SMACCUS : Feeling the FOAM love

Writing this post from O’Hare Airport on my way back to Broome after SMACCUS.  40 hours in an aluminium tube….  [Kevin Fong has re-analysed the safety of air travel, so I’m feeling relatively safe… a bus would be safer!]

Looking back on the conference of the year.  There were some great moments, some spectacular ideas shared and plenty of education.  However, the best aspect of SMACC is the amazing connectedness and camaraderie that I feel at the tea breaks and social functions.  Sure, we all introduce ourselves by our Twitter handles! For the newcomers it seems a bit strange at first, but that moment of recognition when you can connect a smiling face to the years of digital dialogue you have shared is priceless.

On Day 1 I was due to give a talk after lunch.  As always I was a bit nervous.  I had planned a bit of an impromptu experiment in public speaking, and was a little concerned that it may flop!  Sometime in the morning I dropped my credit card in the hallway.  Man, another stress I did not need on the day!  But the awesome thing about SMACC is that a complete stranger, somebody whom I had never met online sent me a Tweet and handed it back within 20 minutes!  That is cool.  At what other conference or mass gathering would that happen?  I was feeling the FOAM Love!  And I knew that my little social experiment in evangelical Karaoke was going to work!  Everyone at this conference wants to be here, to connect, to share and get involved in the FOAM movement.

Sometimes I hear criticism of the SMACC / FOAM movement – people liken it to a cult of celebrity.  Is this true?  I don’t think so.  If anyone at the conference spent a moment chatting to the luminaries like Scott Weingart, Simon Carley, John Hinds, Chris Nickson, Vic Brazil or the other leaders – they would quickly realise that these people have tiny egos and do what they do because they want to improve healthcare.  They want the rest of us to walk out inspired, educated and challenged – to go back home and deliver the best care that is possible.

SMACC was particularly special for me this year.  I was able to meet a heap of the North American FOAMites that I have spent years working “alongside” and admiring.  On day 2 I watched the awesome spectacle that my Ultrasound buddies put together – SONOWARS.  At the end of the session James Rippey asked me to come up on stage.  James is my Ultrasound mentor – a true master under whom I have apprenticed in this crazy electronic age.  Although it did feel a bit indulgent to share this special moment in front of the crowd – I am glad we did.  For this is what FOAM is all about – finding your master, teacher or mentor.  And becoming a teacher to the next generation of brilliant young minds.

And then there was the song…

I wrote these lyrics for my lecture: “No Xray, No Problem!”  It was a talk about how we can use Ultrasound to be better doctors.  But it seems to have served as a sort of anthem for the FOAM LOVE which we all feel.  So here it is [Thanks to  @GruntDoc for the video].  Please share it with your colleagues.  See you in Dublin.   Casey

Imagine there’s no X-ray from GruntDoc on Vimeo.

Countdown to SMACCUS

G’day All

I am sitting in Jackson Lodge writing this post after what has been an amazing week of learning, meeting new friends and seeing some spectacular parts of the U.S.A.   I have been inspired by my fellow Yellowstone US teachers and our awesome students.  And this is just a small taste of what SMACC has to offer!

IMG_3636

My favourite part of the last few SMACC events has been having to opportunity to meet in person all of you – the FOAMites.  Yellowstone has been great, so many new friends… but now I am off to Chicago for the main game, SMACCUS.

So if you are a Broome Docs reader / listener and are coming to SMACC, then please come and say “hello”.  Share a few ideas and if you have a “Lessons Hard Learned” tale that you want to share, just let me know – I will have my mic in hand and want to hear your story.

OK… last chance for a SMACC RUN warmup at altitude – gotta get those lungs working!

See you all in Chicago… or on Twitter if you cannot make it

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

Awesome Ultrasound Learning

Hi All

This is a quick post to let you know about a few great Ultrasound resources that are out there.

Sure everyone knows about the Ultrasound Podcast – unless you are a subpetrous life form!

But – there are a number of really nice, lesser known, well made educational Ultrasound sites out there.  So here are a few of my favourites:

  • SONOSPOT : a really nice blog written by Dr Laleh Gharahbaghian and friends.  There are cases, educational videos and a lot of literature reviews.  She also has a really extensive blogroll on her site – with links to heaps of other ultrasound resources.
  • 5 Minute Sono: From the “southern Gentry” of ultrasound – Drs Jacob Avila and Ben Smith have put together a really slick site with, as you might expect, 5-minute videos of all the common US applications.  Really well done with excellent images and narration. Note to my JMOs – you need to watch all of these videos soon!
  • Highland Ultrasound: a blog with a range of videos – largely aimed at ED and regional nerve blocks.  Written by Dr Arun Nagdev and friends out of Highland Hospital in Oakland, California.
  • Emergency Ultrasound Teaching: another American ED US site – lots of short instructional videos and cases – similar to some others – but spaced repetition is key to learning the art of Ultrasound!
  • The mega-blog Academic Life in EM has a section devoted to Ultrasound – there are great literature reviews of the evidence and cool “US for the Win” cases.  Part of the big ALIEM machine – well done and peer reviewed for high quality.
  • The Sono Cave and US Village are sites run by my own mentors and local west Aussie mates Dr James Rippey and Adrian Goudie & co.  Educational lectures, cases and my favourite are the “report cards” which you can print out for reference or laminate and put on your machine.
  • Ultrasound of the Week – also by Dr Ben Smith. A weekly case study with US to test your sono-skillz and see how the pros do it!  Narrative is key to my learning – so I love the cases and frequency is perfect!
  • Dr Chris Fox is a legendary US teacher out of UC Irvine.  He has put a whole heap of free video lectures up on iTunes  – well worth watching on various topics.  Has a great way of explaining the phenomena you will see and how to apply it in practice.

OK.  So that is the big, tip of the US Educational iceberg – there are so many other great sites out there.

Please let me know on the comments about your site, or a site that you find really useful.  Always on the hunt for some new material and perspectives.

P.S:

If you happen to be a Broome JMO or plan to come to Broome in the future – then check out as many of these as you can.  Having a good grip on the theory and how to apply it is great before you hit the ground and start trying to make decisions.  And that stuff is best taught by experts – doctors whom are masters of the craft.  Then we will play with the probes and our patients will prosper!

Casey

Awesome Ultrasound Learning

Hi All

This is a quick post to let you know about a few great Ultrasound resources that are out there.

Sure everyone knows about the Ultrasound Podcast – unless you are a subpetrous life form!

But – there are a number of really nice, lesser known, well made educational Ultrasound sites out there.  So here are a few of my favourites:

  • SONOSPOT : a really nice blog written by Dr Laleh Gharahbaghian and friends.  There are cases, educational videos and a lot of literature reviews.  She also has a really extensive blogroll on her site – with links to heaps of other ultrasound resources.
  • 5 Minute Sono: From the “southern Gentry” of ultrasound – Drs Jacob Avila and Ben Smith have put together a really slick site with, as you might expect, 5-minute videos of all the common US applications.  Really well done with excellent images and narration. Note to my JMOs – you need to watch all of these videos soon!
  • Highland Ultrasound: a blog with a range of videos – largely aimed at ED and regional nerve blocks.  Written by Dr Arun Nagdev and friends out of Highland Hospital in Oakland, California.
  • Emergency Ultrasound Teaching: another American ED US site – lots of short instructional videos and cases – similar to some others – but spaced repetition is key to learning the art of Ultrasound!
  • The mega-blog Academic Life in EM has a section devoted to Ultrasound – there are great literature reviews of the evidence and cool “US for the Win” cases.  Part of the big ALIEM machine – well done and peer reviewed for high quality.
  • The Sono Cave and US Village are sites run by my own mentors and local west Aussie mates Dr James Rippey and Adrian Goudie & co.  Educational lectures, cases and my favourite are the “report cards” which you can print out for reference or laminate and put on your machine.
  • Ultrasound of the Week – also by Dr Ben Smith. A weekly case study with US to test your sono-skillz and see how the pros do it!  Narrative is key to my learning – so I love the cases and frequency is perfect!
  • Dr Chris Fox is a legendary US teacher out of UC Irvine.  He has put a whole heap of free video lectures up on iTunes  – well worth watching on various topics.  Has a great way of explaining the phenomena you will see and how to apply it in practice.

OK.  So that is the big, tip of the US Educational iceberg – there are so many other great sites out there.

Please let me know on the comments about your site, or a site that you find really useful.  Always on the hunt for some new material and perspectives.

P.S:

If you happen to be a Broome JMO or plan to come to Broome in the future – then check out as many of these as you can.  Having a good grip on the theory and how to apply it is great before you hit the ground and start trying to make decisions.  And that stuff is best taught by experts – doctors whom are masters of the craft.  Then we will play with the probes and our patients will prosper!

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.

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