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Slide Notes

presentation for NOSM 3rd year students



Rare events are just that: rare

That's the challenge of all of med school and medicine


Illustrate the differences between Code Black in the USA and Canada

The hardest thing about radiology? The number one finding in a chest xray is NOTHING.
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Code Orange is the new Code Black

Published on Nov 18, 2015

Breakfast presentation for NOSM 3rd year Academic weekend Jan31/2015 after screening of the Code Black movie

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PRESENTATION OUTLINE

1.

Code Orange is the new...

presentation for NOSM 3rd year students



Rare events are just that: rare

That's the challenge of all of med school and medicine


Illustrate the differences between Code Black in the USA and Canada

The hardest thing about radiology? The number one finding in a chest xray is NOTHING.
2.

Code Black

[or, how I learned to stop worrying and love a crisis]
But....we need to be prepared for disasters


What's anaesthesia? Long periods of boredom followed by discrete moments of panic
3.

Objectives

  • A talk compatible with breakfast
  • Remember what a Crisis is
  • We get it wrong all the time
  • 140 character POEMs
4.

Competing interests?

Yes. I'm a parent
5.

WHAT IS A CRISIS?

...and why do I like them so much?
The story about my first shift with Terry O'Brien and the joyride rollover with 4 kids

Show of hands.

Who likes ER? Why is it appealing as a career and a specialty?

The Walking Dead?

Why does the Western World like the zombie apocalypse trope?

Why, after WW2, did Japanese literature get inundated with apocalyptic scenescapes of a dystopian world?

Because in all these scenarios, everything hangs in the balance each and every day and little things matter a LOT, and survival can sometimes hinge on quick, important decisions. There's MEANING to it.
Photo by jose.jhg
6.

Untitled Slide

wēijī
(VWAY-tchgee)

http://en.wikipedia.org/wiki/Chinese_word_for_%22crisis%22

http://pinyin.info/chinese/crisis.html

"The word 'crisis' in Chinese is composed of the characters for 'danger' plus 'opportunity'"
...at least, according to JFK in 1959

well...no...not actually. It is closer to 'critical point'

Everything changes fast, and it's a moment where small things matter BIG

So, let's keep it simple and get it right
7.

"Critical Point"

What you do matters...it really matters
A crisis is probably more like a Tipping Point

http://en.wikipedia.org/wiki/The_Tipping_Point

Small movements make big differences

So let's make small movements...but the CORRECT ONES


"What you do matters...it REALLY MATTERS"
-Mel Herbert
http://www.emrap.org/
Photo by Kalense Kid
8.

Codes: In order of frequency?

  • Code White
  • Code Blue
  • Code Yellow
  • Code Pink
  • any others???
http://en.wikipedia.org/wiki/Hospital_emergency_codes


Standardized in Canada...mostly
In NBRHC

Blue = cardiac arrest
Pink = pediatric cardiac arrest
White = violent/behavioral situation
Yellow = missing person
Red = fire
Orange = external mass casualty or disaster
Green = Evac
Black = bomb threat
Grey = structural failure/internal disaster
Purple = hostage (never used) or...hot topic at triage
Brown = sewage spill...or poop
Photo by JD Hancock
9.

K.I.S.S.

The thing I like about a crisis is that everything becomes SIMPLE
Keep it that way

Recall the story of the guy I defibbed 14 times
71 yo obese, mostly Italian smoker
sudden onset belly pain, nausea, belching
syncopal episode at home while eating dinner
no past surgical history
Trauma bay 1 in the old hospital
?AAA
gastro?

...and then he CODES



K.I.S.S.

Keep It Simple Stupid
(not Kids In Satan's Service)
10.

NEEDS > SUPPLY

(MDs have limitless work opportunities. Oh great)
Medicine is complicated
Humans are complicated

Crises freak us out

There's lots going on

So...why not make all the moves at once?

Because we can't. We just...CAN'T

"DO EVERYTHING" is the worst Code Status
Photo by Johnath
11.

RESOURCE MANAGEMENT

(an MD is a brain in a jar...)
Back to the zombie apocalypse...

once the shit hits the fan, your job is simple. Be neither.

in order:

- umbrella
- switch the fan off
- mop
Photo by Quelab_NM
12.

Option Paralysis

Look! Chest pain, 1+ leuks and a sore foot. Toradol, nitro and amoxil!
The thing I like about a crisis is that everything becomes SIMPLE


Recall the story of the guy I defibbed 14 times
71 yo obese, mostly Italian smoker
sudden onset belly pain, nausea, belching
syncopal episode at home while eating dinner
no past surgical history
Trauma bay 1 in the old hospital
?AAA
gastro?

...and then he CODES

Keep it that way

K.I.S.S.
13.

Fixation Bias

THE LIGHT AT THE END IF THE TUNNEL MIGHT BE...HEADLIGHTS
47yo woman
smells like anxiety
looks like anxiety
can barely speak English
moved here from BC
has no money
is freaking out

...probably anxiety...

and then we find out she had melanoma before and was lost to followup...

...and then we get the head CT...
Photo by T Hall
14.

PROCESS MATTERS

DIAGNOSIS AND GOOD OUTCOME ARE A REWARD
Medicine: the ultimate Sisyphean trial.

100% of humans get sick and die.

Also, you WILL, in fact, miss a diagnosis, be wrong, or just, in general, screw things up with fair frequency. Also, much of the knowledge you currently cherish is actually incorrect



So, to make it easier on yourself...at each step...simplify and get the moves right

If you don't know, just say so and do your best (accounts for 95%+ of everything we do. This isn't engineering, you know...)

However, when it's possible to "know" what's current, do so.

http://www.thennt.com/
http://lifeinthefastlane.com/foam/
Photo by Muffet
15.

Easy or Hard?

Is THIS scarey?

WPW?
Maybe
16.

Easy or Hard?

Is THIS scarey?

V-fib



There's only one move here...


(actually, it used to be far worse. Remember
ABCs?
ShockShockShock, Everybody Shock? Little Shock! Big Shock! Everybody Shock!)
17.

Easy or Hard?

http://www.trauma.org/index.php/main/images_keyword/stab/


Oh...COOL! No diagnostic dilemma!
18.

Easy or Hard?

oh god. This patient is terrifying. She might be depressed. Or have disseminated TB.
19.

CODE BLUE

A great LIVE calculator of death rates


http://www.worldlifeexpectancy.com/usa-cause-of-death-by-age-and-gender

Play with it

Cardiac is most common...AFTER age 45

For the age of a graduating medical resident, it's...TOXICOLOGY

(but that's a whole other talk)
20.

In-hospital cardiac arrest, best care: half are dead by 4h. 1 in 25 walks out "normal". Like hitting the centre of a BINGO card with a dart.

http://www.nejm.org/doi/full/10.1056/NEJMc1215155

http://jama.jamanetwork.com/article.aspx?articleid=1713589

The Greek study is where we pull this approximation. CPC score ONE was required
http://www.fda.gov/ohrms/dockets/ac/05/briefing/2005-4100b1_03_CPC%20Scale....
note the study seems MUCH more favorable because they ONLY reported survivors at 4h...if you didn't make it thru the code, you weren't even counted

AND MEAN INCLUSION AGE WAS 65!!!! BABIES!

out of hospital, it's FAR worse...
http://www.heart.org/HEARTORG/General/Cardiac-Arrest-Statistics_UCM_448311_...
21.

Out-of-hospital-arrest, standard care: survival 10% and less than half got bystander CPR. Probably less than 1/50 are ever normal again.

22.

Code Blue Playlist: Stayin' Alive [CPR at 110 bpm] Push It REAL Good [depth>5cm] Don't Stop 'Til You Get Enough [>80% hands-on time]

23.

In community cardiac arrest: Don't Do Drugs. AEDs however, resurrect 1 out of 3 dead casino-goers #VivaLasVegas

Drugs in most ACLS codes don't do anything

http://www.thennt.com/nnt/acls-medications-for-cardiac-arrest/


But electricity saves lives

http://www.thennt.com/nnt/defibrillation-for-cardiac-arrest/
24.

Rapid Response (RACE) Teams: Taste Great. Less Filling (of the ICU beds) But do they save lives? Nobody knows. #ShareThePain #CodeBlueLight

It's always FEELS better to have a RACE call than a code

"Best defense against punch? Not be there"
-Mr Miyagi

but your mileage may vary

http://www.criticalcarecanada.com/abstracts/2013/how_does_the_race_rapid_as...

http://www.saferhealthcarenow.ca/EN/events/PreviousEvents/Documents/Nationa...

http://jama.jamanetwork.com/article.aspx?articleid=183005

http://jama.jamanetwork.com/article.aspx?articleid=209512
25.

CODE WHITE

https://ercastblog.wordpress.com/assess-suicide-risk/traapped-silo-safe-mne...
26.

RIO: Rational Thinking Loss, Ideation of Suicide and Organized Plans are important indicators of suicide risk. @emergencypdx #suicide

Evidence? In Mental Health Care, there's very little hard evidence. Even in a tightly observed population

http://bjp.rcpsych.org/content/176/3/266.full.pdf

Scales don't live up to our needs, and aren't applicable in a "crisis"
http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?LinkFrom=OAI&ID=12007002071...

But there are some nimble, useful approaches:

[TRAAPPED SILO SAFE]
https://ercastblog.wordpress.com/assess-suicide-risk/traapped-silo-safe-mne...
27.

Code Orange

28.

pre-hospital Code Orange: bleeding ends saveable lives. Tourniquet limbs. Scoop & Run with shock victims. Don't Stay & Play. ?hemostatics?

http://bulletin.facs.org/2013/09/hartford-consensus-ii/


Class D evidence from the American College of Surgeons
29.

in-hospital: shock and bleeding within 3h = tranexamic acid 1g IV in 10min then 1g IV in 8h. $100 for NNT 67 to prevent death. #TXA

The Crash2 trial is a "pragmatic" trial rather than a traditional well-protocolized trial. Interestingly, that might mean it underestimates the effect

IT MIGHT BE EVEN BETTER. And it's cheap. And can't make you get a blood clot (antifibrinolytic, not thrombogenic)

Best used in combo with a MTP Massive Transfusion Protocol


http://thebloodytruth.com/cheap-and-effective-the-tranexamic-acid-story/

http://emcrit.org/podcasts/tranexamic-acid-trauma/



also probably works in OB/GYN. And dentistry. And...
30.

CODE BLACK

http://emrap.us2.list-manage1.com/track/click?u=941df8fd455d0039955d88e66&i...



https://www.youtube.com/watch?v=5VcSwejU2D0&feature=player_embedded#!
31.

Active Shooter or Mass Casualty: ACS says to improve survival, RUN. Or else HIDE. FIGHT last. So much for Bruce Willis. #hartfordconsensus

Run like your life depends on it, because it does. If taken hostage: 70% of hostages get killed

In reenactment of Charlie Hebdo by trained Texans non-LEOs aware that a shooting is about to happen, armed civilians trying to go Die Hard get killed 11 times out of 12. Nobody took out the assailants. And the only survivor RAN.

http://kxan.com/2015/01/14/texas-gun-owners-re-enact-charlie-hebdo-massacre...
32.

Review Objectives

  • Gory stories go well with breakfast
  • Crisis = Danger + Opportunity...
  • ....TO GET IT RIGHT!
  • K.I.S.S
33.

ACES

https://ispub.com/IJMS/2/1/10030
Photo by Leo Reynolds

James Truong