Où Allons Nous

I’m on the cusp of the ACEM fellowship clinical exam, surrounded by practice OSCE stems, motivating phrases on a white board, and self-critical thoughts about neglected relationships. This milieu is a psychologically provocative one and I find myself reflecting on a particular piece of art by the synthetist painter Paul Gaugin:

D’où Venons Nous / Que Sommes Nous / Où Allons Nous
(Where do we come from / Who are we / Where are we going)

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Where from?

I stumbled into medicine by chance.  Despite coming from a medical family, medicine in general had never been part of my life agenda. My father, a rural generalist solo practitioner, discouraged me from medicine for the first two decades of life.  After following a crowd into law school post- high-school, I dropped out after one day to begin a stillborn apprenticeship as a chef.  The cooking business lasted a year: by chance I read a book by Russian journalist Anna Politkovskaya on the Russian invasion of Chechnya, which was catalytic in reorienting my career aspirations. Medicine became a craft with a tangible, portable skillset that could be exercised in the spirit of social justice. I was able to piggyback off my high-school grades into medical school and muddle my way though, collecting a handful of mentors along the way. A tragic aside – Politokovskaya was murdered in my second year of medicine – the murder motivated by her social justice advocacy through journalism.

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Anna Politkovskaya, 1958 – 2006 – an unfinished life

Who?

Patients often ask me if I am married. I usually make some nonchalant self-assured remark about having a couple of children and a mistress – two kelpies and the emergency department. Beneath the glib attempt to put patients at ease, there is a troublesome reality – without imposing boundaries on medicine, it could easily come to define my life. I am thankfully able to rein it in by fostering a broader perspective on life, society, the environment and the cosmos.

Truth be told, I am far from self-assured. I generally feel like a confused albeit cultured ape. I take pride in honing my clinical credibility and delivering care to vulnerable, anxious and wounded fellow primates. At the same time, I feel ashamed by waste, pollution and potential harm I do to the planet and to patients, as a cog in the enormous wheel of the medical industrial complex. I feel uncomfortable that this technology driven-wheel tends to grind for the haves at the expense of the have-nots. I feel no satisfaction spending public money on exercise stress tests (up to 24 false positives for every 1 true positive in women), or other no-value investigations, therapies or procedures. At the same time, I feel immense satisfaction when I connect with patients and provide explanation, reassurance or comfort. These dilemmas pervade the rest of my life as well. Should I respond to climate change by not having children? Or should I not worry about the planet since we’re just a pale blue dot anyway? Accepting the uncertainty of existence makes accepting uncertainty in medicine much easier.

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The blueish-white speck of Earth with 6 billion kilometres of perspective. Voyager 1, 1990

Where to?

Training in emergency medicine has been a wonderful journey. The cobbles are now more familiar than when I was a truant medical student, however I’m not sure familiarity is where my future lies. I’ve no doubt emergency medicine could be harmonized within the context of the cosmos, but the model of health care in the industrially developed world seems to stray farther and farther from the reasons why I took up the stethoscope in the first place (ultrasound actually; I don’t own a stethoscope).

Paul Gaugin gave up a career as a stockbroker to learn art and paint his way around the world. Perhaps I too may choose a path less worn. Thus far, emergency medicine has gifted me with instruments necessary to manage complexity, uncertainty, stress, conflict and high emotion. Ultimately, I know that wherever I chose to navigate my future, be it in EM or art, I’m well equipped to sail around the shoals and find safe harbour.

Thomas Brough, May 2018

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Rosie and Jade already know how navigate the tricky waters of life
without losing sleep over exams, missed diagnoses or stroke thrombolysis.

The Procedures Course

This week we got 9 of our consultants through The Procedures Course. Added to the one who had already done it, that is half of our senior staff having done the course now.

There are a lot of useful courses around these days, with higher and higher expectations of acute health care and fewer opportunities to maintain skills in the workplace due to specialization, safer working hours and the expectation that clinicians will not learn something new on a critically ill person without having some sort of qualification or experience in it first.

This course is a bit different from most. While the wonderful world of simulation has brought us the chance to practice many critical cognitive and technical skills in safe environments, the use of cadavers in medical training has really dropped off. In Australia, more than the US, we have a squeamishness about cadaver training. As a medical student I spent several hours a week for the first year and a half on cadaver based anatomy workshops but that is largely gone from modern medical training. Clinical training with cadavers remains quite uncommon here.

Thanks to the enormous generosity of the people who asked to donate their bodies to medical training before they died, and the hard work of the team from the Alfred Emergency and Trauma Centre and Trauma Unit, supported by expert faculty including neurosurgeons, ophthalmologists, obstetricians, orthopods and others, we were able to learn and practice a raft of life, limb and sight saving skills this week. It is hard to describe how much more capable I feel as an emergency physician having done this course, and I’ve been one for a while now!

Check out the course website, not that they need the publicity, they have sold out their next course already.

Hog Fat… Is there anything it cannot do?

I’m showing my age clearly because when I searched for that quote online to get the youtube clip of Homer Simpson uttering the words in wistful admiration of a power station powered by hog fat, it was nowhere to be seen. Now that I think of it, that episode probably predates youtube.

Anyway, down to business.

Khiem Ngo has just joined the Bendigo ED Education team as Co-DEMT. I have him to thank for bringing us this innovation.

When you have eaten all the crispy pork belly you can possibly eat (impossible?) use the left overs to create a peripheral IVC ultrasound phantom that is more realistic than any you will buy commercially.

 

Ingredients

  • Pork belly or waste pig skin (ask your butcher as they will often have some that is destined to be tossed out)
  • Long skinny balloons used for making balloon animals
  • Water

Method

  • Fill balloon with water but don’t distend it. Tie it off.
  • Cut pig skin into strips 4-5 cm wide and 15 cm long (2 inch x 6 inch)
  • Blunt dissect a tract through one of the fascial planes. We used a dilator from an expired pigtail catheter set but you could probably use a biro or pencil
  • Use a pair of long artery forceps to feed your balloon through the tract
  • Massage out any air bubbles along the tract

How much does that scan cost?

When I started out as an EM trainee, having dated a radiographer I was very cognisant of the radiation penalties from medical imaging as well as the associated risks of developing a new malignancy.  Over time my conscientiousness in requesting radiology has waned.

My individual threshold for imaging remains relatively high, especially in circumstances where validated clinical decision instruments determine further work-up to be unnecessary.  Nevertheless, arguing the toss over imaging vs not imaging with other teams (who will likely ultimately be responsible for the patient’s care) becomes intellectually frustrating. It is usually easier to facilitate care by ordering a scan and saving one’s energy for something else. Like stroke care. No wait…. forget that one too.

In equivocal cases, appealing to the attendant radiation penalty of a study may encourage deferment in favour of clinical observation.  I put together this infographic to help facilitate such a conversation, and to help me quantify radiation dose and risk of malignancy in preparation for my fellowship exam.

Another way to look at it: if you’ve spent a metaphorical $20,000 worth of medical radiation you’ve probably given someone cancer. And made a radiologist wealthy. Let’s budget our radiation wisely.

P.S. If you’re prepared to pay with personal time to study and scan, ultrasound is free 🙂

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Promises from #ACEMVIC16

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If you enjoyed my talk in Torquay and you want to know more about #FOAMed and how you could benefit from using Twitter here are some resources that you will find interesting

Enjoy your journey on Twitter and I hope that you find it as fascinating as I have! Feel free to message me if you have any queries about this

@cianmcdermott

 

 

 

Lost dogs and lessons in fluid tolerance

Winter and spring have been unseasonably wet for central Victoria. With plenty of moisture in the soil, things were looking green and gorgeous so when a friend asked me to farm-sit for him I jumped at it. Looking after horses, a moustachioed cat and a beautiful border collie were a small price to pay for enjoying a landscape of granite boulders and grape vines. That was until the dog ran away.

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Dusk arrived and Annie was still missing in action. Terrified by the idea of telling my friend about his lost dog, I decided to chase her down. I had been warned about the risk of getting bogged if I deviated off track…. meh! The ground seemed solid, I had a decent 4wd, and I clearly knew better. Spotlights on and eyes scanning, I started cruising across the paddocks. But pride comes before the fall. It was only when the ute suddenly stopped moving did I appreciate that the ground was less fluid-tolerant than my gestalt told me.  Lost car, lost dog, lost for words (other than 4-letter ones), I tried to make meaning of the day’s events and realised it was a teachable moment in the management of sepsis in the emergency department.

 

 

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When patients arrive in the ED with febrile hypotension, we routinely prescribe in excess of 20-30cc/kg of salt water. The pseudoaxiom is that fluid bolus therapy will improve macrocirculation (arterial blood pressure), and therefore improve microcirculation (tissue perfusion). This is unlikely to be true. Empirically “aggressively resuscitating” people with fluid boluses probably causes harm.  Like the fool in the Hilux chasing the missing dog, we chase haemodynamic targets with unproven watery therapies (or disproven if you’re a marginalised African child) that are physiologically suspect and warrant close examination.

The pathophysiology of sepsis is complicated. The basic mechanisms of the disease, however, (at least as we currently understand it) are less complex:  vasodilation and glycocalyx (GCX) dysfunction. Organ dysfunction in septic shock can largely be attributed to one or both of these mechanisms. It is not due to hypovolaemia.

Currently there are no treatments for GCX stabilisation (unless you are a Scandinavian neonate having open heart surgery in which high doses methyl-prednisolone seems to reduce concentrations of a plasma syndecan-1; an alleged surrogate for GCX dysfunction). Current treatments for vasodilation include noradrenaline, adrenaline,  vasopressin, methylene blue, and angiotensin-2.  In sepsis, fluids cause organ dysfunction through worsening interstitial oedema due to GCX dysfunction, and cause vasodilation by stimulating release of naturetic peptides. It is therefore bizarre that it should be used as a first line therapy for septic shock.

Pseudoaxiom one: Fill the tank before you squeeze.

There is no tank to fill in sepsis, and a vasodilated state is probably best managed with vasoconstrictors.  Giving a septic patient a fluid bolus will increase cardiac filling pressures, triggering release of naturetic peptides which cause vasodilation.  Thus in sepsis, fluids can be considered a vasodilator therapy.  If clinicians are concerned that there is inadequate preload, the LV end-diastolic volume should be measured with echo.

Pseudoaxiom two: fluids improve stroke volume

Patients with septic shock have a depressed Starling curve with a reduction in recruitable contractility via increased preload. > 50% of patients with septic shock have diastolic dysfunction which responds poorly to fluid therapy.

img_3269Ognibene FP, Parker MM, Natanson C, Shelhamer JH, Parrillo JE. Depressed left ventricular performance: response to volume infusion in patients with sepsis and septic shock. Chest 1988; 93: 903–1

 

Pseudoaxiom three: fluid stays in the circulating volume

In patients with septic shock less than 5% of administered fluid remains in the intravascular space at 1hr. This fluid leaks from the vascular compartment to enter the interstitium, causing organ dysfunction. The Marik-Philips EVLW curve illustrates the respiratory harms of fluid therapy in patients with increasing filling pressures. In the abdomen, increased initerstital oedema causes intra-abdominal hypertension, gut failure and renal failure.

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Pseudoaxiom four: albumin is the answer when crystalloid fails

The disrupted GCX enables translocation of albumin into the interstitium, where it  continues to exert an osmotic effect causing further interstitial oedema.

Lessons Learnt

The concept of fluid tolerance in pursuit of haemodynamic “stability” in shocked septic patients is as ill-fated as a hunt for a lost dog across a muddy paddock in the dark. Even though there was no surface water visible, the ground swallowed up my ute before I even realised I was on a path to trouble. So too do we drive our septic emergency department patients further into multi-organ dysfunction with iatrogenic salt-water drowning.

So how do I manage septic shock in the ED? After antibiotics are on board I perform a focused haemodynamic assessment using echo to examine preload (LVEDD or LVEDA), contractility (fractional shortening or fractional area change), filling pressures (interatrial septal motion), and diastolic function (E/A, E/e prime).  This takes less than 5 minutes. If patients have had no recent oral intake I replace guesstimated deficits (4, 2, 1 method) then commence maintenance fluids (D5W and providing Na, K, Mg as required [N.B. Australian RDI of sodium is 40mmol, not 154mmol]). I concurrently target a MAP of 65-70mmHg using a combination of noradrenaline, vasopressin and adrenaline, depending on the haemodynamic state.

So what happened to the ute you ask? Like the drowned patient needing CRRT and an inpatient bed before they break the NEAT 4-hour rule, I had to phone a critical care colleague who spent 4 hrs helping me dig the car out of the quagmire and haul it to dry ground.  Annie came back on her own volition without intervention and I scored a well earned “told you so” from her master.

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With thanks to Paul Marik, Thomas Woodcock, Rinaldo Bellomo and John Myburgh for inspiring me to care about fluids.

Special thanks to Caitlin Young for helping to dig me out of my stupidity.