Coda Change

Resa Lewiss gives her insights into leadership. Through her experience training and working in Emergency Medicine and Critical Care, Resa has collated a series of pearls, pitfalls, and lessons shared by leaders. For Resa, there are leaders, and there are follows – more often than not, people know good leaders. Resa firmly believes that leaders look like leaders. She affirms that it is neither a ma...

Medical journals have many possible functions, but the main one for most is publishing science. They are actually better at campaigning and agenda setting, rather like the mass media. Journals are now beset with problems, including failing to include data, publishing lots of poor quality material, being slow to publish, publishing research that is either not reproducible or fraudulent, encouraging...

Antibiotic Use for Sepsis in Critical Care: Steve McGloughlin Steve McGloughlin presents his thoughts on antibiotics and their use in sepsis and critical care. Steve discusses the ABC of sepsis… the trouble is after A for Antibiotics there is not a whole lot else! In sepsis and severe infection, the goal is to change the trajectory of the patient, away from death and to a more favourable outcome....

Per Bredmose discusses the use of inhaled nitric oxide (iNO) in retrieval medicine and critical care. He explains why iNO is useful for retrieval and transport of the critical respiratory failure patient. iNO is not a magic bullet, but rather a bridge that will help you get to where you need to go when treating a patient. Furthermore, it can be useful in both pre-hospital and in hospital care. Wha...

How do you diagnose death? In Critical Care we deal with death on a regular basis and although it seems black and white, that is often far from the truth. Patricia Gerritsen discusses what it means to be dead and how that knowledge can aid you in stopping a resuscitation effort. Patricia presents the degrees of death in her eyes as: Soon to be dead Reversibly dead Irreversibly dead Reversibly, irr...

In Critical Care we deal with death on a regular basis and although it seems an 'on or off' issue where you are either dead or you are not, nothing is more true. Not only physicians but scientists, philosophers, writers and theologians have been debating about the subject for as long as we have become aware of the concept of death. To try to create order from chaos I divide the deceased in 5 categ...

Diagnostic medicine is not simple – Casey Parker discusses the finer points of the diagnostic process in critical care. Diagnosis is not black and white. The world is not black and white. It is all shades of grey and about probability. One tool that clinicians have to deal with probability is Bayes' theorem. Since it was first described in 1763 Bayes' theorem has been applied, rejected, and redisc...

Kate Prior conveys the lessons she has learnt working as a doctor as part of the Medical Emergency Response Team (MERT) in Afghanistan. "Unexpected survivors" are those patients who, according to their injury severity score, should die of their injuries but they survive against the odds. The years of conflict in Afghanistan saw increasing numbers of these grievously injured patients surviving to l...

Peer review is at the heart of science. Yet, as Richard Smith explains in this talk, there are many problems with peer reviewed research. As Richard argues, peer review is not an evidence-based process, but rather a faith-based process. Is it time for something different? Peer review has two main functions: 1) Quality assurance and 2) Improving what is published. However, with that in mind, there...

The exposure of fabricated numbers in published papers by eagle-eyed readers has been due to sporadic serendipity. I am going to describe a semi-automated method that you can take away with you to do some sleuthing. I am going to describe what I found when I analysed over 4500 papers.

Jeff Drazen delivers a powerful message on the use of medical evidence in critical care. Medicine is powered by knowledge, but how do we know what is true and what is not? How do we deal with uncertainty in a setting where outcomes are not closely related to known variables? For example, although there are a few people who have survived jumping or falling from an airplane at high altitude, it is a...

Medicine is powered by knowledge, but how do we know what is true and what is not? How do we deal with uncertainty in a setting where outcomes are not closely related to known variables? For example, although there are a few people who have survived jumping or falling from an airplane at high altitude (http://zidbits.com/2010/12/can-you-survive-a-freefall-without-a-parachute/), it is a rare event....

Michael Perlmutter guides you through the prehospital diagnosis and treatment of sepsis. Sepsis is a difficult diagnosis to make. Even in the hospital, where a plethora of tests are available to assist the clinician. The diagnosis remains a challenging one, due to the very nature of sepsis. A shadowy shape-shifter notorious for its ability to hide in plain sight. For now, even in-hospital, there i...

Endothelium was once thought to be an inert organ. However, it plays an important role in multiple functions. These include coagulation, inflammation and determination of vascular permeability. He then gives a brief overview of the endothelial arrangement, function of the glycocalyx layer and how an injury causing a loss of the protective layer results in holes in the endothelium. The inflammatory...

Bill Knight explains the concept of death by neurological criteria and the complexities surrounding organ donation in such situations. Bill discusses the process of dying, the definition of death, how to approach the neurologically dead patient and how to consider organ donation. Death is a complex topic. Due to advancements in medical technology and processes, the definition of death is a challen...

Greg Kelly focuses on transferable skills from adult practice applicable to the collapsed neonate, taking us first through a systematic approach to the common underlying causes and the physiology behind them. He outlines a comprehensive approach to the clapped out baby even when the underlying cause isn't immediately clear and reassures us that there are plenty of simple interventions we can under...

Allow me to introduce to you this extraordinarily talented doctor. John Hinds became involved in our motorcycle racing medical team as a medical student and progressed to inspirational teacher and natural leader. He had a burning passion for improving the care of the injured and on qualification it was evident he was destined for greatness within the world of critical care. In his role as Delta 7...

Where does the abdominal assessment occur when you manage a paediatric trauma patient? Warwick Teague challenges us to stop just leaving it to the paediatric surgeon as he talks us through his approach to the abdomen in a paediatric trauma, including the key aspects of assessment and treatment - so simple, he says, even a surgeon can do it.

Trish Woods guides you through some clinical pearls in the intensive care management of neonates. The complex physiology of the transitioning required in the journey from foetal life to neonatal presents many challenges and scary moments. Trish helps you to navigate these challenges and to unlock the key to providing quality neonatal intensive care. Many things can go wrong in the neonatal period...

Deirdre talks 'bad blood' – the complex world of critical care haematology. Critically ill patients frequently have activation of inflammatory and clotting pathways. These are likely adaptive responses in the human. When they run riot, or the fine balance between pro- and anti-inflammatory states is shifted, there can be significant morbidity and mortality. Deirdre presents three patients to highl...

Mervyn Singer discusses the use of biomarkers in critical care. Multiple biomarkers - physiological, biochemical, biological - can prognosticate early in critical illness, even in the ED. These biomarkers are numerous - lipids, progesterone, troponin, thyroid stimulating hormone, inflammatory cytokines, mitochondrial dysfunction… so on and so forth! Prognostication can happen as early as the Emerg...

Jim Manning presents the how and why of adrenaline in cardiac arrest. The use of adrenaline in cardiac arrest resuscitation has been popular since the 1960s. Laboratory studies and anecdotal experience showed improved rates of return of spontaneous circulation (ROSC) with the use of adrenaline at small dosages. This led to the widespread adoption of adrenaline administration during cardiac arrest...

Congenital heart disease isn't just diagnosed in the antenatal period and during post-natal examination. Nick Pigott takes us through the three main presentations of congenital heart disease (shock, cyanosis and heart failure) and reassures us that treating these patients is simpler than we think, urging us to consider cardiac disease in the sick newborn. He covers duct-dependent lesions, structur...

Working in a Paediatric Emergency Department that has 52,000 attendances per year, means that at this point I have fallen into almost every possible pitfall associated with communicating with children and their parents, whether it be the seriously ill or the efficient disposition of the worried well and everything in between. The art of appearing to take all the time in the world whilst managing l...

John Glasheen discusses the importance and challenges of trade-offs in prehospital critical care. Every Pre Hospital and Retrieval Medicine (PHARM) mission involves a series of complex decisions. These are made rapidly in a high-pressure environment. Excellent PHARM clinicians are invariably expert decision makers. The ability to identify, accept and manage trade-offs is a key skill in prehospital...