EMCrit Podcast 137 – Delayed Sequence Intubation (DSI) Update

The DSI study is finally published! Listen to this podcast for a discussion of the paper and the things we have learned since the original DSI podcast.

For all of the notes, links to the article and to be able to comment; click over to:

EMCrit.org/DSI

For Mike Stone’s Free DVT book…

Practical Ultrasound: DVT

 

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EMCrit Podcast 136 – Getting Shit Done

get-shit-done-mug-4

So my friend Michelle Lin was kind enough to solicit a “How I Work Smarter” piece on her excellent ALIEM blog. One of the things I mentioned in that piece was a book called Getting Things Done. I’ve since gotten a bunch of questions and comments about the book. I’d like to take a brief diversion from the main topic of EMCrit and discuss a bit about the book and productivity for docs and resuscitationists.

The Books

The Philosophy

A clear mind eliminates stress and allows creativity, so…

Capture all the things that need to get done into a logical and trusted system outside of your head and off your mind, and…

Discipline yourself to make decisions about all the inputs you let into your life, so that you will always have a plan for next actions that you can implement or renegotiate at any moment

(altered from Mindzone Wiki)

Problems with the Book

  1. Mindset of the Author
  2. Based on an erstwhile paper-based world
  3. Can be read as Dogma

The Steps of GTD

Collect/Process/Organize/Review/Do

1. Collection/Universal Capture

Inbox(es)

2. Process

What is it?

Is it an action, spam, or something non-actionable you want to keep?

Action Processing

  • Decide if you want to Do it, Don’t do it, Delegate it, or Put it in your system
  • Is it a project?
  • What is the physical next action that must occur to bring you 1 step closer to completion
Next Actions & Projects

cascading for gtd

Reference Processing

Things you just want to keep or references for actions

Eliminate Paper!

scansnap

 

3. Organize-If you are not doing it right now, put it in the system

  • NirvanaHQ or Omnifocus
  • GCal with Fantastical
  • Add all reference material as links in your system

Calendar

Only things that absolutely must happen at this date/time

Lists on Task Management System

nirvana lists

Especially important to have a someday/maybe list, a waiting list, and have a thorough understanding of scheduled events.

4. Review

Daily

  1. Try to process all email
  2. Kill all paper
  3. Clean off Desktop
  4. Look at Calendar
  5. Look at Focus and Inbox
  6. Make a To-Do Card
  7. Pack for next day

to-do-card

Weekly

(this list is from Mindzone wiki)

  1. Loose Papers
    • business cards, receipts, etc. – put in in basket for processing
  2. Process Your Notes
  3. Previous Calendar Data
    • review for remaining action items, reference information, etc.
  4. Upcoming Calendar
  5. Empty Your Head
    • write down any new projects, action items, etc.
  6. Review “Projects” (and Larger Outcome) Lists
    • ensure that at least one kick-start action is in your system for each
  7. Review “Next Actions” Lists
    • Mark off completed actions & review for reminders of further action steps to capture
  8. Review “Waiting For” List
    • Records appropriate actions for any needed follow-up & check off received items
  9. Review Any Relevant Checklists
  10. Review “Someday/Maybe” List
    • Check for any projects that may have become active and transfer them to “Projects” & delete items no longer of interest
  11. Review “Pending” and Support Files
    • Browse through all work-in-progress support material to trigger new actions, completions, and waiting-fors

Quarterly

Higher Level Goals and a super-thorough version of weekly review

Yearly

Vision, Life, Clean Out All Files, Am I going in the right direction?

5. Doing

Happens naturally if you use the method above. However, I alter the canonical method with my daily to-do card and the focus section of nirvana

The Initial Dump (this comes first, but is being discussed last)

You will fall off the wagon

Not a problem, redo the initial dump and start up again

Flowcharts

Here is a pdf of the simplified workflow from DavidAllenCo.

A more elaborate version is here:

David Allen Workflow

GTD Flow from DavidAllenCo

Other People’s Take

Things to Do Immediately

Please tell me your thoughts on this episode. Use the comments section below

Now on to the Podcast…

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EMCrit Podcast – Trauma Thoughts with John Hinds

john-hinds

@docjohnhinds is the man behind Cricolol

I recently brought him to our EM Critical Care Grand Rounds at @stonybrookem

He gave two fantastic lectures! I then brought him back to EMCrit Studios to record a few of the take-home lessons from his talks.

See Cases from the Races on the RagePodcast site to see the inspiration for this ‘cast.

Blunt Traumatic Arrest: a Road Racing Doc’s Approach

If the patient is in blunt traumatic arrest, John and his team immediately perform the following before any further assessment:

  1. Intubation using a bougie and confirmed by waveform CO2
  2. Perform Bilateral Finger Thoracostomy
  3. Place Pelvic Compression Device
  4. Straighten Long Bone Fractures to Length
  5. Administer Fluid Bolus (Administer Blood if In-Hospital)

Only then reassess and decide what to do

Impact Apnea

Airway positioning and rescue ventilation can save a life

More on this soon when the Wilson, Hinds, Davies study is published. Until then, see the LiTFL CCC Entry

Central Line Placement

In John’s unit, they use infraclavicular left subclavian for all ICU CVC placements

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EMCrit Wee – I Thought This Would be the One, but Nope….

Hug a Researcher

EMCrit specializes in Type 2 Translation and Implementation. That crap wouldn’t exist without the researchers. Go find a Critical Care Researcher today and give them a hug.

But they Weren’t Sick Enough…

SSC Reverses their Stance on EGDT (Sort of…)

What do folks thing EGDT still brings to the table?

Cognitive DeBiasing

Please ask yourself, before you air your viewpoints in public, are you displaying Confirmation Bias

bias-cartoon

Shown to Me by G. Kovacs

 

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Podcast 134 – ARISE has arisen; now where do we stand on Severe Sepsis in 2014

SMACC-Final-Sepsis1

So the Arise Study (Australasian Resuscitation In Sepsis Evaluation) just dropped. The amazing guys at the Bottom Line did a summary (saving me a bunch of work)

Baseline Characteristics

baseline characteristics

Table S5-Therapies in the first 6 hours and 3 days

table-S5

Videos from a Prime Author

Hear from Sandra Peake

Recognition-Find em’ Early

SIRS+

Lactate or Persistent Hypotension (Arise used 1 liter)

I would use STOP Sepsis Campaign Modification of SIRS Critieria, so you don’t need to wait for cbc

SNAG-0016

Treatment-Treat the Source/Perfuse the Tissues

sepsis priorities

Antibiotics

Another trial showing early abx are associated with goodness

If a patient is sick and you don’t know what is going on, just give them appropriate spectrum abx. If a patient is persistently hypotensive and you don’t know why–give them abx.

Source Control

Early, early, early

Don’t box ‘em with the tube

See the Hemodynamic Kills Lecture

The Right Amount of Fluid

Use whatever method you want, but you should probably give between 3-4 liters

Early Vasopressors

Give them peripherally to get them in fast and then you should probably put in a line

If you have given 3-4 liters, the patient probably deserves pressors for venous squeeze before giving more fluid

Check Your Work

Serial lactates?

Put them in a Monitored Setting

b/c of the way septic patients die

Other Stuff

Blood

No role for blood, except in niche cases, until Hb < 7 from the recent TRISS Trial (PMID 25270275)

Fewer pts got blood in EGDT group of either ProCESS or ARISE than the original EGDT study

Dobutamine

who the hell knows

Want to Hear from the Primary Investigator?

Oli Flower did a podcast in which Anthony Delaney addresses many comments from this post. Here’s Oli:

Thanks Scott for your insights on ARISE and the state of play of sepsis management in 2014.

These open discussions that your podcast stimulates are incredibly important and essential for translating research findings into practice, and getting the important messages and critical interpretation of the data to as many people as possible!

Yesterday I interviewed the ARISE PI Anthony Delaney to hear his take, now he’s allowed to finally talk about the results, and I went through a lot of your listener’s comments to get an answer from the horse’s mouth.

The interview is here:
http://intensivecarenetwork.com/delaney-arise-study-emcrit-dogmalysis/

Cheers,
Oli

What do you think? Let me know below.

Now on to the Podcast…

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EMCrit Podcast 133 – The First Prehospital REBOA

field-reboa

A few months ago, we spoke about REBOA-resuscitative endovascular balloon occlusion of the aorta. You might have thought to yourself, “Interesting, but I’ll never be doing that.” Well, not so fast, on today’s podcast we speak to the retrieval doctor that performed the first REBOA in the field.

REBOA in the Field and the ED

Gareth-Davies

In London, the idea of bringing REBOA to the field and the ED was made reality by Gareth Davies. Dr. Davies is Chair and Medical Director of the London Air Ambulance (London HEMS), one of the best HEMS services in the world. In the first part of the podcast, we hear how he conceptualized and enacted the plan to bring REBOA to the field.

REBOA Training at London HEMS

REBOA Training at London HEMS (Photo by Andy Patton @AndyP_91)

The First Prehospital REBOA

JonnyPriceThen we speak with Jonny Price, Anesthesia and Intensive Care registrar doing a secondment in HEMS. At the time of the events of the podcast, he was flying with London HEMS. His story of the first prehospital REBOA is fascinating.

Special thanks to Cliff Reid for making these interviews possible.

EVO-Logo-on-White

SMACC Equipment Videos Online (EVO) Competition

Consider submitting a video and winning a free registration to SMACC Chicago. Go to the SMACC Site and Enter Now.

Now on to the podcast…

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Podcast 132 – MoTR – Toughness Part I with Michael Lauria

pj

Today, I interview Mike Lauria on the concepts of toughness and resilience.

The Rationale of Selection Courses/Indoc

80-90% Attrition for the PJs Indoc

One of the things that people, I think, find distasteful about selection programs in the civilian word is that it uncovers fundamental weaknesses and shortfalls.  This is no commentary on the intrinsic worth of the individual.  It doesn’t necessarily mean that they are smart or dumb.  But it is indicative of some inability or failure to meet a standard.  While it is hard for many civilians (and military members for that matter) to swallow, perhaps not everyone is cut out for a particular discipline.  Maybe we shouldn’t be forcing training, pushing people along, coddling individuals to maintain the outward appearance that a program is “successful” if an individual can’t make it through some sort of initial pipeline.  Perhaps a benefit of selection is making sure that the right people are there to begin with and the individuals that were simply not made for it are directed elsewhere.

I lost the source for the above quote, but I think it describes the process well. If anyone has it, please send me the attribution.

Builds an innate Espirit de Corps and a common thread of self and team-reliance

Residency as the Pipeline

Should we have culmination tests and exercises at the end of residency?

Stress Inoculation/Cognitive Tempering

Mike discusses four stages to do this right:

  1. Conceptualization-give a background of stress responses, why they happen, and what to expect.
  2. Train and educate on the skills and tasks we want to see performed under stress. Then give the tools to deal with the expected stress. The latter is where we may be failing our learners
  3. Do a dry run to train in simulation without added stressors
  4. Run the same training with stress inoculation

How can we make #4 work in EM/CCM?

Sound, distractions, equipment failures, and deliberate poor communications

So what tools can we offer for #2?

Mike offers an acronym: Beat The Stress, Fool

  • B is for Breathe. Breathe tactically. See the On Combat Podcast for a description (and there is an app for that too: Tactical Breather App)
  • T is for Talk. Self Talk. Positive self-talk is used by athletes and any elite performance group.
  • S is for See. Visualization. Visualize yourself performing the task exactly how you want to see it done.
  • F is for Focus. A key word to activate the state you want. Mike has chosen “focus” as his word. We then had a brief discussion of the book, the Art of Learning by Josh Waitzkin. The author creates an entire relaxation and mindset ritual that eventually gets boiled down to a key word or short set of actions. You’ll be hearing more about this book on the podcast.

When Mike asked if I had anything to add to this excellent set of tools, I discussed this TED Video by Dr. Amy Cuddy:

 

So maybe…Beat the Stress, Foolish Padawan with a P for posture??

Too Much Macho Militarization?

Mike posted a Youtube Video Addressing this question

Cliff Reid’s Resus.me Post on Self-Defense

During the intro, I discussed the contentious self-defense post on resus.me

Update

Some Anesthesia programs are already doing a modified interview process–thanks Lauren!

SNAG-0001

Here is the article: (non-tech-skills-interview-process)

Now on to the Podcast…

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EMCrit Podcast 131 – Cut to Air: Surgical Airway from SMACC Gold

machete

This is the resource page for all things Crics (Cricothyroidotomy)

We spoke a ton about cricothyrotomy way back in episode 24; this is an update

Understand the Surgically Inevitable Airway (thanks, Rich)

In appropriate circumstances (prophylactic cricothyroidotomy) has numerous advantages, not least the potential to secure and check the ‘rescue airway’ in a calm and unhurried manner, without hypoxia, before an emergency arises

— NAP4 Study

Anatomy

Use a Checklist so you are Ready!

CricCON2

Click for Full-Size

Click for Full-Size

Here was the original CricCON Wee

Which Trach Should you use?

Needle Cric

I don’t recommend this method, but some just will never feel comfortable cutting the neck

Cricothyrotomy Lecture Videos

Build a Cric Trainer

Here are My Slides

Now on to the Video…

EMCrit Podcast 130 – Hemodynamic-Directed Dosing of Epinephrine for Cardiac Arrest

epi-pen

Today on the podcast, I address the last little bit from my SMACC lecture on the new management of the intra-arrest: hemodynamic, individualized dosing of epinephrine.

normanparadisadonehThe podcast is interspersed with clips from Professor Norman Paradis

Articles/Posts on Epinephrine by ACLS Guidelines

  • (15306666),
  • http://www.emdocs.net/epinephrine-cardiac-arrest/
  • http://www.jems.com/article/patient-care/new-resuscitative-protocol
  • (24846323)
  • (19934423)

Epinephrine Dosing Based on DBP

Three Swine Study

(Crit Care Med. 2013 Dec;41(12):2698-704)

(Resuscitation. 2013 May;84(5):696-701)

(24945902)
Here is the abstract from the latter study:

AIM: Advances in cardiopulmonary resuscitation (CPR) have focused on the generation and maintenance of adequate myocardial blood flow to optimize the return of spontaneous circulation and survival. Much of the morbidity associated with cardiac arrest survivors can be attributed to global brain hypoxic ischemic injury. The objective of this study was to compare cerebral physiological variables using a hemodynamic directed resuscitation strategy versus an absolute depth-guided approach in a porcine model of ventricular fibrillation (VF) cardiac arrest.

METHODS: Intracranial pressure and brain tissue oxygen tension probes were placed in the frontal cortex prior to induction of VF in 21 female 3month old swine. After 7minutes of VF, animalswere randomized to receive one of three resuscitation strategies: 1) Hemodynamic Directed Care (CPP-20): chest compressions (CCs) with depth titrated to a target systolic blood pressure of 100mmHg and titration of vasopressors to maintain coronary perfusion pressure (CPP)> 20mmHg; 2) Depth 33mm(D33): target CC depth of 33mm with standard American Heart Association (AHA) epinephrine dosing; or 3) Depth 51mm(D51): target CC depth of 51mm with standard AHA epinephrine dosing.

RESULTS: Cerebral perfusion pressures (CerePP )were significantly higher in the CPP-20 group compared to both D33 (p<0.01) and D51 (P=0.046), and higher in survivors compared to non-survivors irrespective of treatment group (P<0.01).Brain tissue oxygen tension was also higher in the CPP-20 group compared to both D33 (P<0.01) and D51 (P=0.013), and higher in survivors compared to non-survivors irrespective of treatment group (P<0.01).Subjects with a CPP>20mm Hg were 2.7 times more likely to have a CerePP>30mm Hg (P< 0.001).

CONCLUSIONS: Hemodynamic directed resuscitation strategy targeting coronary perfusion pressure>20mmHg following VF arrest was associated with higher cerebral perfusion pressures and brain tissue oxygen tensions during CPR. University of Pennsylvania IACUC protocol #803026.

Human Study by Dr. Paradis

Coronary Perfusion Pressure and the Return of Spontaneous Circulation in Human Cardiopulmonary Resuscitation

(10.1001/jama.1990.03440080084029)

Coronary perfusion pressure (CPP), the aortic-to-right atrial pressure gradient during the relaxation phase of cardiopulmonary resuscitation, was measured in 100 patients with cardiac arrest. Coronary perfusion pressure and other variables were compared in patients with and without return of spontaneous circulation (ROSC). Twenty-four patients had ROSC. Initial CPP (mean±SD) was 1.6 ± 8.5 mm Hg in patients without ROSC and 13.4 ± 8.5 mm Hg in those with ROSC. The maximal CPP measured was 8.4 ±10.0 mm Hg in those without ROSC and 25.6 ±7.7 mm Hg in those with ROSC. Differences were also found for the maximal aortic relaxation pressure, the compression-phase aortic-to— right atrial gradient, and the arterial Po2. No patient with an initial CPP less than 0 mm Hg had ROSC. Only patients with maximal CPPs of 15 mm Hg or more had ROSC, and the fraction of patients with ROSC increased as the maximal CPP increased. A CPP above 15 mm Hg did not guarantee ROSC, however, as 18 patients whose CPPs were 15 mm Hg or greater did not resuscitate. Of variables measured, maximal CPP was most predictive of ROSC, and all CPP measurements were more predictive than was aortic pressure alone. The study substantiates animal data that indicate the importance of CPP during cardiopulmonary resuscitation.

Good Review on Epinephrine

Epi Review

AHA Cardiopulmonary Resuscitation Quality Statement

by Meaney P. et al (Circulation 2013;128:417)

Metrics

  • CCF>80%
  • Rate 100-120
  • 5cm depth
  • Full Recoil
  • <12 BPM, Minimal Chest Rise

Monitoring/Feedback

  • Art/CVP CPP>20
  • Just Art Line DBP>25-30 (I disagree)
  • ETCO2>20 mm Hg

If DBP < 20 optimize compressions or vasopressors (Circulation 2011;123:e236)

CVP can be higher during the poor flow of the arrest state (3970745),(Am J Emerg Med. 1985 Jan;3(1):11-4.), and (3946853) and this one had a mean of 16 (10.1161/01.CIR.80.2.361)

so I would shoot for 35-40 mm Hg

Goal is to give less epineprhine

Hemodynamic-directed CPR Review

(24783998)

Now on to the Podcast…

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Bibliography

MotR – Mike Lauria on “Making the Call”

Mind of the Resuscitationist Wee

MikeLauriaMike Lauria is the @resuspadawan. You’ll be hearing a lot more about Mike when he comes on the show for an interview. For now, know that he was Air Force Pararescue, now a medic on the Dartmouth-Hitchcock Advanced Response Team (DART), and will be starting medical school in the Fall. He has a special interest in cognitive decision making under stress, aka the Mind of the Resuscitationist.

Recognition Primed Decision Making (RPD)

Sources of Power by Gary Klein

OODA Loop

From 40-second Boyd. Read a summary on wikipedia

ooda-loop-small

Cognitive Unloading

  • Standardization & Preparation
  • Checklists
  • Premade Decision Points and Triggers

Cognitive Rally Points (Stop Points)

  • Hard and Soft Rally Points
  • Take a Deep Breath

Build Decision Making Power

  • Deliberate Practice
  • Review Experiences
  • Timely Expert Feedback
  • Socratic Method-Suck it Up!
  • Simulation

Stress Inoculation

  • Cognitive Tempering
  • The Rule of 130%-do the basics better than anyone else
  • Limbic Learning-emotional reaction burns it in
  • Train until you can’t get it wrong
  • You fall to the level of your training

Stay Flexible

  • Cognitive Flexibility
  • Acknowledge BIases
  • Ask disconfirming questions

The Slides

Now on to the Lecture…

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