The RAGE Podcast

Hello, RAGErs! This is a quick update about a new project from the RAGE team and friends… The Resuscitology Course. This is a two-day residential course for resuscitationists in the Blue Mountains, New South Wales, Australia on May 9-10th 2018. The faculty are  Brian Burns, Karel Habig, Geoff Healy, Nat May, Chris Nickson, and Cliff Reid. Find out more by listening to the podcast and visiting Resuscitology.com. Thanks again for listening to the RAGE!

We’re ready to RAGE again! This one is 85:26 min long and includes: * Introduction… kind of (starts 00:00 min) * ‘What’s bubbling up?’ (starts 02:08 min) — Dr Smith’s ECG blog, DAS Guidelines for tracheal intubation of the critically ill, “The Human Factor” and trauma team performance. *  ‘DNR’ (starts 14:58 min) — the RAGE team discuss the concept of ‘do not resuscitate’ and consensus resuscitation plans, challenges and tips for family discussions and decision-making, and a host of tricky situations (e.g. the family that wants ‘everything’, patients who want to be organ donors, suspension of DNR orders for operations, and patients with advance care plans who attempt suicide).. * ‘A blast from the past’ by Peter Brindley on ‘Joseph Lister’ (starts  80:44 min) * ‘Words of Wisdom’ from Karel Habig (starts  83:41 min) The RAGE podcast is on  iTunes here and the RAGE podcast audio feed is available here. Here are the show notes for this RAGE Session : Introduction * This one features Peter Brindley (@docpgb), Karel Habig (@karelhabig), and me (Chris Nickson, @precordialthump). What’s bubbling up? * Dr. Smith’s ECG Blog * Higgs A, McGrath B, Goddard C et al. Guidelines for the management of tracheal intubation in critically ill adults British Journal of Anaesthesia. 2017 (published online) [article] * Hicks C, Petrosoniak A. The Human Factor: Optimizing Trauma Team Performance in Dynamic Clinical Environments. Emergency medicine clinics of North America. 2018; 36(1):1-17. [pubmed] “DNR” * Burns JP, Truog RD. The DNR Order after 40 Years N Engl J Med. 2016; 375(6):504-506. [website] * Patients and families that want “everything” done (LITFL CCC) * Quill TE, Arnold R, Back AL. Discussing treatment preferences with patients who want “everything”. Annals of internal medicine. 151(5):345-9. 2009. [pubmed] * Advance Care Planning Australia * Medical Treatment Planning and Decisions Act 2016 (Victoria, Australia) * Holt GE, Sarmento B, Kett D, Goodman KW. An Unconscious Patient with a DNR Tattoo N Engl J Med. 2017; 377(22):2192-2193. [article] * Cooper L, Aronowitz P. DNR tattoos: a cautionary tale. Journal of general internal medicine. 2012; 27(10):1383. [article] * ‘Unacceptable’ that families ‘not told of resuscitation plans’ (BBC, 2016) – base on an RCP audit * Doctors ‘forced’ to allow suicide (BBC, 2013) * Geppert C. Saving Life or Respecting Autonomy: The Ethical...

Happy New Year! The next ‘proper’ RAGE session is on track for recording in about a week or so. In the meantime, here is a talk on ‘Simulation for Elite Performers’ by Chris Nickson from last year’s Performance Psychology in Medicine Conference run by the Institute of Prehospital Care in London. The podcast is 34 min 38 sec duration. Thanks to Tom Evens and the conference organisers for such a great event, as well as Mads Astvad (ScanFOAM) for managing to rescue the audio! Mads also put together the video version below: Mads also pointed out (another) error I made… I mistook Walda for Wally! The RAGE podcast is on  iTunes here and the RAGE podcast audio feed is available here. Thanks again for listening to the RAGE!

It is time to RAGE again! This one is 61:38 min long and includes: * Introduction… kind of (starts 00:00 min) * ‘What’s bubbling up?’ (starts 04:48 min) — an ED checklist for cognitive debiasing, are ‘cold’ platelets ready for primetime, the ART trial and the open lung approach to ventilation using recruitment manoeuvres *  ‘What’s The Sats Target?’ (starts 22:55 min) — the RAGE team discuss what SpO2 targets to aim for, in which patients and diseases, and the tricks and traps of real-world clinical practice. * ‘A blast from the past’ by Chris Nickson on ‘Rudolph Virchow’ (starts  52:52 min) * ‘Words of Wisdom’ from Cliff Reid (starts  57:10 min) The RAGE podcast is on  iTunes here and the RAGE podcast audio feed is available here. Here are the show notes for this RAGE Session : Introduction * :-) What’s bubbling up? * Graber ML, Sorensen AV, Biswas J et al. Developing checklists to prevent diagnostic error in Emergency Room settings . 2014; 1(3). [article] * Mike Clancy’s Cognitive Checklist Diagnosis: Interpreting the Shadows by Pat Croskerry et al (Google Books) * All Doctors Are Jackasses by Chris Nickson (LITFL) * Johnson L, Tan S, Wood B, Davis A, Marks DC. Refrigeration and cryopreservation of platelets differentially affect platelet metabolism and function: a comparison with conventional platelet storage conditions. Transfusion. 2016; 56(7):1807-1818. [pubmed] * FDA Approves Cold Platelets For Resuscitation * ART investigators writing group. Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2017; 318(14):1335-1345. [pubmed] [article] Open Lung Approach To Ventilation (LITFL CCC) Lung Recruitment Manoeuvres (LITFL CCC) What’s The Sats Target? * Oxygen Saturation Targets in Critical Care (LITFL CCC) * Oxygen: The Molecule that Made the World by Nick Lane * Grocott MP, Martin DS, Levett DZ, et al. Arterial blood gases and oxygen content in climbers on Mount Everest. The New England journal of medicine. 2009; 360(2):140-9. [pubmed] * Unger S, Cunningham S. Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis. Pediatrics. 2008; 121(3):470-5. [

The next RAGE session is here! (we’re no longer numbering them as the low numbers are depressing…) This one is 95 min long and includes: * Introduction and ‘What’s bubbling up?’ (starts 00:00 min) — head rotation for effective ventilation, The Procedures Course, FOAM social capital and wellness, Tips for New Doctors.. *  ‘Optimizing Crisis Resource Management’ (starts   14.29 min) — an interview with Peter Brindley followed by thoughts from Karel Habig * ‘dasSMACC reflections’ (starts  67.09 min) * ‘A blast from the past’ by Karel Habig on ‘John Scott Haldane’ (starts  87:55 min) * ‘Words of Wisdom’ from Peter Brindley (starts  92:36 min) The RAGE podcast is on  iTunes here and the RAGE podcast audio feed is available here. Here are the show notes for this RAGE Session : Introduction * ‘How to give an unforgettable talk’ (LITFL) — a story about Gile Brindley (not a blood relative of Peter Brindley…) What’s bubbling up? * The Procedures Course * Head Rotation for Mask Ventilation (Resus.ME) * Everybody’s free – Top Tips for the Class of 2017 (St Emlyns) * The Ties that Bind: Social Capital and the Psychology of FOAM by Mike Lauria (EMCrit) Optimizing Crisis Resource Management * ‘Optimizing Crisis Resource Management’ (free ebook from the Royal College of Physicians and Surgeons of Canada) * ‘Crisis Management in Acute Care Settings: Human Factors and Team Psychology in a High-Stakes Environment’ (3rd edn, 2016) by Michael St.Pierre, Gesine Hofinger, and Robert Simon * ‘Thinking, Fast and Slow’ by Daniel Kahneman (Google Books) * ‘Streetlights and Shadows: Searching for the Keys to Adaptive Decision Making’ by Gary Klein (Google Books) * Talks by Pat Croskerry at SMACC Chicago (2015) * Robin Dunbar (Wikipedia) and his books: ‘Grooming, Gossip, and the Evolution of Language’ (Google Books) and ‘How Many Friends Does One Person Need? Dunbar’s Number and Other Evolutionary Quirks‘ (Google Books) dasSMACC Reflections * The SMACC website * Talks by Peter Brindley at previous SMACCs * Look out for the upcoming podcast release of all the talks from dasSMACC… Blast from the Past *

‘Three Men and a Microphone’ is a special edition of the RAGE podcast (let’s face it, RAGE podcasts are so infrequent they’re all special!) featuring RAGE Resusciteer Cliff Reid in conversation with these special guest RAGErs: * Geoff Healy (prehospitalist/ retrievalist/ anaesthetist) * Brian Burns (prehospitalist/ retrievalist/ emergency physician) This one is a monster – it is 2h 48 min 59 sec long!!!  It is NSFW (contains some profane verbiage) so don’t let your kids listen in… Here is the run sheet so the you can skip to the bits you want:   Introduction 0:00 Intro: NSFW 2:38 Welcome – what we’re busy with at the moment 10:13 Highly functioning organisations 18:00 Airway audit 19:06 Operations research and A.P. Rowe 23:42 Role of SOPs, SOPs vs protocols   28:37 QUESTION: Describe training experiences that have shaped you Anaesthesia in Australia -Geoff getting patronised Trauma in Ireland – Brian being unsupported EM in England – Cliff getting pimped Importance of honesty and humility as a mentor Mike Clancy’s public cerebration – teaching you how to think Phoning a friend when you’re the boss Calling the boss in – differences between the UK & Australia 3 reasons to call the boss: to let you know, to seek advice, to ask you to come in.   1:05:05 QUESTION: What is your experience of trainees, and what attributes of good and bad trainees do you observe? The lurker, the stalkers, the shopper, the sharp-elbows Our experiences as underconfident trainees Turning yourself into the (mythical) shit magnet John Hinds’ approach to keeping sharp Consultants who are hummingbirds Avoiding institutionalisation – getting experience in remote/rural units   1:29:24 QUESTION: Give your advice on how to be a good resuscitationist The word resuscitationist EMS Gathering in Cork and big wave surfers Extending your training – fellow posts and other experiences Acquiring experience with restrictions on working hours The limitations of learning from textbooks and life support courses Can we accelerate the acquisition of experience using technology? Lionel Lamault & prehospital ECMO Comfort zones and task fixation Geoff likes to ‘bosh’ people Cognitive rally points Unexplained different approaches to fluids in paeds resuscitation Being treated as a gas monkey in ED A new word  – resuscitationism The Jason Bourne game and developing spider-sense Too sick to be intubated?   2:07:30 QUESTION: What are you currently struggling with in your careers? Being a coach Having trainees who are better than we are / were Top Gun pilot caution against overperformers Thoughts for bosses who have trainees who are smarter or more skilled than they are: (1) They make you look good; (2) You might learn something; (3) The future is brighter for patients The challenge of getting senior clinicians involved in simulation Struggling to improve and get outside our comfort zones, and continue to evolve as consultants A pantyhose anaesthetic

On August 17th 2016, Associate Professor Vincent Pellegrino, Head of the ECMO service at The Alfred ICU, discussed ECPR during an in-house education session. His discussion included: * the difficulties with ECPR definitions and selection criteria * Approaches to ECPR, ranging from cannulation techniques and types of cannula, to role cards and the importance of teamwork * Outcomes for ECPR and the evidence for the technique Listen to the talk to find out more – the podcast is 37 minutes long. THE VIDEO THE SLIDES For more on ECMO check out INTENSIVE and EDECMO.org. The RAGE podcast is on  iTunes here and the RAGE podcast audio feed is available here. Thanks again for listening to the RAGE!

Here is the ‘bootlegged’ video footage of John Hinds’ defense of direct laryngoscopy in the prehospital setting. John brings all his usual wit and mischievousness to the defence of the tried and true way of getting a tube between the cords anywhere and at anytime. The audio has been released on the RAGE podcast, and is 7 minutes 30 seconds long. For more John Hinds, go to RAGE’s John Hinds tribute page. The RAGE podcast is on  iTunes here and the RAGE podcast audio feed is available here. Thanks again for listening to the RAGE!

On November 11th 2015, Professor Steve Bernard (@AmbVicMedic), Medical Advisor to Ambulance Victoria, presented a smorgasbord of ‘Updates in Resuscitation‘ at The Alfred ICU junior medical staff teaching session. He discussed: * Recent data from registries on in-hospital and out-of-hospital cardiac arrest (OHCA), particularly from Victoria, and the reasons why OHCA results may be improving * Options for treatment of refractory VT/VF, including the CHEER2 trial * The RINSE trial: is intra-arrest cooling with ice cold IV saline for OHCA a good thing? * Highlights from the recently released updated ILCOR guidelines, which will form the basis for the next ARC guideline update Listen to the talk to find out more – the podcast is 47 minutes long. For more talks by Steve Bernard, check out INTENSIVE. The RAGE podcast is on  iTunes here and the RAGE podcast audio feed is available here. Thanks again for listening to the RAGE!

RAGE will be coming out hibernation post-SMACC and the first signs of reanimation come in the form of this ‘preSMACC miniRAGE’ featuring Cliff, John and Karel. Register for SMACC Chicago 2015 now and come up and say ‘Hi’ to the RAGE team!  FIRST HALF The first half of this miniRAGE is a preview of what the RAGE gang are doing at SMACC Chicago 2015… Including “IT’S A KNOCKOUT”: SECOND HALF The second part of the podcast is all substance, with discussions of the following: * our favourite app, the GoodSAM App * Oxygen therapy, specifically this trial led by Dion Stubbs and Steve Bernard from The Alfred: AVOID: Air Versus Oxygen in ST-Segment Elevation Myocardial Infarction and the trial by friend of RAGE, Paul Young titled HOT or NOT trial: HyperOxic Therapy OR NormOxic Therapy after out-of-hospital cardiac arrest (HOT OR NOT): a randomised controlled feasibility trial. * John discusses Helicopter Emergency Medical Services, including Survival benefit of a physician-staffed HEMS assistance for severely injured patients and  Willingness to pay for lives saved by HEMS * … and Cliff continues his intraosseous obsession with (1) Intraosseous infusion rates under high pressure: a cadaveric comparison of anatomic sites, (2) Intraosseous hypertonic saline: myonecrosis in swine, (3) Intraosseous hypertonic saline: safe in swine and (4) Discussion post about intraosseous hypertonic saline at Sydney HEMS * Finally, listeners will find out why handstands are awesome:  Handstands: a treatment for supraventricular tachycardia?, Impact of a modified Valsalva manoeuvre in the termination of paroxysmal supraventricular tachycardia and Handstands keep you awake. By the way, because someone actually bought a pair of RAGE shoes they are still in production – check ’em out and buy ’em here: http://aliveshoes.com/rage Thanks again for listening to the RAGE!

Listen to this miniRAGE for key information on registration for SMACC Chicago 2015. and to find out what the RAGE team will be doing at #smaccUS. I’ve reposted LITFL’s SMACC Chicago is coming… here: The programme for SMACC Chicago is now online for all to see. It has been a real joy to work on this — the opportunity to bring together the best people in critical care, to talk about the best topics in critical care, is one to be relished. We have assembled an awesome lineup — both behind the scenes to build the fire, and front stage to light it… as you will see in the programme. Most importantly, registrations are opening very soon: 0800h November 6th (AEST). Check out the ICN post titled SMACC Chicago Rego Opens 5 November for equivalent opening times throughout the world’s time zones, and some important tips about registration. The first 500 residents / registrars / paramedics / nurses / pharmacists / PAs (or other non-attendings / non-consultants) will be able to register at the discounted price of US$595. This is ‘cost price’, and is fully inclusive of all events in the 3 day program, the welcome reception, Gala night and all coffee and lunch breaks. The first 800 specialists/ attendings also get discounted prices and there are 250 student tickets at only $350. Also, to help avoid lumping you with transaction fees, you can pay by direct deposit in either USD, AUD or Euros, depending on where you’re coming from. Note that if you want to attend one of the more than 30 pre-conference workshops, you have to register for the conference first, then the workshop separately. Be warned, some workshops sold out within a couple of weeks at smaccGOLD. Check out the SMACC program(me) online, or download the brochure here: SMACC Brochure Vive la FOAM!

NeuroRAGE is a special edition of the RAGE podcast featuring these special guests: *  Mark Wilson, prehospitalist with London HEMS and neurosurgeon with the NeuroTrauma unit at Imperial in London *  Oli Flower, intensivist and NeuroICU enthusiast at Royal North Shore Hospital in Sydney – co-organiser of SMACC and Intensive Care Network. This edition is 82 min 03 sec long and includes: * Introduction, including a welcome to Mark and Oli, along with usual supsects Cliff and Karel… (starts 00:00 min) * ‘What’s bubbling up?’ (starts )1:31 min) — shout outs and interesting discoveries from the world of FOAM and elsewhere featuring the GoodSam app (again), A talk on transport of Ebola patients, SMACC Chicago, ESICM’s live feed of ‘Hot Topics’ such as the ARISE trial results, and Cliff Reid’s ‘through the rabbit hole’ experience with ketamine as a patient. * the NeuroRAGE participants discussing ‘Traumatic Brain Injury and a bit about the Spine’ (starts 17:13 min) * the NeuroRAGE participants discussing ‘ICP Monitoring’ (starts 45:22  min) * the NeuroRAGE participants discussing ‘Intracerebral haemorrhage and Subarachnoid Haemorrhage’ (starts 55:09  min) * the NeuroRAGE participants discussing a ‘smorgasbord’ of other neurocritical care questions, including the ‘cranial screwtop manoeuvre’ (starts 79:14  min) * ‘A blast from the past’ by Oli Flower on the origins of the EEG  (starts ? min) * ‘Words of Wisdom’ from Mark Wilson (starts 80:36 min) The RAGE podcast is on  iTunes here and the RAGE podcast audio feed is available here. Here are the show notes for the NeuroRAGE Special Edition: Introduction * The GoodSam app * SMACC Chicago * A talk by Alexander Isakov on ‘EMS: Transport and Care of Patients ill with Ebola Virus Disease’ (Emory University Grand Rounds) *  The ARISE trial results (ESICM News) * Wade Davis on “Dreams of Endangered Cultures” (TEDtalk) * Midazolam smoothens adult ketamine sedation (Resus.ME) Ketamine-induced dysphoria and hallucinations: Traumatic Brain Injury and a bit about the Spine * Laroche M, Kutcher ME, Huang MC, Cohen MJ, Manley GT. Coagulopathy after traumatic brain injury. Neurosurgery. 2012 Jun;70(6):1334-45. doi: 10.1227/NEU.0b013e31824d179b. Review. PubMed PMID: 22307074. * Stocchetti N, Maas AI. Traumatic intracranial hypertension. N Engl J Med. 2014 May 29;370(22):2121-30. doi: 10.1056/NEJMra1208708. Review. PubMed PMID: 24869722. * LITFL CCC entries on TBI: * Traumatic Brain Injury (TBI) Overview * Traumatic Brain Injury (TBI) Assessment * Traumatic Brain Injury (TBI) Management *

Anand ‘Swami’ Swaminathan is an Emergency Physician in New York. He is one of the co-creators of EM Lyceum, and a major contributor to Lifeinthefastlane.com, primarily through R&R in the Fastlane and The LITFL Review, as well as other FOAM resources. Swami is a skeptic of the benefit of adrenaline in cardiac arrest. This is his brief response to Scott Weingart’s Cutting Edge Intra-Arrest Care at smaccGOLD and Weingart’s subsequent discussion about intra-arrest meds with Rob Mac Sweeney on EMCrit. For a summary of the articles discussed check out Swami’s ‘Epinephrine in Cardiac Arrest‘ post on emdocs.net, which includes links to all of the relevant studies. Scott Weingart also has another relevant discussion in EMCrit Podcast 130 – Hemodynamic-Directed Dosing of Epinephrine for Cardiac Arrest. Thanks again for listening to the RAGE!

Relax, we didn’t really delete the discussion of The ProCESS Trial from RAGE Session Four… We just chopped it out to be published separately as a miniRAGE. This is what we’re talking about: ProCESS Investigators, Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, Pike F, Terndrup T, Wang HE, Hou PC, LoVecchio F, Filbin MR, Shapiro NI, Angus DC. A randomized trial of protocol-based care for early septic shock. N Engl J Med. 2014 May 1;370(18):1683-93. doi: 10.1056/NEJMoa1401602. Epub 2014 Mar 18. PubMed PMID: 24635773. [Full Text] [Supplement] So, following on from Haney’s comments on the Surviving Sepsis Campaign response to ProCESS, here is the RAGE team talking about what it all means for the management of septic shock. Learn more here: * The ProCESS Trial (INTENSIVE) * Podcast 120 – The ProCESS Trial with Derek Angus (EMCrit) Thanks again for listening to the RAGE!

RAGE Session Four is here! (at last…. you say) It is 61  min 46 sec long and includes: * Introduction, including a welcome to new RAGE team recruit John Hinds and apologies from Cliff… (starts 00:00 min) * ‘What’s bubbling up?’ (starts 01:16 min) — shout outs and interesting discoveries from the world of FOAM and elsewhere featuring regional anaesthesia, the GoodSam app, the Surviving Sepsis Campaign response to the ProCESS Trial, Brain Impact Apnoea and the ‘Tamiflu’ debacle. * the RAGE team discussing ‘Getting The Right Side Right: RV infarction and RV failure’ (starts 13:39  min) * the RAGE team discussing another ‘Humans in the Resus Room’ topic: ‘I Want to Stop, But Someone Else Doesn’t’ (starts 37:03 min) * ‘A blast from the past’ by me (Chris Nickson) on ‘Jack Barnes and the Irukandji Enigma’ (starts 55:07 min) * ‘Words of Wisdom’ from motorcycle legend Guy Martin via John Hinds (starts 59:14 min) The RAGE podcast is on  iTunes here and the RAGE podcast audio feed is available here. Here are the show notes for RAGE Session Four: Introduction * John Hinds speaking about Cricolol at the smaccGOLD cricoid pressure debate: Cricoid: To Press or Not to Press? (RAGE) What’s bubbling up? Regional Anaesthesia * Beaudoin FL, Haran JP, Liebmann O. A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial. Acad Emerg Med. 2013 Jun;20(6):584-91. doi: 10.1111/acem.12154. PubMed PMID: 23758305. * Black KJ, Bevan CA, Murphy NG, Howard JJ. Nerve blocks for initial pain management of femoral fractures in children. Cochrane Database Syst Rev. 2013 Dec 17;12:CD009587. doi: 10.1002/14651858.CD009587.pub2. Review. PubMed PMID: 24343768. * De Buck F, Devroe S, Missant C, Van de Velde M. Regional anesthesia outside the operating room: indications and techniques. Curr Opin Anaesthesiol. 2012 Aug;25(4):501-7. doi: 10.1097/ACO.0b013e3283556f58. Review. PubMed PMID: 22673788. * Gadsen J. Regional Anesthesia in Trauma: A Case-Based Approach. Cambridge University Press; 1 edition (November 12, 2012) (website) * Wu JJ, Lollo L, Grabinsky A. Regional anesthesia in trauma medicine. Anesthesiol Res Pract. 2011;2011:713281. doi: 10.1155/2011/713281. Epub 2011 Nov 21. PubMed PMID: 22162684; PubMed Central PMCID: PMC3227428. * Mike Stone’s video showing how to perform a fascia iliaca block with ultrasound: FICB Refresher from Mike Stone on Vimeo. Other topics ‘bubbling up’: * TechTool Thursday 050 GoodSam (LITFL) * Surviving Sepsis Campaign Guidelines 2012 (LITFL CCC) and SSC Response to ProCESS (pdf) (RAGE discussion about ProCESS coming ...