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Critical Care and Clean Underwear

A primer for mid-level medical students as they are about to enter into solo ward care

Themes:

process > outcome

hallway thoughts (as you're running to the code)

Keep It Simple, Student: There are five tools you can use to get yourself out of trouble that aren't even "medical"

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PRESENTATION OUTLINE

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Critical Care

and clean underwear
Photo by Enrique_L.
2.

a primer for mid-level medical students about to embark on solo ward rounds where people might be really sick and stuff

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Objectives

  • Keep It Simple, Student
  • Remember what Crisis is
  • Process > Outcome
  • 140 character POEMs
4.

Audience Participation!

Name a medical crisis you've helped with
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What made it "hard"?

  • I fruck out!
  • WTF was going on???
  • I started so suddenly
  • It went so fast
  • I didn't know what to do
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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
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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
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"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
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Easy or Hard?

Is THIS scarey?

WPW?
Maybe
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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!)
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Easy or Hard?

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


Oh...COOL! No diagnostic dilemma!
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Easy or Hard?

oh god. This patient is terrifying. She might be depressed. Or have disseminated TB.
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I'll now prove to you that once it's a CRISIS, it's EASIER

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The CRM "Panic List"

  • Recognition/Acceptance
  • Good Communication
  • Leadership/Roles
  • Lifelines
  • Fix the Fixable, then Step Back
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Case 1: Bloody Mary

  • HIV+ 54yoF
  • cirrhosis, jaundice, obese
  • unhealing foot ulcers
  • garbage bag around foot
  • foot is pouring blood like a faucet
  • OMFGFMLWTHisthis?
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Case 2: Mile High Club

  • 77yoF flying to Ecuador
  • collapses in chair 2 min before takeoff
  • GCS 6, sweaty, SOBAR
  • "She's got esophageal spasm"
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Case 3: Roadkill 2000

  • Driving back to NOSM for educational rounds
  • 2 vehicle MVA, smoking wrecks, 3 victims
  • man trapped, grandma GCS 3, boy GCS 9 and femur #
  • It's February, in Blind River
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The Critical Care Haiku

  • Welcome to ER
  • Today the shit hits the fan
  • Your job: be neither
Photo by ! / dino olivieri / www.onyrix.com
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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)
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What's a REAL Code Blue?

(Not "Code Blue, A1)
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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)
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What is universal in Code Blue?

  • It's common: every heart stops eventually
  • However, TREAT BASED ON DIAGNOSIS. Not all Blues get CPR
  • O2, lines, monitors for diagnosis
  • Underlying cause?
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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.
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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_...
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Out-of-hospital-arrest, standard care: survival 10% and less than half got bystander CPR. Probably less than 1/50 are ever normal again.

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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]

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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/
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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
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CODE WHITE

https://ercastblog.wordpress.com/assess-suicide-risk/traapped-silo-safe-mne...
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What's a REAL Code White?

(not "Code White, Heron Lodge")
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Things that are universal

  • Stay safe. Trust your feelings
  • Pack mentality
  • Use your surroundings
  • Haldol 5/Ativan 2
  • What am I? A doctor or a Klingon Security Officer?
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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...
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Code Orange

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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
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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...
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CODE BLACK

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



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

James Truong