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Chris Nickson
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Chris Nickson
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critical care  - 
 
In case you have been hiding under a rock - the late John Hinds on 'Crack the Chest, Get Crucified' from SMACC Chicago. Doc John is sorely missed by us all:
http://ragepodcast.com/crack-the-chest-get-crucified-by-john-hinds/

A John Hinds tribute page, with links to all his FOAM contributions is available here:
http://ragepodcast.com/john-hinds/
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Chris Nickson
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intensive care  - 
 
Quick question - can anyone recommend a good simulator for bronchoscope-assisted percutaneous tracheostomy?
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Vacuum cleaner tube perhaps? :-) 
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Chris Nickson
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critical care  - 
 
As promised in a thread on acid-base a few weeks ago, the first of David Story's smaccGOLD talks has been released:

 'Is chloride a poison?'

(previous thread on the Stewart-Fenci approach: https://plus.google.com/102345709116553575043/posts/8QFD7xP1Fuq)

Share your thoughts!
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Chris Nickson
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Discussion  - 
 
Some FOAMcc updates

Only 3 more members needed for the FOAMcc G+ community to swell to an amazing 1,000 members - thanks everyone for making this happen!

Remember you can use the #FOAMcc  hashtag to search for links and resources on Twitter, with selected tweets and links retweeted and shared by the @FOAMcc account. Journals such as 'Critical Care' (@Crit_Care) are now using the #FOAMcc  hashtag too... 

Finally, do YOU want to get published in a critical care journal? Why not write for Critical Care Horizons, the FOAMcc journal that will soon be launched by Rob Mac Sweeney and Andrew Ferguson - it is free to publish and free to read.

That's all!
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Chris Nickson
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critical care  - 
 
Philippe at 'Thinking about Critical Care' has got a bee in his bonnet about the administration of chloride-rich fluids...
http://thinkingcriticalcare.com/2014/06/16/another-plea-please-stop-embarassing-us-foamed-foamcc/

What do you think?

This is what I reckon:

While I’m wary about the possibility of chloride being a renal toxin, we really should not be too dogmatic about this. There are no great studies to support chloride-restriction yet (high quality studies such as the SPLIT trial are underway) and purely physiological rationales always tend to come back and bite us down the track.

There is a major confounder in the Yunos 2012 JAMA paper (http://jama.jamanetwork.com/article.aspx?articleid=1383234). The chloride-rich arm included lots of gelofusine (gelatin solution), the chloride-poor harm had no gelosfusine (that’s right, ZERO). There was also a reduction in albumin use in the chloride-poor arm of the trial. It is plausible the acute kidney injury (AKI) seen in this trial is due to colloid not chloride. This is particularly relevant given the RCTs showing that other synthetic colloids like tetrastarch cause AKI.

Meanwhile, I’ll be avoiding unnecessary chloride-excess but I’m not going to bust anyone’s balls about it (too much!) until the data backs me up. I’m eagerly awaiting the completion of SPLIT, the results of which we expect to be presented at SMACC Chicago in 2015 by lead investigator Paul Young…
http://www.anzics.com.au/ctg/current-research/33-clinical-trials-group/current-studies/354-split

Cheers
Chris
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I second that motion, as a CCM fellow with IM as a base specialty it is embarrassing to discover that a patient who has been in the unit for several days, now has a nice hyperchloremic metabolic acidosis - as they say, nothing "normal" about normal saline (for those with computer order entry, try and get your CPOE consortium to make sodium chloride the search phrase instead of normal saline) 
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Chris Nickson
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emergency medicine  - 
 
+Reuben Strayer has an interesting synthesis of approaches to intubation in the emergency setting in his latest post on EM updates. When to use RSI, DSI, KSI (ketamine-supported intubation) or awake intubation?
What do you think about it?
Rapid sequence intubation, the simultaneous administration of a paralytic and induction agent immediately followed by laryngoscopy, provides the optimal view of the glottis and prevents emesis. RSI...
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Is it really appropriate tot intubate the near-arresting patient without any sedative or analgetic at all? Risking awareness (unethical) and realising that a laryngoscopy is an extremely painful stimulus?
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Chris Nickson
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critical care  - 
 
Hi all
Registration for SMACC 2015 opens Nov 5th/6th (depending on your timezone). There are limited numbers of cheap tickets available for trainees, students, paramedics, nurses, pharmacists, and other 'non-medical specialists'. Workshops are also limited numbers.
You will be able to register here:
http://www.smacc.net.au/register-now/
All the best - hope to see you in Chicago.
Chris
(I don't want to use this venue for advertising - but I 'd hate for people that want to be there to miss out!)
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Dr. Nickson, I would like to share a toxicology report with you.  Is this possible? 
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Chris Nickson
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Discussion  - 
 
 
Opiates For Severe Asthma - A Conversation with Dr. Leo Stemp


From: Reuben Strayer
Date: Sun, Oct 5, 2014 at 3:30 AM
To: Leo Stemp

Thanks for your comments, Dr. Stemp, in the recently released AmJEM letter. [ http://goo.gl/DQc3Ps ]

I have never heard of opiates used or recommended for severe asthma. Are you aware of any data to support this practice?

reuben

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From: Leo Stemp
Date: Wed, Oct 8, 2014 at 8:18 AM
To: Reuben Strayer


Reuben, sorry for the delay in responding, your message wound up in my spam box. 
 
In a general medical-surgical ICU, resp failure accounts for 85-90% of the admissions for acute illness.  So our business is, essentially, the management of respiratory failure, and our #1 goal, therefore, is to avoid intubating people (bec once they're intubated, play time is over.)  So when someone presents with resp distress, of any etiology, there are two treatments that are administered, to every patient:
 
1. Treatment aimed at alleviating work of breathing (WOB) -- bec you must prevent resp muscle fatigue.
2. Treatment aimed at the underlying cause of the resp distress.
 
Everybody focuses on #2.  We focus on #1, bec all the money is in #1.  If you don't prevent resp musc fatigue, you'll have to intubate the patient, and the game is gonna be over pretty quickly.  Any monkey can give bronchodilators, steroids, Lasix, etc.  But that won't cure your resp distress, certainly not quickly enough.
 
In view of that, opiates are the first line treatment for all manner of respiratory distress, bec they slow the resp rate, which is one of the two ingredients in WOB.  See pages 3-5 of the first attachment for a full discussion of this.
 
But there's also a second reason for using opiates, which among all patients with resp distress, is unique to patients with asthma -- and that is the magic of a slow resp rate.  See the second and third attachments for a full discussion of why you MUST slow the resp rate in asthmatics.
 
It's interesting that you commented that you'd never heard of opiates used for severe asthma.  About ten years ago, I was at a big conference in NY City put on by the Society of Critical Care Medicine (the national organization for critical care docs) on newer modes of mechanical ventilation.  All the big national and international gurus in mechanical ventilation were presenting.  The major topic of discussion was actually noninvasive ventilation (esp BiPAP).  Most interesting (to me) was that not a single person mentioned the use of opiates for resp distress -- and in our ICU, opiates are the FIRST line treatment for any manner of resp distress.
 
So your email is the second time I've heard someone say that they'd never heard of opiates used for resp distress.  And you're right, there's no data on this that I know of, and very few people are knowledgeable about it, for reasons that mystify us.  It's all straightfwd physiology.  We keep telling our ED docs how to treat resp distress, but they don't get it.
 
Well, give it a shot and let me know how it works out for you.
 
Best,
 
Leo

Three attached documents:
http://goo.gl/lCSclF
http://goo.gl/CGURcz
http://goo.gl/jbUiAs

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From: Reuben Strayer
Date: Wed, Oct 8, 2014 at 9:08 AM
To: Leo Stemp

Thanks Leo. 

I've just scanned these documents, thank you for sending them. If what you say about opiates in asthma is even partially true, you really must publish something, anything, to get the idea out there - even if your unit is not set up to do anything experimental, just do an observational case series. Then someone else can subject the therapy to science. 

I read every paper on severe asthma that comes through the EM literature, and there is nothing on this, and I've heard nobody speak of opiates as an asthma therapy, and it's in no guideline.

It makes sense, decrease the respiratory rate - that's certainly what we do when we intubate them. But as you note, it goes against conventional teaching and is therefore scary to give a respiratory depressant to a patient in respiratory distress. We need some science; you saying it works is not enough.

Thanks again for sending me these documents, much food for thought. 

reuben

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From: Leo Stemp
Date: Wed, Oct 8, 2014 at 10:53 AM
To: Reuben Strayer

Yikes.  Reuben, that's my point:  What I sent you is science (whether it's published or not).  Don't wait for the publishing world to catch up to what YOU think makes sense, from a physiologic point of view.
 
Leo
 
"The lack of controlled studies has led to vehement rejection of [these] approaches despite ample scientific logic for [these] treatment concepts.  Unfortunately, the rigidity of the Western scientific approach, which demands absolute proof and total rejection of the unproven, is sadly adverse to patients afflicted with [disorder] and can prevent the acceptance of effective treatment regimens for an entire generation.  Practicing physicians, not so tightly bound by protocol guidelines and the ideological necessity for scientific proof required by academic centers, and facing daily and personally the unfolding tragedies of the “untreatables”, often are in a perfect position to discard outmoded concepts and initiate ‘unproven’ but very effective treatment innovations."  – Paul Altrocchi, MD, Chairman, Dept. of Neurology, Palo Alto Medical Clinic
 
Norman Geschwind, the late professor of neurology at Harvard, commented in an article in The Encyclopedia of Medical Ignorance that "there is a widely held supposition that one’s scientific peers are honest, well-informed, not swayed by prejudices, and open to imaginative ventures into the unknown.  It is my purpose here to point out that in the field of the neurology of behavior, major advances were neglected, not for a few years but for nearly half a century."

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From: Reuben Strayer
Date: Wed, Oct 8, 2014 at 11:01 AM
To: Leo Stemp


>Don't wait for the publishing world to catch up to what YOU think makes sense, from a physiologic point of view.

Sorry you feel that way, Leo.

Thank you again for a stimulating idea.

reuben


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From: Leo Stemp
Date: Wed, Oct 8, 2014 at 5:53 PM
To: Reuben Strayer
Cc: George E. Karras, Julia Bonacum, Kathy Hutchins

Reuben, it just struck me -- now I get why nurses and physicians don't use opiates to treat resp distress.  Like you say, it goes against the grain to give a resp depressant to someone in resp distress.  But that's only if you don't understand resp failure.  Once you understand the physiology of resp failure and work of breathing, it is immediately apparent that opiates are mandatory to prevent gross resp failure.
 
Those of us in the ICU not only intimately understand the physiology, but we're intimately familiar with dealing with resp failure, so we have no fear.  It's probably like sky diving, I'd imagine -- frightfully scary to the novice who doesn't know anything and has no experience, but as easy as putting his pants on for the instructor with 30 years under his belt.  Now I get it.

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From: Leo Stemp
Date: Wed, Oct 8, 2014 at 5:58 PM
To: Reuben Strayer


Reuben, not that it's any help to you, but I forgot to say that we have rescued dozens and dozens of asthmatics in the ED simply by giving them fentanyl and CPAP.  There's nothing more catastrophic than an intubated asthmatic, so when we get a call from the ED, we get down there fast!  I've yet to have to intubate one that they've called me about (FWIW).  To be honest, the rescue of a desperately tight asthmatic with fentanyl and CPAP is so childishly simple and effective, it's embarrassing when we go down there.

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From: Reuben Strayer
Date: Wed, Oct 8, 2014 at 7:18 PM
To: Leo Stemp


Sounds like a remarkable approach Leo. Thanks again. 
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I agree with his #1 and #2 thought process, however I caution this - if #2 is caused by, say a metabolic acidosis and your ABG shows 7.40/15/90/10 (as a ludicrous example), giving a narcotic to reduce WOB is going to be disastrous. However, if it is more of a dyspnea (subjective air hunger, asthmatic moving air ok but uncomfortable etc..) and the ABG is 7.55/20/90/24 then I think narcotics would be ok. 
I try to be objective about "respiratory muscle fatigue". If you start at a pCO2 of 40 (normal), have a respiratory process that causes respiratory distress and your subsequent pCO2 are 20,19,18,19,20 I cannot logically conclude there is fatigue. If I see 20,22,24,30 with worsening acidosis (and not just a reversal of the underlying process) that I move toward assistance.
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Chris Nickson
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Discussion  - 
 
What debates would you like to see at SMACC Chicago on the following topics:
1. Education
2. Critical Care Controversies
3. Paediatrics
4. EBM/ Research
Share your ideas and we'll aim to please!
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Suspect not quite good enough for SMACC but debate coming is whether vaccinations and bio markers will make children's emergency medicine specialists redundant in a decades time... (I've heard an vaccine specialist talk on something like this)
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Chris Nickson
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Discussion  - 
 
ON EARLY ADOPTION:

Are you an early adopter? Should you be? How can we distinguish good early adoption from bad early adoption?

These are questions that fascinate me and talks related to this theme were prevalent at smaccGOLD (no coincidence!). Those of us who are emergency physicians and/or intensivists are sometimes perceived as being earlier adopters than those from other specialties. In particular, those of us using FOAM/ social media for education are likely to be in the vanguard.

Is this a problem?

+Simon Carley  was handed the task of dealing with this explicitly in his SMACC talk 'What to believe and when to change?'
http://stemlynsblog.org/believe-change-st-emlyns-smacc/

I am reminded of an Osler quote about never using a drug that is less than 10 years old...

On a related note, was a talk by Tony Brown ('Is the peer reviewed journal dead?), as already highlighted on this community by +Jesse Spurr here: https://plus.google.com/111077302796124705127/posts/7tcmKgR5s5c

... and emergency cardiology clinician researcher Louise Cullen on 'Why most published research is wrong':
http://stemlynsblog.org/louise-cullen-published-research-wrong-st-emlyns/

Simon's talk, in particular, was a not-so-veiled throwing down of the gauntlet to +EMCrit , who had previously spoken about 'Cutting edge intra-arrest care'. For example, Scott advocates use of vasopressin, steroids and epinephrine in cardiac arrest based on a phase II trial from Greece (he has already discussed this with Rob Mac Sweeney here: http://emcrit.org/wee/rob-mac-sweeney/).

All of this makes Scott's response essential listening: http://emcrit.org/wee/on-the-beliefs-adopters-straw-men/

It is worth reflecting on what makes YOU believe in something, and what makes YOU change YOUR beliefs. I'm interested in your thoughts.
---

UPDATE 26 June 2014:

Simon Carley just released his SMACC-Back-Back response to Weingart:
http://stemlynspodcast.org/2014/06/
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Incidentally, the Social Media Tsunami that TTM kicked off about whether to change practice was the inspiration for having this talk at smaccGOLD.
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Chris Nickson
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resuscitation  - 
 
I think #FOAMcc members should read/ listen to these if they haven't done so already:

(1) Weingart on errors of commission and omission
http://emcrit.org/wee/motr-commission-and-omission/

(2) +Richard Body  from St Emlyns on 'do no harm' versus a risk benefit analysis:
http://stemlynsblog.org/ethical-dilemmas-in-emergency-medicine-part-3-primum-non-nocere/

I think the two inform one another, but I won't spell it out - I'd like to see what you all think.

BTW, I'm not sure how good +EMCrit would be at exploring underlying frames in a debrief... ;-) There are many potential reasons why someone doesn't perform a procedure that is needed. Fear of commission error is one, others include 'the bystander effect', not feeling like one is sufficiently competent, fixation error on other tasks, and the rest of the 'cognitive storm' that can lead to 'chicken bombs' going off all over the shop.

These +Cliff Reid  posts are must reads too:

Chicken bombs and muppet factors
http://resus.me/on-chicken-bombs-and-muppets/

It's up to you:
http://resusme.em.extrememember.com/?p=4929

Enjoy!
Should we err towards errors of commission or omission?
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3 comments
 
Great thoughts there, Chris.  Thanks for sharing!

I think the +Cliff Reid post 'Chicken bombs and muppet factors' has to be one of the most awesome blog post titles in the history of  #FOAMed .
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Chris Nickson
owner

Discussion  - 
 
A reminder to #FOAMcc  users of how this community is moderated. Posts that simply advertise links authored by the poster are removed unless they appear to be an honest attempt to start a discussion or provide information genuinely of interest to the community. Twitter is a better way to simply share links, as people can choose to follow you (or not). It is important the G+ community page does not become a vehicle for spam. I'm happy to discuss different points of view on this. Thanks everyone, Chris
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Story
Introduction
An oslerphile suffering from a bad case of knowledge dipsosis. I spend much of my time trying to keep calm amid a storm of interests that include: emergency medicine, critical care, toxicology,  clinical epidemiology, simulation and the internet-learning revolution.

I’m also known as @precordialthump
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