Medmastery: AC/SIMV modes

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The team at Medmastery are providing LITFL readers with a series of FOAMed courses from across their website.

Checking out the Mechanical Ventilation Essentials course today with a video exploring assist control (AC) and synchronized intermittent mandatory ventilation (SIMV) modes on a ventilator.

Further reading:

Guest post: Josh Cosa, MA, RRT-ACCS, RRT-NPS, RCP. Registered respiratory therapist and respiratory care practitioner, Clinical Education Manager at Philips.

I received my license to practice in 2003 and I have been teaching, managing, monitoring, and modifying ventilator settings ever since. I live in Southern California and have learned from and worked with some of the best teachers anyone could meet.” –Josh Cosa

Medmastery: AC/SIMV modes sabrine

How to be The Shop Floor Clinician

LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Once in a while we don’t have to be Epic. We can be a plain worker bee, low ranking, mission brown, a serf. We are permitted to hitch up our strides like peasants, and get on with the business of hoeing through the garden of the unwell.

Such freedom, you say. None of the high-level responsibility of being in charge of the department. No duty phone. No behaving like an epileptic desperado when asked to go to a flow meeting. Just good, honest toil.

I’ve been doing this job for a while now, and I’d like to share with you some of the wisdom I’ve attained over the years. I believe I may have something to offer – the wealth from my experience. We are now all schooled in wellness and life-balance, and I have taken this gentle, lapping mindfulness to heart. I usually start rostered days by rising at five a.m, meditating for twenty minutes, then fixing an oaty berry bowl of deliciousness, after which I write down a list of things that I craft into an acrostic poem; things about gratitude, goals for the day, things I can teach my juniors, things, other things, aphorisms. And I absolutely would do these things, except that I don’t. Ever. Most days I drive in, late and flustered, already slightly rageful at the insolence of traffic cones, unbreakfasted, in mismatched scrubs, and the most mindful thing I do is try and compose a humorous but slightly pathetic tweet whilst stuck at traffic lights, so that by the time I get into the heaving department, this place bursting at the seams with Very Unhappy People, I will have two, maybe three replies by kind people saying, there, there, it will all be alright. I hope to God they mean it.

I stride in fortified. I have four likes and a retweet. A record. Somebody cares for me.

Faced with a handover, and a to-do list that would make a self-help author blanch (shock this person, drain the CSF from another, placate this patient, find out what’s wrong with this one – please – and maybe this one too), I focus on the main apothegm that will get me through the day. Smile, be kind, and work on being only a minor train wreck. It mostly works.

I fire up the plough. I dive into the innards of people. On the whole my job consists of figuring out what is not wrong with people. I have become an expert in recognising the dark matter of the emergency pathology universe – once I know what is not, I can work out where to deal with what is. This should be simple, except my day is now less ploughing, more running in a blindfolded steeplechase, and not on horses, but cows with a particularly dementing strain of bovine spongiform encephalitis. There are barriers and pitfalls and lava pits and sink-holes. It is not pretty.

As a responsible leader, I do not look at social media while at work. Although perhaps I should reward myself with a little glance every now and then. This means pulling out my phone every two to three minutes to refresh twitter. I tell myself it’s to keep up with the erudite critical care information on this forum. I check my status. One more like. Because I am surreptitious about doing this, and also highly trained (and certified) in hand hygiene, I have taken to wiping down my phone with alcohol gel so many times, the skin on my hands is brittle and cracked, my pockets have an unsettling greasy feel to them, and the phone, while not quite tipsy, is almost unreadable.

I am very keen to teach the interns something. Five minute teaching, bed-side pearls, teaching on the run, that sort of thing. But thus far the potential clinical encounters have been a large-bodied nudist who is currently in dispute with God, several patients with hazy chest pain, a scandal involving a nursing home where one inmate swallowed another one’s tablets, and an extremely briefly run cardiac arrest. I offer nothing. When I do haul an intern aside, me sternly demanding this be a teachable moment, he presents his latest patient to me. I go in to see the patient. This is not the same patient he presented. Different story, different examination features, perhaps even different gender. I kindly confront him about this. He assures me it is the same patient. We sigh.

I, in the meantime, have a patient load all of my own. Decisions decisions. Much of my time is spent trying to work out which specialty team to speak to. Specialties are a broody taxonomy round these parts. I have become accomplished in defusing cantankerously answered consults. An ophthalmology registrar walks past. I know this because he is wheeling luggage, as though he’s navigating the duty-free stores at Heathrow, and he looks scared. I ask if I can help him. Turns out he is scared, and was trying to find the seminar room. Other specialties come and go. Most of them don’t really like us, often for no other reason than we add to their already over-burdened workload. It took me a long time to realise this. Most of them secretly think we’re quite competent, but are afraid to say so, as if this might somehow open the floodgates.

I see more patients. I listen to the shadows and the echoes of the stories in these brushes with humanity. I pull my notebook from my scrubs pocket, and jot things down. After all, I like to write, and these details are the lifeblood of novels. Unfortunately, when I take my notebook out on wash day, I realise I cannot read a single word of what I’ve written. Not one. I also have, on rotation, a set of books that I keep in the other pocket. Virginia Woolf, Keats, other small anthologies of poems. Like my extreme commitment to mindfulness, I read and reflect on these often. Which, actually, is also an Instagram-grade falsehood. Mostly they simply offer succour by being close to me throughout the long day, even if I never read them. I am a poor excuse for a novelist, I realise, and go back to focusing on being a doctor.

For an hour I look after the unbuckled body of a boy in a motorbike crash. I think he might die, and for the duration I have a nameless ache in my entrails, part nausea, part fear, that despite all I know and all I can do, it might not be enough. I might not be enough. He hangs on long enough to get to ICU. A minor success. Cases like this, however, feed on your adrenaline, leaving you tired and depleted. I wish, for the millionth time, that we had little rest-pods; white, comfortable, softly lit refuges, where nobody could reach you for twenty minutes. We don’t. Instead I buy another coffee.

I return to it. The training registrars with whom I work are quite brilliant. I learn bucket-loads from them, and I am sustained by their commitment and energy. We have this quaint setup where they assure me they are learning from me, and are grateful for the on and off floor teaching. They say this sincerely, and we all smile.

Emergency medicine evolves faster than Monsanto canola. It’s hard to keep up with all the latest and greatest (oops, better check twitter again), but, funnily enough, it’s the doing of the basics well that seems to be the most effective tool for the best patient outcomes. Perhaps there’s something to be said for us plodders, turning up again and again, year after year, just trying to do the best for the single patient in front of us. No system or institution is perfect. Ours certainly isn’t. But I honestly believe we do a very good job for most of the people that have the misfortune to hurtle through our doors on their bad days. Their days are our days. We’re in it together, we, the proletariat of medicine. I clock off, joining the queue shuffling out the doors in our overalls.

‘How to be’ series. An Instruction manual for those in Critical Care

How to be The Shop Floor Clinician Michelle Johnston

Jellybean 94 with Salim Rezaie – Teaching teachers about teaching

LITFL • Life in the Fast Lane Medical Blog LITFL • Life in the Fast Lane Medical Blog - Emergency medicine and critical care medical education blog

Teaching teachers about teaching; lets get super-meta.

The Teaching Co-Op. (The event formerly known as The Teaching Course.) It’s in Alcatraz, Brisbane and Copenhagen. It’s in Melbourne, Manchester and Manila. I’d be exhausted just thinking about it if it didn’t sound like so much fun.

Salim Rezaie is a softly spoken, erudite, talented attention avoider. He wants to credit someone else, he wants you to be happy, he wants to perfect the next slide for his next talk. He doesn’t want to give his next talk quite as much as he wants to make the slides but we, the consumers of his inimitable style, are not complaining. Instead we are signed up subscribers, following and forwarding his work because it’s good, very good.

Salim is a bit of a pro. He started out on ALIEM. He started RebelEM as a blog and then he got a podcast up and running. He got into this whole education #FOAMed thing, and from his involvement he became increasingly interested in the processes of the whole teaching/training/learning/simulating/feedback thing. So much so that he realised that there was an appetite, a need, for a resource that helps teachers get better at teaching. We are educators, we are motivated, we know some stuff, but we are often isolated within our various institutions as the education woman or man. We don’t have our own little cadre of education enthusiasts close by to ask for help, to compare notes, to share techniques.

So Salim set one up. He formed a team. He formed a cooperative. He is the leader but the is an incredibly modern type of super-collaborative empathic leader. He is soaking up ideas from all sources. He has gathered a group of super-impressive women and men that help him out. Let’s think for a second about the Teaching Course Faculty. To shed light on this lets bring in my resident philosophical conundrum machine; Cormac.

My son Cormac asks me some very important questions. Last week he asked me a good zombie apocalypse question; “Come the Zombie Apocalypse which of your friends would you want with you to help you survive?” That is an interesting question, it is a thought experiment in utilitarian ethics.

I’d suggest there are a few candidates in the Teaching Coop faculty.

Of course one would have to get into the whole #MetaMoments thing that The Teaching Course is embracing, that means feedback, lots of feedback. The imagined “Flipping MedEd Zombie Apocalypse Survival Team” would be giving and receiving lots of feedback. There would be lots of eye contact and hugs. Hopefully not too much to distract them from the zombies which would give the wrong sort of feed back altogether.

“Whats that noise? Feedback! I hate feedback. No, wait, hang on, I love feedback.”  Neil Young.

Feedback is a love hate thing for many of us, but then have you ever been taught how to take feedback? Give it, maybe, but take it? We can tease ourselves for being a bit meta about all this stuff but there is a reason we are talking about it. If we are mentoring young nurses and doctors, if we are running simulation sessions, (and we are), then we do need to think about all this and more.

The Teaching Course is a constantly evolving set of distinct and imaginative units. There’s presenting skills and simulations skills, there’s mindfulness stuff and an awful lot more. If you are an educator then this course is definitely worth a look. It is so good you may wish to go more than once.

I would. I’d go just to get more down-to-earth wisdom from probably my favourite Texan. (Apologies to Cordell Walker.)

Accidental, old fashioned, sage and reluctant FOAMed star, it’s Salim Rezaie @srrezaie

Check out these Jellybean Podcasts with other Teaching Course Faculty;

It’s like a Jellybean Playlist. I might go and build that Playlist on SoundCloud.

Thanks to Salim for coming along on the podcast. I asked Salim for a piece of music that was from where he was from. He came back with Thunder by Imagine Dragons. I came back with the world famous instrumental version of that song by the legendary Molotov Cocktail Piano and just in case that wasn’t huge enough for you our outro comes from the 8-Bit Misfits and their own misinterpretation of the classic. All of those available on iTunes and so many other places.

Further Listening

JellyBean Large

Jellybean 94 with Salim Rezaie – Teaching teachers about teaching Doug Lynch