WICS Summer Meeting

The day has arrived. Here we are at RNLI College in Poole and the weather is grey! Nigel Chee welcomes everyone and explains why WICS is a great network of Wessex hospitals, building upon the high quality of teaching and patient care.

Zudin Puthucheary – Getting Wasted in Critical Care

Zudin delivers an excellent talk with meaningful clinical messages. Our critically ill patients are often frail and this directly links to poor quality of life or death. Survivors suffer from muscle wasting and weakness, which inhibits their return to baseline. We need to have discussions with frail patients and their families early, preferentially before admission, to make informed, shared-decisions about life-prolonging and invasive therapies.

Lots of agreement throughout the room. Zudin states what we’re all thinking and backs it up with evidence. His talk is excellent and his message is clear – we need to change how we approach these frail patients.

Zudin Puthucheary

Duncan Chambler – An ICU Update

Duncan Chambler gives a brief summary of the latest research in Intensive Care Medicine. A blog post from this talk is available on The Bottom Line website, a project delivered by Duncan and his colleagues, which started here in Wessex.

Duncan Chambler’s 6 key statements

Ryan Waters

Mr Waters presents three different cases that illustrate the difficulties faced with traumatic brain injuries.

The first is a repeat offender! A young man that unfortunately has repeat injuries and has been in hospital several times, resulting in a devastating and life changing degree of damage.

The second is a happier story. A young man subject to a traumatic injury and significant haemorrhage. The team felt it was unsurvivable without devastating disability, but the story ends with a photograph of him receiving his GCSEs!

Finally, an older man falls and sustains a less severe injury but over the period of a weak the swelling becomes devastating and he dies. This leaves the tea with questions about what they should or could have done to change this course.

Dan Harvey – Devastating Brain Injury

Following on from Ryan’s talk, Dan delivers a gripping talk from the perspective of a neuro-intensivist and national lead for the topic.

Dan illustrates some of the futility in prognosticating and the nature of our biases. He walks us through the recommendations within the recent FICM guideline on Devastating Brain Injury.

Marcus Peck – Increasing Signal to Noise Ratio in Circulatory Failure

Marcus starts by introducing the concept of cognitive biases. He refers to a complex but informative infographic. He also directs us to an excellent book Evidence-based Physical Examination.

With the aid of an amazing spotlight presentation pointer, Marcus talks us through a series of cases where focused echocardiography (FICE) has made real life-saving changes to the management of his patients. By the end of the talk we’re all convinced that we should be proficient and competent at this!

He lets us in on a secret: FICE and CUSIC are coming together to form FUSIC. This will be a modular, competency-based ultrasound curriculum to support Intensive Care Medicine professionals with applicable bedside tests.

He encourages all staff to consider skilling up, and suggests that Outreach nurses would be the ideal staff to have access to FICE / CUSIC / FUSIC.

Paws and Valerie

Just before lunch, Valerie presented Paws. Paws is a very well behaved German shepherd, who visits patients in hospital. Valerie tells us some amazing stories of how Paws has helped children and adults through difficult times. Absolutely fantastic!

Victoria Fussey – Behavioural Insights

More about Victoria on the Behavioural Insights website.

Victoria’s first admission, that she has never set foot inside an Intensive Care Unit, only makes this more intriguing!

She introduces the role of Behavioural Insights Team and for the second time today we hear about System 1 and System 2 thinking.

Victoria talks is through the EAST four stage framework to ‘nudge’ individuals towards better behaviour.

  • Easy: changes should make the preferred behaviour easier and errors less easy to make.
  • Attractive: changing the language to include social norms, accessible information, impact of bad behaviour will drive individuals towards desired behaviour
  • Social: demonstrating that the desired behaviour is ‘normal’ encourages individuals to follow; there is also an impact when different people ask for individuals to act, such as whether the request comes from a nurse or a doctor.
  • Timely: information that prompts behaviour should be timely and related to current situations.
Victoria Fussey explains the TESTS framework for implementing changes

Duncan Wyncoll – Refractory Septic Shock

Duncan’s biography is impressive. A long history of research and clinical practice. This will be a great talk!

To start, he asks if we have considered source control, antibiotic dosing, alternative diagnoses and sedation practice in our sickest of patients. He references a paper by his team summarising their clinical practice: Refractory Septic Shock: our pragmatic approach.

The key statements come so fast I’m struggling to keep up!

  • Albumen is worth giving in this cohort and is supported by subgroup data in ALBIOS.
  • Steroids lack robust positive data from trials but most clinicians will give them when faced with refractory shock.
  • Vasopressin not commonly used.
  • Angiotensin 2 is yet to be licensed in Europe. Duncan states that he is worried about how it is being used in USA without much data to support it.
  • Place a femoral arterial line. Duncan stresses this point and tells the room to wake up now! Radical pressures will tend to be lower, resulting in over squeezed and under column resuscitated patients.
  • Give thiamine and vitamin C, which are low in critically ill patients.
  • Consider clindamycin or linezolid, to prevent toxin-mediated disease from staphs and streps.
  • Consider IVIg for Staph aureus and Group A Strep disease
  • Give sodium bicarbonate 100-200ml 8.4% over one hour (and repeat) if pH < 7.15
  • Consider 24 hours of very high dose CVVHF 50-100 ml/kg/hr, but it might reduce antibiotic, vitamin and helpful cytokine concentration.
  • Other options include calcium, phosphate, epoprostenol, GTN, plasma exchange, methylene blue, cytosorb and ECMO.

Ross Fisher – The Broken Clinician

After an amazing build up by Nigel, Ross opens his talk with “F*ck! f*ck!” Where do you go from there?

He tells a story of surgery on a young patient with kidney cancer. A moment hits him when he realises he’s made an error, and the child has come to harm due to his action.

Ross talks to us about Kintsugi, a Japanese form or art by which an item that has broken is repaired with gold leaf such that it is more unique and stronger than before it is broken.

The presentation, as delivered elsewhere before, can be found here.

Ross Fisher delivers a power Bruce Lecture

Salisbury and that time the Russian’s (may have) visited

To finish the day, James Haslam, Andy Nash, Sarah Clark and Stephanie Hill give us an in-depth report on the experience of Novichok poisoning in Salisbury.

Due to the nature of the content and he current restrictions, we cannot share the talk online unfortunately.

Everyone in the room is clearly impressed. The strong leadership and teamwork really comes across. They managed the whole incident whilst also keeping the doors open to usual business. They also kept the media out and had no leaks of information.

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