Webucation 30/8/17

Webucation this time comes from subjects encompassing departmental ethos, paediatric and adult trauma, ECG dilemmas and even TED talk skills. As always credit to the original content creators. Do visit their sites.

• What really happens to a SAH?
• Pseudo lung point on U/S
• Bouncing kids and their injuries
• Don't kill your audience with bulletpoints
• STEMI or not STEMI... that is the question
• Is it ever too late to trauma activate?

• Nurse led codes
• What if your child had an arrest (this is a "must hear")

The last 2 links are worth the listen on your way home or on a jog. They describe and portend resuscitation at its best when elements align. Both talks show what can be if we get the heady mix of training, tech and guts right.

Tupac on nurses

Having learnt some hard lessons when I was fresh and having been on the treatment side of medicine, I can attest to the truth of the following video. This is a never ending shout out to the nurses who embody the spirit of healing.
Testify Zdogg...

Smells like team spirit

In times of crises, certain traits are desirable and some, admirable. One of those is situational awareness. What is most desired is knowing your limits and calling for help.

A competent registrar notified me of an impeding airway disaster:

• Semi conscious patient in respiratory distress
• Oro-pharyngeal tumour (undergoing chemo)
• Bleeding acutely from unknown site in oropharynx or lower
• Shocked clinically
• The best description I can give to those who understand is "peri-arrest".

Here's the really good news though:

• A RSI checklist had been commenced prior to my arrival
• The airway team had been called
• Nursing staff were ensuring all the items on afore-mentioned checklist were prepped
• Tranexamic acid given
• Cric kit was opened and location marked (as best we could due to oedema)

The inevitable happened and the soon GCS deteriorated as did BP. Subsequently, this followed:

• Ketamine 
• Unmatched blood as soon as we got it
• Peripheral pressors 
• Paralysis and attempt by Anesthetist
• Continuous suctioning of blood with no view of cords
• Bougie assisted intubation with no desats and good CO2 trace
• Good post intubation care

The whole hospital team successfully oxygenated and ventilated this patient. I did practically nothing. Which is why I am elated. This was a triumph for systemic preparation & team sport...

... but it all started with a keen-eyed doctor with the sense to know they couldn't do it all by themselves. 

Remember:

Checked on my own list

So our 1st post of the new year will serve a reminder to me most of all rather as education for others. Its about not spilling blood.

A patient with COPD and IHD presented with SOB and a wheeze to the department and bronchodilators were started with a normal looking CXR.
He was looking much better but suddenly went into a malignant broad complex rhythm and was promptly defibrillated. ROSC was achieved in a few minutes and a decision was made to intubate him for hypoxia as well as post arrest airway protection.
A RSI checklist was commenced and I was asked by a competent nurse whether a 2nd IV line was needed. For a brief few seconds I thought about forgoing that step and to quickly proceed with what looked like a difficult intubation and the myriad of complicated following steps...
Somehow and from somewhere, cooler thoughts prevailed and I got an available med student to insert one under guidance.
In compliance with Sod's Law; prior to intubation, blood was seen to be leaking from the trolley and pooling on the floor from the site of the accidentally avulsed 1st IV line.
Disaster mitigated, undoubtedly, by nurse and papyrus safety net!
Last line of this masterpiece by "The Boss" goes - God have mercy on the man who doubts what he's sure of.

Our checklists can be found here.
The debate (funny one) rages on here.
Extreme checklist mania here.

Have a fruitful 2015.

Teaching in the Toilet

Great intellectual things you can do in the toilet. Teach staff how to take blood sample properly. And it works!!

Testing the effects of educational toilet posters: a novel way of reducing haemolysis of blood samples within ED. Corkill, D. Australas Emerg Nurs J, 2012 vol. 15(1) pp. 31-6.

But you probably need to design your poster properly, and there is no information on where is most effective - behind the cubicle door, in front of the urinals, or on the mirror... go figure