There has been an exponential rise in COVID-19 cases. There is no doubt we’re feeling the effects of that all over the world. Many people, especially it seems, the lay public and politicians, have a hard time understanding the meaning of ‘exponential’. The scariness of exponential growth shown here with E.coli Image by Stewart EJ, Madden R, Paul G, Taddei F (2005) / CC BY-SA But can exponential rise continue? If cases double every 3-4 days, then based on today’s figures from the Johns Hopkins Dashboard (1st April) by May 6 there will over 8.7 billion people infected, which is more than e ..read more

One of my nursing colleagues was telling a story the other day about one of the first resuscitations we did together in the ED several years ago. It demonstrates the principle of establishing control of a sub-optimally coordinated team by using some form of attention grabber. She kindly agreed to write down her recollection for me to share here: I have finally found 2 minutes to sit down and write you the story I was telling you about the other week…. We were in the middle of a resus in the ED, it was chaotic, loud and messy. I remember you calling out in a commanding voice for everyone to sto ..read more

This video shows the mechanism for dislodgement and deformation of humeral intraosseous needles and how to avoid this. In summary, if you need to abduct the arm (eg. for thoracostomy), keep the thumbs down (ie. have the arm internally rotated at the shoulder). Otherwise the IO catheter may bend or fall out. References: 1. Pasley J, Miller CHT, DuBose JJ, Shackelford SA, Fang R, Boswell K, et al. Intraosseous infusion rates under high pressure. Journal of Trauma and Acute Care Surgery. 2015 Feb;78(2):295–9. 2. Paxton JH, Knuth TE, Klausner HA. Proximal Humerus Intraosseous Infusion: A Pref ..read more

Towards Excellence in Resuscitation – Analysing Difficult Resuscitation Cases #2 Occasionally we step out of the resuscitation room feeling like a case should have gone better, but it can be hard to put our finger on just where it went wrong. In my last post I discussed the STEPS approach to analysing resuscitation cases: Self, Team, Environment, Patient and System. Occasionally you can get a case where the STEPS seem to be aligned but things still feel bad. In which the outcome was unsatisfactory because the plan was wrong, or the team wasn’t able to execute the plan. Consider the followin ..read more

Towards Excellence in Resuscitation – Analysing Difficult Resuscitation Cases #1 A resuscitationist agonises. These words, expressed by Scott Weingart during a podcast we did together, ring true to all of us who strive to improve our practice. Driven by the passionate conviction that we should never lose a salvageable patient through imperfect care, we relive cases and re-run them through our mental simulators to identify areas for improvement. In the search for actionable items though, we occasionally exit this process empty-handed. Something about a case felt wrong although ostensibly all ..read more

I find clinicians are quick to consider sepsis and hypoperfusion/ischaemia as causes of a raised lactate, but slow to include other causes in their differential. Although an elevated lactate has been shown to be associated with worse outcomes in numerous studies, not all causes of a raised lactate are sinister. It’s therefore important to diagnose the cause both to allow the right treatment and to avoid assuming an inappropriately poor prognosis. This 12 minute video offers an approach to diagnosing the cause of elevated lactate based on an understanding of lactate physiology using a simple ..read more

Described as ‘the contemporary successor to the 2500-year-old Hippocratic Oath‘, the World Medical Association (WMA)’s Physician’s Pledge provides guidance for the global medical community. I think all healthcare providers would do well to read this from time to time, and ask themselves where in their work they or their colleagues might be deviating from these principles, and what they could or should be doing to more closely adhere to them. The Physician’s Pledge   AS A MEMBER OF THE MEDICAL PROFESSION: I SOLEMNLY PLEDGE to dedicate my life to the service of humanity; THE HEALTH AND WELL ..read more

“What’s your leadership style Cliff? How do you like to run the emergency department?” Our new fellow had asked a reasonable question. Although I’d never had to summarise it before, my reply came immediately: “I see my role as doing the most for the most by reducing the sum total of human suffering in the ED – both patients and staff”. I hadn’t really reflected on this before. Obviously my clinical priority is resuscitation, but the reality is that resuscitation only contributes to a small proportion of ED workload. And when our resources and attention are prioritised to the resus room, t ..read more

This guest post from a fellow retrieval clinician contains a powerful message for us all. We have a responsibility to recognise the inevitability of clinician error, and to develop systems within our organisations to support those involved to avoid the ‘second victim’ phenomenon. – 0:01: Error – Noun – A mistake I was the picture perfect hire, I had tailored most of my career for our line of work: retrieval. I was a senior FRU Paramedic with a background including the hottest terms: “clinical development”, “ultrasound”, “research”, “educator” and the useless alphabet soup that one inevit ..read more

This is a guest post from Dr Per Bredmose, anaesthetist and retrieval medicine physician in Norway, also known as Viking One I struggle to ventilate the patient in the resus room, airway pressures are high, the bag doesn’t empty properly. In my mind I plan ahead for the next step. Through my mind goes the thought – is this the one, the one that I cannot ventilate? Statistically it is not likely to be, but I am prepared to add two-person technique, airway adjuncts like nasopharyngeal or oropharyngeal, or supraglottic devices that I use frequently in theatre. I feel confident in the use of thes ..read more