SMACC Day 3

The last but by no means the least. How did the conference see out the last day of this fantastic event…..

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Victoria Brazil, ‘Putting the patient into patient safety‘ spoke on the importance of patient experience and mentioned her departments processes of improving stroke thrombolysis and the use of simulation which included testing the systems with a volunteer with go pro cameras strapped onto them. This and other similar experiences help to highlight experiences from the patient and relatives point of view, which is often something that is difficult to truly appreciate.

She also talked about the evolution of the doctor-patient relationship and suggested that the role may evolve from looking after our patients to forming a partnership with them. The 3 take home messages from her superb talk were

  • be curious about patent experience
  • partner with patients for safety every day
  • explore ways to make it happen

Pat Croskerry, ‘How to think straight; cognitive debasing‘.

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It’s not what we don’t know that gets us into trouble, it’s the way we think about things. He spoke about system 1 and system 2 thinking and told us that 95% of our day to day thinking is system 2. Pat also talked about the high intensity decision making that we experience in ED

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and the most common cognitive errors that are made in the ED

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He talked through how to become better decision makers and Pat stated that the main way to do this was by cognitive debasing.

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Cognitive debiasing is not easy and there will need to be a multifaceted approach to achieving it. The literature base is growing on the topic and he gave some good examples of further reading

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And last of the morning sessions was Kevin Fong with ‘Lessons from space‘. The talk was about risk and what we can learn from systems outside of medicine. Kevin gave a superb and engaging talk and spoke about obvious examples of risk that we all tolerate, for example different iv fluids being in near identical bags, the same with many antibiotics and drugs. He referenced simple but effective solutions such as changing the appearance of such items

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Kevin gave some poignant examples of errors made in aeronautical history and the lessons that were learnt and then forgotten. He warned that medicine should not follow the same line.

The concurrent of ‘Grey matters’ was up next. with Tom Bleck speaking on subarachnoid haemorrhage.¬†He spoke about what matters with SAH;

  • Rapidly identify patients with an aneurysmal SAH and secure the aneurysm quickly
  • Lower MAP before securing the aneurysm but not afterwards
  • Detect and manage early complications, stress cardiomyopathy, neurogenic pulmonary oedema and cerebral salt wasting
  • Detect vasospasm early-clinically, electrophysiologically, sonographically and radiologically
  • Manage clinical vasospasm aggressively-augment pressure and flow

Tom explained how to understand the disease and presentation;

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Rebleeding of unsecured aneurysms occurs in 9-17% on day 0 and then 1.5%/day for the next 13 days, rebelling carries a 75% mortality.

Next up Andrew Naidech, ‘Intracerebral haemorrhage; down not out.’ Andrew talked about the importance of assessing outcomes in a patient orientated scale and that scales such as the modified rankin scale may not reflect a true picture of dependance/independanc and further work n these scales would be needed

Bill Knight on ‘10 things you need to know about traumatic brain injury‘, Bill talked about the importance of minimising the secondary injury

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Bill’s top 10 were

  1. ………we don’t yet know what we don’t know
  2. Early aggressive care, don’t inappropriately prognosticateIMG_7225
  3. Surgery – early decompressive craniotomy
  4. Monitoring – monitor what we need to use to provide best outcomes. Monitoring doesn’t save lives, it’s the reaction to it that does
  5. Mechanical ventilation – neuroprotective ventilation
  6. Early -DVT prophylaxis, feeding, glucose control, mobilising, tracheostomy and PEG (as needed)
  7. Avoid extremes of physiology – fall back in the ABCs and target normality
  8. Analgosedation – consider ketamine
  9. Reverse anticoagulationIMG_7224
  10. Mechanical support tailored to their physiology, keep collars loose, have head up to support their needs, keep them comfortable. In conclusion;

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Up last before lunch was Mark Wilson with ‘Goodbye GCS‘. He spoke about the evolution of the way we define consciousness before GCS

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Mark spoke about the way GCS had initially been used to plot the change in consciousness but now we use it as a one off measure as well. He also highlighted that GCS has now been incorporated into multiple different scoring systems but that it’s design wasn’t perfect, ¬†looking at a GCS of 4 for example the associated mortality can vary 3 fold depending on its E,V,M breakdown.

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Mark talked about other options to GCS- FOUR (Full Outline of UnResponsiveness) amongst others. The fact that fixed dilated pupils could be due to a number of

IMG_7232reasons was reinforced and also the fact that this isn’t a reliable prognostic feature which was highlighted with a superb case.

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Mark’s take home message was not to abandon GCS but to focus on the following;

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After lunch we had David Newman talking about ‘Dogmalysis and Pseudoaxioms‘. This talk was phenomenal and falls in line with the amazing work David does over at SMART EM. He ran through a number of pseudo axioms that people still hold strong. He asked EM physicians to come together and challenge these poor areas of practice and drive the speciality forward. This is THE podcast to listen out for when SMACC release the sessions, it was inspiring, exceptionally informed and funny and will enthuse your love of EM.

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Unfortunately flights meant that staying for the end of the conference wasn’t possible but no doubt there will be some superb coverage via social media, blogs and podcasts. Importantly just like the last couple of years SMACC will be releasing the talks via their iTunes feed and website over the next few months, be sure to check them out.

A huge thanks to the organisers for a fantastic time, we’ll see you all in Dublin!!

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