Intubating the Critical Patient

Hi Team,

It has been a slow month on the blog and podcast as I have been working on a few other projects… one of which is very exciting and will hopefully be unleashed in 2016.

Can’t say too much about it but it is a collaboration with one of my favourite ED docs and is going to be something a bit special for my fellow Aussie bush docs.  Anyway – here is a bit of a taste of the sort of thing I have been working on.

Todays’s video is a simulated critical care airways case.  Mr Roger Flower is a 73 yo chap in type 1 respiratory failure who is starting to clap out.  He is going to be transferred 2000 km to the closest ICU via Flying Docs… but first we need to take control of his airway and ventilate him of the trip.

There are many ways to skin a cat and many tools with which to do it.  This is how our team functions in Broome.  Big thanks to my colleagues Drs Dave Hailes, Trent Little, Nick Gilbert and Rachel Cane (CN) for being the guinea pigs in this sim.

I hope you enjoy it and please feel free to offer your insights, preferences etc – only by sharing do we all learn.

On with the show (it’s about 15 minutes)…. DIRECT DOWNLOAD HERE

This version has been compressed to make it easy to download.  If you would like a high-res copy, just let me know.

If you are keen to read / hear more about some of the techniques used – follow these links to the best Med Ed out there:

DSI from Dr Weingart

Apnoea Oxygenation  more from Drs Weingart and Levitan

RAMPing via LITFL critical care compendium

Own the Oxylog an oldie but a goodie!

Casey

 

PlayPlay

PODCAST: Really Rural Surgery with Dr. Bret Batchelor

Dr Bret Batchelor is a Canadian GP working in rural British Columbia.  He is also a part-time surgeon practicing his “Extended Surgical Skills” in a small town.

Over the last year Bret has been podcasting at “Really Rural Surgery“.  The podcast is a heavily evidence-based look at the practice of Surgery & procedural Obstetrics with a focus on doing common procedures in the small towns.  There is a strong flavour of “medical myth busting” which we love!

Bret was kind enough to spend half an hour chatting with me about his practice, the ethos of rural procedural work and how to train in the field.

If you are interested in Rural Surgery or EBM check out the podcast and site here.

Bret is on Twitter @ReallyRuralSurg  – he is a super smart guy and keen to spread the word – so ask him some questions and send some comments to the site.  Are there any questions you want answered about everyday Surgery?

Here is the podcast:

DIRECT DOWNLOAD

Casey

Dr Dave Forster: A tough airway made easy

Welcome back!  Apologies for being away for a few weeks.  You may know that a large part of the FOAM community was attacked, hacked and disabled by malignant robots last month.

Thanks to Dr Mike Cadogan and his band of merry men we are now back online along with other awesome sites that fell victim to this pillaging ( KIDocs, St Emlyns, The RAGE podcast, etc).

In case you missed the podcast was still alive during the carnage over at the LITFL bunker… and I managed to record a little chat with my local hero and fellow Broome Doc – Dave Forster.

Dave is a man of many talents, he is a gadget guy = remote controlled airplanes etc.  He is therefore a master of the Atari and fiberoptic bronchoscope!  And many don’t know this – but if you download the free “Introduction to Bedside Ultrasound” textbook and check out the SUSSIT chapter – his is the really, really hairy chest used for still images.  (And yes, he does routinely wear a Bon Jovi T-shirt to work… overdressed for Broome some might say 😉

Dave F

What a man: sono-model and master of the airways.  You can even follow him on Twitter after a few years of arm twisting he is on there @DavidFo00088350

In this podcast he outlines his approach to a really tough, “back to the wall” case where an airway needed to be placed in a really difficult scenario.

Sure there are some great technical pearls in here, but for me it is all about the team and how a confident, communicative leader can turn a shit storm into a sleigh ride.

Have a listen HERE.  Then spend a moment thanking Mike Cadogan and his team for all this stuff that you, our fantastic audience, get for free.  Without folk like Mike we would not have FOAM… and the Medical world would be a bigger, emptier and less safe place.

Casey

PODCAST: Pushing Pressors in the Periphery

The mantra of the Broome Docs site is “bringing great care, out there.”  And today’s topic goes right to the heart of that theme.  It is one of my pet topics – so apologies in advance if the rant is too long or detailed.

This is a discussion about the early management of septic patients.  I live and work in an area where this is a common and deadly problem.  Care is far from the idealised ICU practice.  However in recent times the playing field has been levelled by new data that suggests that maybe a simpler approach can deliver good outcomes.  So this is my attempt to deal with a wicked problem – remote resuscitation of the shocked septic patient.

Although I am talking about how I think we can do it well in remote areas, I imagine some of this discussion is just as relevant in a big city ED.  Specifically this is an attempt to make a case for the early and liberal use of vasopressors [particularly noradrenaline] in patients with septic shock.

There has been a huge amount of evidence published and paradigms shifted in the last 12 months when it comes to the early management of sepsis.  EDGT is out.  What is in?   Well –  solid, careful and timely delivery of the basics of:

  1. resuscitation,
  2. early appropriate antibiotics with
  3. aggressive source identification and control.

It has been famously stated that in the  post-EGDT era: it doesn’t matter what “shit” you give, as long as you “give a shit”.  The substantial improvements in patient outcomes over the last 12 years have come about probably as the result of clinicians being more aware of the urgency of care and being proactive in their management.   We have also likely reduced the rate of iatrogenesis in that time period.

So this discussion focuses on the first part of that triad of early care for the septic patient: RESUSCITATION.  In most small hospitals the resuscitation basically includes IV fluids and after that has failed some sort of vasopressor.  Here in rural Australia there are really only 2 commonly used ‘pressors’ – metaraminol [darling of the bush anaesthetist] and noradrenaline [norepi for my N. American readers!].  Now I know that some will argue that Norad is not just a vasopressor, and that is true.  However, at the doses it is commonly used its main effect is on the venous circulation.  So humour me!

OK – so here we go.  I am going to try and convince you that we ought to be using:

  1. Noradrenaline
  2. through a peripheral cannula (initially)
  3. early in the Resus phase
  4. in a concomitant or synergistic manner with judicious fluids

Now I realise that there are several controversial / new ideas in that list.  So have a listen to the podcast as I try to make a case for using this newish, some may say aggressive, strategy in the early management of septic patients.  I am specifically referring to patients whom are being cared for in low-resource centres – places without 24 hour cover, no Crit Care facility or ICU trained Docs.  That maybe in the middle of the Kimberley – or it could be in your local hospital between the hours of midnight and six AM!

Have a listen.HERE

Casey

REFERENCES:

Dr John Myburgh’s excellent discussion of “FLUIDS: 2015” on the ICN Podcast is here

Dr Paul Marik’s recent dissection of : “the demise of EGDT” [from Acta Anaesthesilogica Scandinavia ]

the NEJMs trilogy of the:

Dr Bai et al Early versus delayed administration of norepinephrine in patients with septic shock.  From Critical Care Oct 2014

Ricard’s RCT of central vs peripheral catheters in ICU

Loubani & Green systematic review of peripheral vs. central vasopressors Journ of Crit Care June 2015.

Weingart: Podcast 107 – Peripheral Vasopressor Infusions and Extravasation

PODCAST: Dr Airell Hodgkinson

Gday and welcome back to the podcast after a short hiatus as I checked out the fish in Fiji…  Ahhh.

Today’s podcast is a conversation I had with my former colleague and mentor Dr Airell Hodgkinson.  Airell is a rural GP Anesthetist based in Albany – the southern end of WA.

He is a real thinker and has similar interests in trying to ensure our rural patients get the best quality care which they deserve.  Airell has recently concluded an audit of the local Albany cohort of “fractured NOF” patients.  He has collected the data to see how this group of high risk patients fare in Albany and compared it to those whom were transferred to a metropolitan hospital for surgery / anaesthesia etc.

The data is quite interesting – but not yet published… so watch this space.

Although it is an audit of older people with NOFs – there is a lot we can learn from this review – particualry when it comes to the decsion-making around transferring rural patients to tertiary care for serious illness.  Although it seems like a good idea on first thought – one has to consider a lot of factors when making these decisions with our patients.  As there are a lot of problems associated with transfer – especially for conditions with a time-critical course and where the rate of bad outcomes can be high.

From the outset – the Broome Docs motto has been: “delivering great care, out there!”  And it is something that I think about a lot – are we doing the best thing by this patient by keeping them in a small rural cetre – or could they get better care in the city?  This is a really tough call – especially when the patient wants to stay in the bush and for you to do “your best”.

In Broome, our capacity to provide great care has increased in recent years for conditions like sepsis, mental health clients, trauma and other medical emergencies.  As such the lines have moved in terms of who we keep or whom we send “south” (or east!)  Most of my practice is shaped by anecdote and receny bias – so it is really nice to see Airell has managed to collect some hard data around a group of patients where there is no good answer often.  This is a dynamic and wicked problem – one where there are many unknowns. BUt now we have a bit of data to have htat important discussion with our patients before deciding on the best place for their care.

OK – onto the podcast!
DOWNLOAD HERE