SMACC: Medical Student Review
One of the great aspects of the SMACC conference was that it had broad appeal to a wide spectrum of health professionals involved with critical care.
Three medical students (Arghya Gupta, Amy Cui and Mel Chin) have written their own review of the conference.
We promise that we are not related to them and, in the spirit of FOAMed, have paid them nothing!
We thank them for their honest opinions, and for their time, in writing this review.
Arghya Gupta:
Day 1
Coming from a world outside critical care to SMACC, I was blown away not only by the end product of an excellent conference, but by the genuine passion and interaction that was committed to by the convenors, the speakers, the delegates, and the world at large.
The Bayside Auditorium of the Sydney Convention and Exhibition Centre played host to all the plenary sessions of SMACC, which opened up with a ceremony which saw Oli Flower deftly taken care of by a professional wrestler. But somehow, like all professional wrestlers, he returned to host, chair, and present for the rest of the three day program, alongside Roger Harris.
The show opened with the bang of Scott Weingart’s theory of ICU/ED overlap and the need for everyone in crit care to aim to be a resuscitationist before John Myburgh hit us with the pros and cons of dobutamine and adrenaline. Cliff Reid finished the session by loading onto us the knowledge he had about the devil’s semen – propofol, in the context of being calm and knowing when to give the right thing, and not letting things descend into a clusterf#*$.
In Concurrent breakouts after the morning tea break, the fluids that were consumed earlier were discussed in the Auditorium. Weingart and Anthony Delaney made clear points about how we had to consider each indicividual patient before directing our therapy at certain patients, before Myburgh raised the ante just a little by stating that unless you could see a bucket of fluid pouring out of someone, a Hartmann’s infusion would be overkill. Even if in the ICU or in the ED we don’t see the fluid levels recompense, a week later on the wards, the patients redefine the meaning of bloating. Then, as if to calm things down, Michelle Johnston told us when shock was shock, and when it was not, and that in many cases, we should never be judging books by their covers.
The afternoon plenary was all about FOAM, and no better introduction was provided than by Joe Lex, before we could all take a ‘Facebook five’ to recollect thanks to Victoria Brazil. The conference was all going well, when Simon Carley raised the issue of whether we were preaching to the converted, and whether we had to get the wider community involved, and the afternoon panel gave good thought and discussion to that.
Day 2
Tuesday morning, after a long night for some competitors opened with Mike Cadogan talking about the development of GMEP and the MedEd portfolio. For someone uninitiated to the FOAM world as much as others, this was a real insight into the possibilities of what could be achieved. Scott Weingart spoke about the importance of breaking each procedure into the smallest of components – each suture, each needle stroke, and practising bit by bit, as well as the wonderful effect of reading before and after doing things. Simon Carley spoke about the effects of FOAM in the UK, before Joe Lex talked about experience and though even at times one wouldn’t feel confident doing things, sometimes critical care was about knowing what to do when no one else knows what to do either. Anyone who wasn’t left wide-eyed was after Kia Wahlfinished the morning with a video showing how the new technologies of Google Glass and youtube features could change medical education around the world.
The Tuesday morning breakout in Bayside 105 was a wonderful anecdotal session, started by Joe Lex talking about his years on the frontline as a paramedic and a physician, and the things which we assumed and missed, which could lead to devastating consequences. Michelle Johnston gave us a clean break from the medicine altogether with allusions to the great wordsmiths before presenting us a poem of her own and a special patient. Karel Habig talked about medicine from a birds eye view and the fun and difficulties associated with that while Casey Parker confirmed he wasn’t a porn star, but he still had many talents due to his outpost practice in Broome bringing in everything from obstetrics to ophthalmology, and being the only ‘specialist’ on hand, even if that meant just a week of learning in medical school.
The afternoon free papers session brought up a spice market of options, which had Bayside 104 talking mostly about social media and technology. Tessa Davis presented her project of sharing educational resources for a price, but only to use all that money for paediatric care resources in remote areas. Margaret Hansen, a nurse educator, raised the idea of conducting research through contacting family members of the critically ill in the ICU via text message. Hugh Stephens, a hero of the #smacc2013 hashtag, duly spoke about the possible dangers of the activities of doctors on social media and on the internet in general, and patients adding their doctors as friends on facebook. David Townsend and Aaron Sparshott spoke with a wonderful graphical presentation of how their #interncrisis campaign to raise public awareness of the medical school graduate bottleneck worked to get six million politicans and tens of politicians on a budget of $37. The session was closed by Isaac Thangasamy with the idea of the Journal Club on a Twitter basis, and provided with example the current one going on between urologists around the world.
The afternoon plenary was the SONOWARS final, which saw the Tweed team take on the Auckland HEMS team. As a model on stage, I can assure you whilst both teams showed a bit of anxiety, I would be more than confident that any of the people on stage could diagnose a millilitre of free fluid on an eFAST on the side of a mountain if need me. With the results going up on GMEP, it was a good example of how there can be fun, education, and interaction all in one go.
Amy Cui
Earlier this week, I was given the chance to attend the SMACC 2013 conference, a three-day event that involved inspired talks from critical care doctors looking to update our current approach to medicine. How were they proposing to update medicine? What did this mean? And what did social media have to do with critical care? Those were the questions running through my mind as I arrived blearily early on a Monday morning for the conference registration.
Day 1
Day One’s afternoon talks were no less interesting, with a wonderful session on the future of medical education chaired by Chris Nickson, an ebullient young emergency physician from across the ditch. Here, a thoroughly satisfying explanation for the social media focus of the conference, hinted at so enticingly throughout the earlier sessions, was finally given. According to the first speaker Joe Lex, the future and past of medical education are/were always grounded in free, open access medicine (FOAM). Today this sort of education is facilitated to an extraordinary degree by social media, through blogs and commentary, free videos, podcasts, twitter remarks and whatever else is coming online now. Social media used during the conference itself (in the form of a #SMACC2013 twitter feed) also actively proved how barriers could be broken down between speaker and audience, with power and access now given directly to what might otherwise be a relatively silent body of people.
The sleepiness and doubts were soon washed right out of my system after an immediate bombardment of powerful and enthusiastic speeches from Scott Weingart, John Myburgh and Cliff Reid – all critical care physicians with a bold, opinionated take on life in the ED and ICU. Scott, an emergency doctor and creator of the EMCrit podcasts, gave us an intense 25-minute spiel about his belief in the ‘resuscitationist’ – a doctor who provides maximally aggressive care to his/her patients, whether that be curative or palliative, and ensures that standard of care is not dictated by where the patient is in the hospital complex. John, an intensivist, gave a stimulating talk about the benefits of using adrenaline as the “neurohormonal augmentation agent” of choice in the resuscitation environment. Cliff concluded the morning’s early session with psychosocial advice on how to make things happen in the emergency room. He introduced the idea of ‘resus room thermodynamics’ and exhorted the importance of maintaining situational awareness in emergency scenarios to prevent the team from descending inevitably into a state of chaos.
The rest of the morning was given over to concurrent sessions discussing Shock, Trauma and Paediatrics. I chose to settle into the Trauma session and was given a taste of several physicians’ research and unpublished ideas about the lessons in war, haemodynamics in resuscitation and the feasibility of trauma department auditing. I learnt that, out of the pain and destruction of war, many necessary guidelines to trauma treatment principles have emerged. I learnt too that in the acute trauma setting, it is safe to set a lower blood pressure target for a period of time, particularly if the patient is not elderly and not suffering from a traumatic brain injury.
Day 2:
Paul Young’s “Fever: Friend or Foe?” was a thought-provoking presentation on some of the benefits of fever, particularly in patients who are septic or have an infection. While he cautioned that the whole truth about how the beneficial effects of fever might be weighed against its harms is as yet unknown, he gave examples of several promising studies that might move the balance in favour of not aggressively treating mild fevers. An upcoming HEAT study looking at paracetamol vs. placebo in the ICU will hopefully enable physicians to draw a more definite conclusion from the results.
Jeremy Cohen’s “’Roids in Sepsis” gave us an interesting insight into the efficacy (or lack thereof) of steroid treatment during infection and used a couple of landmark papers to illustrate his point. The first was a JAMA study published in 2002 by Annane et al, which concluded that low dose steroids significantly reduced the risk of death in patients with septic shock and relative adrenal insufficiency. The second paper, published in 2008 in NEJM by Sprung et al concluded the opposite. After noting the flaws in each study – and sadly this medical student failed to catch what they were – Cohen spoke about more current studies, which show counter-intuitively that a decreased cortisol level is actually associated with better patient outcomes.
Lewis Macken’s “Targeted Temperature Management After Out of Hospital Cardiac Arrest” sifted through the research behind recommendations for hypothermic treatment in a post-arrest patient, and showed that these strident recommendations are really only based on moderately strong evidence. A new trial currently under way, the Targeted Temperature Management (TTM) study will hopefully shed new light on how cardiac patients should best be managed.
Anthony Holley’s “Trauma, Transfusion, Coagulopathy and Procoagulant Activity” provided an excellent overview of coagulation issues in trauma victims. He mentioned numerous studies and guidelines related to bleeding and clotting in post-trauma patients, and emphasised the life-saving importance of checking for post-trauma clotting, particularly in bleeding patients.
Tim Leeuwenburg’s “Improving Pre-hospital Care in Rural Australia” gave us a memorable taste of what pre-hospital care involves, and was very effective in driving home the message that pre-hospital care, particularly in rural Australia, is ‘not for enthusiastic amateurs’. After throwing in some sobering statistics (trauma outcomes are four times worse in the bush than in the city), Leeuwenburg looked at models for pre-hospital care overseas and showed how we might learn from them.
Ezra Limm’s “Unused Peripheral IV cannulas” talk took a good look at the statistics of unused IV cannulas and showed that there are significant numbers of patients who receive a cannula without a real indication for it. Ezra spoke about the increased risks of infection and urged us to think more carefully about whether a venepuncture might be just as effective before we put a cannula into a patient.
Una Nic Ionmhain’s “Comparison of Toxicological Trends in Deliberate Self-Poisoning Cases” was an interesting comparison of the most common poisoning agents ingested in Perth, Western Australia, and in Dublin, Ireland. Ionmhain noted that while in both cities, sedatives, anxiolytics and hypnotics were the more common medications ingested, Perth patients were far more likely to present with an anti-cholinergic toxidrome due to anti-histamine ingestion.
Unable to attend the conference on Day Three due to a compulsory tutorial at hospital, I was determined to make the most of Day Two. Once again, the excellent repertoire of talks made it difficult to fail in this endeavour. The ideas that resonated the most for me during the morning session were those espoused by Scott Weingart, as he reprised his guest speaker role for a second day. The ‘path to mastery’, as described by Scott, gave a bit of an epiphany moment to me, a medical student struggling with the difficulty of ploughing through what seems to be an unending field of medical knowledge. In the next talk, Joe Lex’s ideas about ‘gerontogogy’ (the education of senior physicians) added food for thought to the ongoing debate about lifelong education. And Simon Carley, speaking about anarchy, explored the subversive, equalising nature of social media communication.
Memorable too on the second day of SMACC 2013 was the ‘Sonowars’ contest, which pitted two finalist teams against each other in a competition of ultrasound ability and knowledge. Both teams were impressive in their attempts to gain the upper hand, and they provided us with an entertaining afternoon, which was also wonderfully instructive in the art of ultrasound.
I greatly enjoyed this opportunity to be a part of the SMACC 2013 conference, and the experience has certainly changed how I feel about the use of social media in medicine. The EMCrit podcast and the Global Medical Education Project (GDEP) are just a couple of the online sites that are now on my radar. I look forward to participating in the social media discussion and one day contributing to the plethora of FOAMed resources out there on the web.
Mel Chin (Mel)
Day 3
The final day of SMACC2013, Wednesday, opened with Scott Weingart giving a talk about the “Mind of the Resuscitationist” and the salient points of what it means to be a resuscitationist. Knowing one’s environment, hospital system, knowing the skills and resources around you, knowing equipment well and their limitations, also being very situationally aware are key points I took away from this talk. Also, the hallmark of the resuscitationist as being someone who talks about ‘logistics’ as opposed to ‘strategy’ especially in difficult cases, the scenario and management plan has already occurred in one’s mind with all the surety, precision and skill at hand. He elucidated on this with a patient case he had that had terrible gastrointestinal bleeding, the prompt communication and elicitation of assistance from a gastroenterologist, the hospital administrator and the collaboration with another consultant who had the needed skillset to save the patient- and they did. The patient recovered. Completely.
Cliff Reid’s “How to Be a Hero” was an incredibly moving talk. I found myself (I think along with other twitter confessors), doing a quick backhand swipe for stray tears for Cliff’s recounting of the loss of his friend due to an incredibly tragic accident and how, despite dying from traumatic hypovolaemic shock, his friend was able to lucidly reassure and help the person they had set out to rescue. His view as to what a ‘hero’ actually was, I think resounded and rang true for people in the audience. That it often is an uncomfortable position to stand up against the crowd mentality, to be able to overcome crowd momentum –or inertia-, as he describes the bystander effect for its deadly combination of ineffectuality and paralysis. He also talked about some of the infamous thought experiments and psychology explorations into the human psyche but also spent time on the more uplifting aspects of humanity in times of crisis. It was very illuminating to look at some of the research (The Hero Imagination Effect) out there regarding this in times of emergent crisis, where approximately 70% of people remain paralysed and unable to do anything, 10% go “ballistic” and approximately the remaining 20% take on the role of the ‘hero’ and are able to initiate rescue and assistance. There was a very pertinent question directed from the audience about the position of the hero and being sometimes, very wrong despite resolute belief and justification for the decision at the situation and how, to come to terms with and deal with the aftermath. Reid’s response was one of empathy as he himself has struggled with the same conundrums, acknowledging the position of those who have had similar experiences and tragedies, but he resolutely expounded still that it is still better to “live with remorse, than with regret”.
Chris Nickson: “All Doctors are Jackasses” was a humourous –but deadly serious and cautionary check- tongue in cheek commentary that doctors are only human and definitely vulnerable to cognitive errors especially when multiple factors are in play. The concepts of (just to name a few)“anchoring, confirmation bias, blindspot errors and premature closure” as well as external factors such as situational awareness, sleep deprivation, stress and competing environmental demands” were the definitely a recipe for a “perfect storm of errors”. The use of a patient case (the awkward, idiosyncratic and down-right weird), was a great way to elucidate these cognitive traps and how, the patient that you least want to see, or keep in the emergency department, is probably the one that you probably should see most and exercise greater metacognitive awareness. The books recommended by Nickson by Pat Croskerry “Patient Safety in Emergency Medicine” and Daniel Kahneman’s “Thinking fast and slow” are already on my to-read list due to this talk.
Simon Carley’s talk on “Wrestling with Risk” dealt with the need to be a “probablistician, as opposed to a diagnosticican” and the caution and need for deeper scepticism with regards to the tests used for patients. He nicely elucidated on this with regards to the use of the Well’s and PERC scoring scales for patients presenting with the diagnostic possibility of pulmonary embolus and also highlighted how such scoring systems work in the general population indirectly because of how low the disease prevalence is in the community itself. He then cautioned about how, in contrast, this would not apply in certain patient subgroups, such as those with malignancy. He encouraged the need to police one’s words to the patient and their families, especially on discharge from the emergency department and the need to use wording couched in ‘probability’ rather than ‘certainty’. I felt as well, that he highlighted the need to understand the short-comings and strengths of tests well, in order to truly apply them effectively and safely. The need to understand pre-test probability and also the application of likelihood ratios struck home to me how important it is to truly think clinically with an evidence based approach.
I felt these talks were riveting, sobering and yet also inspiring. It was a much needed and unusual set of talks, but I think needed as a reminder as to why people do what we do (or in my case, will one day do). It’s easy to forget why people have ended up in the profession of medicine and perhaps for some, it was an ‘accidental’ journey of why not. Either way, it remains the fact that as doctors and individuals with a set of hard earned and possibly life-saving skills, the core of it remains that we should not forget what it means to give someone else- and their family- a second chance in the face of overwhelming impossibility, resistance and fear of litigation. I think for myself, whilst currently undergoing the hum drum of medical school and squeezing in facts and yet more facts, I think this particular morning’s session reminded me why I started graduate medical school in the first place.
After the morning session, the day was split into 3 concurrent breakout groups.
I went to Concurrent 15 : “The Heart of the Matter”. It opened with Louise Cullen’s (who is part of the Emergency Cardiology Group) “Taking the pain out of ACS” and was fantastic overview of the current cardiology marker uses, the need to understand a test very well but also know its limitations. The upcoming possibility of the perhaps more sensitive and specific test of heart fatty acid binding protein was also touched on.
John Larkin on “Extreme ECG Encounters” and had a couple of great cases that had been quite tricky to diagnose. It was a useful and interactive session as well as he highlighted certain ECG examples and scenarios that had been unusual in its presentation. There were certain websites that he had recommended as high value, such as Amal Mattu’s and his collaborative project with Dr Smith’s ECG site.
Sharon Kay’s session on “Echo for Everyone: 5 Things Never to Miss” was a clear and great way to introduce Ultrasound to keen amateur aficionados. She also clearly highlighted the need for correct and appropriate views and corresponding clear medical documentation for what views were used in the emergency department due to leading possible assumptions and medical errors when the patient is transferred to the cardiology ward. She closed the session with a sobering, true case of a patient who had been discharged from an Australian hospital with an abdominal aortic dissection and had been failed to been diagnosed despite ultrasound views. The views unfortunately, had been inadequate and had there been colour and more views and appropriate documentation, it would have been picked up sooner. She also empathetically raised the need for doctors to ask for help if unsure or out of depth, in order to avoid such tragic errors.
Roger Pye’s “ECMO Anywhere” was a really nice overview on the evolution of ECMO historically and in Australia and some of the challenges and amazing success stories with ECMO use in the refractory, difficult patient cases. The lifestyle and challenging demands of ECMO implementation and the possible logistical nightmares in transporting equipment and patients was touched on and definitely gave me an insight into the innovation, dedication and ingenuity often required by Pye and the team/staff involved. Cost was touched on and surprisingly – not too bad at all, with attributed cost of ~$1200 for the ECMO circuit, however, the true costs really more associated with bed stays and staff costs.
The afternoon Concurrent session which I attended was Concurrent 16: “All Things are Poison”
Key points touched in on in Geoff Isbister’s “Does Antivenom Work?” – that antivenom is really not that necessarily effective even when given after the time of the bite or even prior to the bite, as seen in animal studies. In a case that he explored which involved a young girl who had been stung by box jellyfish, it would seem that her father’s efforts to start early CPR and contact of emergency medical services was probably more lifesaving and neurologically effective than the administration of the anti-venom itself when administered. Also, the route of administration is pretty important: Don’t do IM! Give it intravenously for the fastest and more potent effect. Pertinent questions were raised as to what is appropriate as dosage amounts and when the optimum timing would be for initial doses and when redosing. Main points raised were that early resus and factor replacement would optimise therapy.
Nick Buckley’s “Paracetamol: More than Meets the Eye” gave an overview as to the demographics of patients presenting to the ED with paracetamol poisoning- usually young women and attempted suicide with paracetamol overdose. Pertinent questions were raised as to when it was ideal to scavenge, administer therapy (NAC regimen), when and over timeframe should therapy be administered as a dose or as an infusion. It ended on a watch-this-space note, that it’s still not really known what is the ideal and evidence based proven therapy regimen for such cases.
Andrew Dawson’s “Tropical Toxicology: Lessons for the Developed World” was a great overview as to organophosphate poisoning in Sri Lanka where accidental and intentional self-poisonings is a common presentation to hospital. He raised an interesting point that perhaps in the developed world, our usage of protective gear and decontamination equipment may be a touch excessive given that in poor, developing countries, despite little safety personal protection equipment, the incidence of nosocomial poisoning is minimal. He also gave an overview of the different and most common forms of organophosphates and their side effect profile. He emphasized on the need for early and aggressive atropinisation and perhaps the use of pralidoxime is a two edged sword that needed cautionary application. The use of rocuronium and suxamethonium were interesting therapy possibilities raised in the discussion session as well. Pertinent use of the GCS as a good predictor for survival and the use of respiratory and cardiac end points during therapy were also highlighted.
Mark Little’s “It’s Natural and therefore it must be safe- Do we really ask about what else people are ingesting” opened with an interesting and challenging diagnostic case where a young man had presented to hospital through the year with similar presentations of hypokalaemia and renal failure, from seeming idiopathic causes. The patient in question was a generally fit male, who ran marathons and competed regularly with no other significant medical history. It was only on the final presentation, when the resident had noticed a gym bag full of complementary alternative medicines when the pieces clicked into place. The case highlighted the very valid need to ask patients about their use of over the counter and alternative medications especially when bought from the internet. The diagnostic difficulty of pinpointing the culprit toxin was a long and arduous process, which also involved communication and discussion with alternative medicine practitioners, the toxicology hotline, toxicologists and relevant internet sites/forums. So, beware if you ever see your patient taking “Himalayan Mountain Salts” indeed!
The day concluded with the SIMWARS: which was in a couple of words “BLOODY FANTASTIC”.
Being a newcomer to ED simulation and participated in a couple of simulation scenarios, it was an incredible learning experience to see well-honed and experienced teams dropped into the deep end in a very public setting. Kudos to the teams (St Emlyn’s, Sydney HEMS GSA, RPA ICU team) who participated so good naturedly and professionally. St Emlyn’s took home the enviable title of winner of SIMWARS with the smooth execution of the diagnosis, treatment and management of the brown snake envenomed patient despite being out of depth with such native-Australian snakes in the UK!
It definitely helped me realise how difficult such situations can be and also how great teams who work well together make things seem so easy, but also, most importantly, the profound need for clear communication, decisive decision making, situational awareness and destination planning, role and task allocation within such demanding environments. The use of twitter as a direct interactive way for audience participation was particularly commendable and effective in helping the audience be a part of the diagnostic and management process, but incredible entertainment value as well for both teams and audience! By the way, it was a very nice touch having a plastic brown snake suddenly appear from the lady’s bag in scenario 1.
As a quick ending comment, I was ecstatic at having been able to attend SMACC2013 and am already looking forward to SMACC2014. I think the conference has deepened my already existing interest in critical care and am incredibly appreciative of the availability and accessibility of high equality medical resources and teaching on the internet. Free open access medical education (FOAM), indeed has probably become an integral part of my medical school learning over the past 3 years and I feel that it will probably become part of my own practice in the near future as I progress on after graduation. I hope to apply some of the very valid lessons and pearls imparted from the speakers at the conference, which have been borne out of years of experience and wisdom. I am also very appreciative of how approachable people generally were at the conference in the tone of ‘no wanky introductions’ indeed, which has been a very pleasant tangent from the formality and rigidity of traditional medical conferences. Thanks SMACC2013, a resounding thank you to the team behind it all and very much looking forward to SMACC2014!