FOAMcast will be back shortly with regular core content-cutting edge mash ups. However, we would be remiss not to take a moment to focus on a conference that inadvertently created FOAMcast…and is coming to Chicago in June 2015. SMACC – Chicago (#smaccUS) June 23-26, 2015.
The etiology: FOAMcast was dreamed up whilst milling around the exhibition hall at SMACC, discussing how even core content and “basic” medicine seemed cutting edge and important here. These projects can be dreamed up via Twitter or e-mail but I think there’s something special engendered by the propinquity of Free Open Access Medical education (FOAM) mixed with the physical conference. Our fate was sealed when Dr. Victoria Brazil happened to stop by to say “hi” while we were hyped up on “long blacks” and blabbering away about what we would call our project. For better or worse, FOAMcast was born.
- Note: Please do not blame Dr. Brazil for our off-beat humor or the podcast. She had no idea what we were up to and does not endorse FOAMcast or Drs. Jeremy Faust and Lauren Westafer.
The talks at SMACC were unparalleled. The speakers inspiring, the slides clean, the material relevant, and the audience questions thoughtful. We learned from social workers (Liz Crowe’s hilarious talk), nurses, medics, and doctors from around the globe. In fact, we became friends, even the pre-med university student. We learned from them all.
The Core Content – There were a cornucopia of excellent core content talks; for example, Natalie May’s pediatric pearls, Aortic Catastrophes, and the Meaning of Acidosis by Dr. David Story. There are too many to list and they’re all worth a listen and can be found on iTunes or via the Intensive Care Network. Even the sonowars were brilliant. For example, Drs. Matt Dawson and Mike Mallin taught us to visualize cardiac view using humans. The awkward apical 4 chamber view for cardiac ultrasound:
In this episode, we only had time to hit just a few heavy hitters that haven’t made it onto our other podcasts.
- Dr. Mallemat beautifully describes various methods of assessing fluid responsiveness – from IVC ultrasound (used alone, approximately equal to CVP), stroke volume variation, to passive leg raise and more advance ultrasound techniques.
- Use dynamic markers rather than static numbers, which seemed to be universally lousy. Trend the patient’s response in order to give them “as much fluid as they need, and not one drop more.”
- Source control is key in sepsis. If a patient has an infected gallbladder, obstructing kidney stone, etc – call surgery. Advocate for these patients.
- ProCESS (and now ARISE) have demonstrated that protocols don’t necessarily have to be followed in order to reduce mortality in sepsis. We have become increasingly good at identifying and treating sepsis since the original EGDT trial. In his words – you don’t have to do sh*t, you just have to give a sh*t (Note: you still have to provide basic resuscitation, antibiotics, etc; you just don’t have to do the fancy stuff).
- He had more pearls about lactate – such as in his collaborative, the number predicted badness but trends mattered less.
- One cannot predict blood pressure based on the presence or absence of a pulse in various anatomic locales (i.e. if there’s a pulse at the radial artery, then their systolic blood pressure is at least >80 mmHg). This myth was taught for years and still persists in some trauma bays; however, even the evidence and the two most recent iterations of ATLS agree with Dr. Reid [Deakin et al]
- The Berlin definition of ARDS [ARDS Definition Task Force]:
- Acute worsening of respiratory failure (< 1 week)
- Edema not solely due to hydrostatic pulmonary edema (i.e. should not be due to heart failure or fluid overload)
- Bilateral infiltrates on CT/CXR *(subjective)
- PaO2/FiO2 ratio <300 mmHg with at least 5 cm H20 of PEEP
- The premise of Dr. Mac Sweeney’s talk; however, is that we ARDS is problematic because:
- ARDS is a disease we can’t diagnose – Many of the criteria, although seemingly helped by the Berlin definition, are still subjective (ex: CXR Sensitivity 0.73; specificity, 0.70 [Figueroa-Casas]
- The diagnosis of ARDS is of limited clinical utility. What he means by this is that the definition doesn’t really affect management and nearly all drugs targeted towards ARDS fail to show benefit consistently. The ARDS care that does work, like lung protective ventilation and fluid balance, these are just good critical care. Proning may work, but doesn’t seem to pan out in everyone [Guerin]. Dr. Mac Sweeney is also a little sweet on ECMO, awaiting future studies.
- People don’t typically die from ARDS even though ARDS is associated with a 40-50% mortality rate. Yet, only 10% of people with ARDS die of ARDS or respiratory failure. Most people with ARDS die because they’re super sick.
- Most people with ARDS don’t have ARDS. Autopsy studies have demonstrated that ~50% of people who met Berlin criteria for ARDS didn’t have the pathognomonic feature of ARDS, diffuse alveolar damage (DAD). The other half of the patients had pneumonia, abscesses, COPD, or other processes [Pinheiro et al, Thielle et al].
- The crux of the ARDS issue per Dr. Mac Sweeney -It seems that ARDS is a fairly diverse spectrum with some subjectivity to the criteria. If approximately half of the people diagnosed with ARDS don’t have ARDS, then it’s no surprise that the therapies don’t benefit them. He leaves better identification in the hands of researchers.
- In medicine we use teams or “tribes” to cope with stress, work together, and rally – Tribe Emergency Medicine, Tribe Anesthesiology, Tribe Surgery, etc. While making snarky comments, if in jest, may boost the morale and confidence of our team, this may be detrimental to overall patient care