis is all about the general spread of electrical activity across the heart.  

Here I look at leads I and II.  Usually the R waves should both be positive as here:

In left axis deviation the R wave in II is now negative so they pointing away from each other or 'leaving'.

Leaving = Left Axis Deviation

This is a sign of ischaemia 

Here the R wave is I is negative so they reaching for each other.

Reaching = Right axis deviation

RAD is a sign of RVH

This is important to notice ST elevation - STEMI (2mm or more in 2 or more chest leads or 1mm or more in 2 or more limb leads) or ST depression or T wave inversion - can be seen in NSTEMI

Be wary if you see regional ST depression - this could be reciprocal depression so make sure you look for ST elevation in other leads

Remember to look at the J point - the point where the S wave joins the ST segment - this can be raised in young, thin patients giving the appearance of ST elevation.  This is caused benign early repolarisation or 'high take off'

T waves can also point to other conditions - the tall T waves in hyperkalaemia; biphasic T waves in hypokalaemia or ischaemia; or flattened in ischaemia or electrolyte imbalance.

U waves, small deflections after the T wave can be seen in a number of conditions; hypokalaemia, hypothermia or antiarrhythmic therapy like digoxin

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My colleague James Pratt has made an excellent e-Learning package on ECG interpretation which can be found here

Geeky Medics have a great page on ECG interpretation here

ECGs courtesy of the amazing Life in the Fast Lane

You can hear our ECG Interpretation podcast here:

UMEC, I MEC, We MEC

It was an honour to be asked to present at the 4th annual Undergraduate Medical Education Conference (UMEC) at the University of Nottingham on 7th July.  It's a great opportunity to see the great work being done to improve the teaching of our students.  

I think we were all impressed by the work of WAMS (Widening Access to Medical School) a programme run by medical students in association with work by the university to widen access to students who might otherwise not go to medical school.  I was very lucky with the support from home I received; many are not so lucky. 

                                              The DREEAM team out in force for UMEC 2017.

It was great to hear from my fellow podcaster Charley Peal on her work 'Nifty Fifty' giving clinical students a booklet of 50 challenges such as escorting a patient to X-ray to help them orientate and stay on the ward.  Or as she and her fellow medical fellow Becca Noble put it ''avoid being a trip hazard''.  Not saying I actually caused people to trip up when I was a medical student but I certainly had some near misses.

There was a good discussion about the difficulties of sharing educational resources.  This is why I support FOAMed despite its detractors.  No paywall; no firewall.  The challenge is quality control of course but I've often thought that there's great work going on that just isn't celebrated enough.  I've regularly been in conferences and felt it just seems like some institutions are better than others at getting their message out there.  There must be reasons at the individual level to explain this but it must also be due to leadership and the culture of an institution.  

We also discussed the conundrum at the heart of medical education I feel.  Our students want to pass exams.  We want them to be safe doctors.  It's sad but understandable when in the past I've had to cancel sessions because they're near exams and whilst they'd help the students as doctors I know engagement would be poor if I put it on.  

My DREEAM colleague Matt Govan kindly filmed me.  It's actually hard to boil a subject down into 7 minutes and it took a lot of practice.  Looking at it I hope it shows a progression with using the P3 approach to presentation.  The last time I presented I was told I dance about a bit so here I'm routed to the spot by 'anchoring' against the podium.    

In my last blog at Das SMACC I mentioned how SMACC has helped change the approach to conferences at this philosophy was evident at UMEC; short presentations, workshops dotted amongst the schedule with social media being used throughout.  As someone who attends a lot of conferences it's a great development and one to be continued.  Thanks to everyone at the UMEC organising committee.  

Das SMACC Day Three

And so Das SMACC ist fertig and I am sat in my office in Nottingham reflecting on an amazing three days.  Thank you to all who made Das SMACC happen and thank you to my colleagues for accompanying me on the ride, tolerating me and allowing me to convert their voices into MP3 format.

So, Day Three.  It's fair to say that I was not in the best of humours at the beginning of the day which may have had something to do with the Das SMACC party the night before.  Maybe.  

LIGHTING THE FLAME: CRITICAL CARE EDUCATION
Chair: Simon Carley
Panel: Jenny RudolphWalter EppichChris NicksonVictoria BrazilSandra ViggersDaniel Cabrera

The morning however was worth the trek in.  An inspiration panel of educationalists (new word for me) on the future of education in Critical Care. There is a Storify thread which you can follow here as otherwise my succinct points below won't do it justice.

  • How do we train doctors now to deal with the future? - train the basics well and use these as the building blocks for the future, teach empathy and compassion as these will still be needed as automation increases
  • Interprofessional education should be the norm and used throughout medical school, teach the fundamentals (anatomy, pathology) together and then subspecialise later - I completely agree with this and think this should be the way all universities function, if I come to power...
  • We don't actually teach how to be a doctor at medical school, we teach students how to be a resident (F1) which is where they learn to be a doctor - Amen Walter!
  • Don't focus on learning from simulation, rather simulate to learn from work
  • The future will not be simulation centres but rather each hospital having a fluid, focused simulation team who will able to provide expertise to all departments within the hospital, we can't assume anyone can facilitate simulation, treat it as a skill like ECMO or REBOA
  • Look at your coaching conversations, tailor your approach, ask your students what they would like you to look out for at the beginning of the session - YES! Definitely going for this approach in the future, I regularly find it hard to discuss everything in a debrief
  • Always talk after simulation, whether good or bad or indifferent
  • Also a big discussion on the best time to give feedback and Work Based Assessments - a recurring problem I have!  
  • We don't train people to give or receive feedback - another recurring problem

How to Fail - Kevin Fong

Another new man crush!  Anaesthetist/Astronaut Kevin spoke about failure.  The old saying is true; it's not an option.  Failure will always happen.  We have to adapt to accept this and approach our safety mechanisms and responses to failure appropriately.  Hypercompetence is a myth.  Hubris is wrong.  We have to have 'graceful failure' otherwise human factors fails and we will let out patient down.  I also liked his point that maybe the only reason medical science began to see the heart as a pump was because mechanics had invented a pump and we had a frame of reference.  Makes me wonder what fundamental point we're currently missing because we don't have that frame today.  

Helping Without Harming - Jenny Rudolph

An inventive and entertaining talk.  Rather than being annoyed at someone and thinking WTF think another WTF (What's Their Frame?)  The hashtag #WTF2WTF is alive and kicking on Twitter and it will be interesting to see how this goes.  More about fundamental-attribution bias.  Thought provoking, something I will try.


The Global Refugee Crisis: Why it’s Critical that we Care - Vera Sistenich

The only talk to get a standing ovation.  I can't do it justice, watch it at the SMACC website.  The more people who watch the better.

How to Fail… Part Two - Martin Bromiley

We all know his late wife's story.  How he does it I don't know but another great talk.  A man with much to be angry about who actually chose to understand and help.  His thoughts were inspiring on human factors:

  • "I would't do what they did" - not helpful, next time you catch yourself thinking that think instead "Why did it make sense at the time?" 
  • Confident humility - no one is too senior to seek feedback
  • Look at our systems in place, do they make it hard to be right and easy to be wrong?

This isn't a cop out but I genuinely couldn't do the last session featuring Martin Bromiley and James Piercy justice so please check it out on the Das SMACC site.  Amazing human beings and it was a privilege to hear them.  I hope I don't have to go through what they did but I hope I could always be as kind.  

So that was Das SMACC.  Personally I love FOAMed and it was great to be with like minded people in an amazing city.  Berlin is an amazing mixture of beauty and horror and needs to be seen.  What about SMACC?  It is a bit cultish if I'm honest.  I can see the point of some of its detractors pointing out the swearing, the hashtags, how something is either great or sh*t.  And it has made 'celebrities' of medics - yes I know the irony as someone who blogs and records his voice in his spare time - which is something that may create challenges in the future.  But I loved it.  SMACC has challenged the old school.  Conferences where someone stands at the front and talks with no engagement are thankfully dying out.  It's been great to see the smart conferences adapt with workshops, social media and an open minded approach.  'Punk movements' like SMACC are the vehicle of such changes.  I hope I will always be so open minded. The focus on the next generation and innovation was a pleasure to see as well.  Danke Berlin.  Danke Das SMACC.

 - Jamie