Lessons Learned and Take Home Messages From dasSMACC – Day 2

Written by Matt Astin REBEL EM

The 2017 edition of the Social Media And Critical Care (SMACC) conference was held in Berlin, Germany this year (#dasSMACC). Over 2000 emergency physicians, intensivists, anesthetists, EMS providers, and nurses piled into the Tempodrom for three days of inspiring lectures and an all-around good time. This conference is truly a leader in innovation and continues to push the boundaries of medical education and entertainment. Here are some of the lessons learned and take home messages from the second day of the conference.

dasSMACC – Day #2

A multi-disciplinary panel started the day discussing inter-professional issues in medicine (i.e. Tribes). The panel was lead by Walter Eppich and including Jesse Spurr, Liz Crowe, Carol Hodgson, Ashley Liebig, and Sandra Viggers

There should be one tribe in medicine…the human tribe. The common mission in medicine should also be patient care which can help unite the tribes

We all belong to multiple tribes with different sets of rules

We generally judge others by their actions, and ourselves by our intentions, so be generous to others

Leaders in medicine are often those that have been there the longest or those willing to raise their hands, not necessarily the most qualified. Leaders need leadership training

You are an emotional contagion. Your attitude sets the stage for the daily culture

Tribalism in medicine can cause worse care, due to narrow views, patients becoming body parts

South Africa has a great intern system using wrist bands to indicate fatigue: Green Band = Working <24hrs Orange Band = Working 24 – 30hrs Red Band = Working >30hrs



Culture is created by everyone. We all need to take responsibility for the culture at each of our own work places

The good part of tribes is they help build cohesion and a team, but the bad part about tribes is it can create friction between tribes and gets in the way of patient care (Protective within teams, but destructive across specialties)

In the real world we introduce ourselves by our names…why don’t we do this at the workplace

Chris Hicks gave a talk about making complex problems simple:

Managing complexity is about limiting variables, reducing goals to habits, basic steps, process over outcome

When things get complex, it is our ability to simplify that will see us through

Simple can be harder than complex because you have to get your thing straight -Steve Jobs-

Develop habits—habit breaks down the complex. It becomes harder not to execute, than to execute. Habit also allows you to identify outliers and variances

Emergence—process of self-organizing in complex situation, bringing individual behavior into a group alignment; with good team setup and task allocation, team can solve much more complex tasks than any individual can

Organize teams not by specialty but by a specific goal (i.e. chest tube team, airway team, pelvic binder team, etc…)

Factor Down—breaking down the problem into manageable parts

Limit Variables—you can’t constrain chaos, but you can allow only certain paths for it to take

Take Home Points Lean on Habit Foster Emergence Factor Down Limit Variables

Dream big but plan simple

Maaret Castren pondered the Future of Out of Hospital Cardiac Arrest. The chairwoman of the European Resuscitation Council and the International Liaison Committee on Resuscitation talked about where we are today and how to improve

50% of patients with sudden cardiac death had symptoms up to 4 weeks prior to their death

No one in ventricular fibrillation should die. If they do, we need to look at what we did wrong. (For clarification, VF should not be the final rhythm at the time of death.)

The best systems in the world only have about 20% survival for out of hospital cardiac arrest

The European Resuscitation Academy has published an article on 10 steps to improve cardiac arrest survival

Most medical treatments have been designed for the average patient. One size does not fit all in cardiac arrest

Nikki Stamp, cardiac surgeon, offered a guide to the resuscitation of the post cardiac surgery patient. This includes pacemakers/ICDs, valve replacements, and CABG:

Causes of the need for resuscitation in these patients include ischemia, mechanical issues, arrhythmias, and unknown causes

Loss of pacing capture can mean the heart is distending, which is a bad thing

If this patient arrests, get on the rhythm early because they have a propensity for VT/VF. Deliver 3 sequential shocks (not part of ACLS) and pace early

Manual CPR can be done on a patient with a left ventricular assist device, but not mechanical CPR

Bottom Lines:

Shock early, pace early

Most should not die with a closed chest

ECMO/CPB is there to be used

LVAD = CPR and expert advice

Manage the at risk patient as a team

Ashley Liebig was tasked to argue that doctors don’t rule the resus room. She relayed the story of how she challenged this. She also noted that doing something different opens the door to criticism. She offered 5 ways that doctors don’t rule the resus room.

Ergonomics—it is not just for the carts and cabinets. Placing people in the optimum place makes things easier

Nurse-led codes—Nurses do ACLS before the doctor arrives. Let them run the code. This provides a cognitive offload for the doctor to gather more history and determine the cause that can be treated.

Assigned roles—Having a single role frees people up to perform that role to the best of their ability without having to worry about what else they need to do

Communication—what more needs to be said. Free dialogue and closed loop communication insures completion of tasks

Briefing—breaking down what went well and what can be improved following the resuscitation offers continual opportunities for improvement.

Two New York docs in the resus room pitted Reuben Strayer and Scott Weingart in a point/counter-point battle. Natalie May moderated this session while collecting money in a jar for charity for any curse words uttered. A decent amount of money was collected.

Sympathetic Crashing Acute Pulmonary Edema (SCAPE) is the Nursemaid’s elbow of the resus room.

Non-Invasive Ventilation (NIV) should be started on every patient in respiratory distress. This is an intubation-saving procedure

SCAPE should be treated with a 1-2 mg bolus of IV Nitroglycerin (mg, not mcg) followed by a drip starting at 100-200 mcg/min. Alternatively; the drip can be started at 400-500 mcg/min

Perintubation hypotension is associated with cardiac arrest. Strayer recommended the dirty epinephrine drip, while Weingart touted push dose epinephrine

Daniel Lichtenstein discussed whole body ultrasound centered on the lung. Lichtenstein is a giant in the world of point of care ultrasound, performing initial research in the late 1980s and early 1990s. He lamented on not coming up with a flashy acronym for his scan identifying abdominal blood in trauma patients (i.e. FAST).

For cardiac arrest, use the Sesame protocol. This is a fast process that can be done while compressions are being performed

The Blue protocol is a step-by-step approach for lung ultrasound

Michele Domico dropped some pearls on pediatric cardiac disease

If you don’t think about it, you will never see it

A child with fatigue is not normal

Don’t get locked into a single diagnosis. Anchoring on only one diagnosis can be disastrous.

If you think something is abnormal, it probably is, regardless of what the parents say.

Beware of “quiet tachypnea.” Increased respiratory rate without increased work of breathing can be a sign of decreased systemic perfusion.

Beware of cognitive bias. You provide a new set of eyes when you see the patient. The previous diagnosis may be wrong

If a patient has multiple visits to the doctor, but is not getting better, think cardiac causes

BNP measures myocardial stress. Troponin measures myocardial death

MJ Slabbert offered some insights of decision-making:

Decisions you make determine the actions you take

“Without data you’re just another person with an opinion.” -W. Edwards Deming

“Not everything that counts can be counted, and not everything that can be counted counts.”-Albert Einstein

Protocols are the safety net for the novice, but can be shackles in difficult situations. Experience allows you to go outside the algorithm to direct care of the patient. This is a process call naturalistic decision-making.

Medicine is a science of uncertainty and an art of probability – William Osler

Daniel Cabrera gave a nod to classic 16-bit video games (think original Nintendo) in his talk on anaphylaxis

Only 50% of anaphylaxis patients receive epinephrine

Only 40% of patients are discharged with an Epipen

Only 20% of patients receive appropriate follow up

They will survive your 1 st misdiagnosis of their anaphylaxis, but they may not make it back to you the 2 nd time

misdiagnosis of their anaphylaxis, but they may not make it back to you the 2 time Death in anaphylaxis comes from cardiovascular collapse, but also from lack of education and access

Don’t wait for hypotension or respiratory failure to give epinephrine

50% of patients will require a 2 nd dose of epinephrine. This dose should also be given IM

dose of epinephrine. This dose should also be given IM Options for refractory anaphylaxis include: epinephrine drip, glucagon, norepinephrine, vasopressin, methylene blue, and ECMO

The final session of the day was a panel discussion entitled Resuscitation for the Resuscitationist. Scott Weingart was the chair for the panel, which included Steve Bernard, Jim Manning, Sara Gray, Maaret Castren, MJ Slabbert, and Lionel Lamhaut:

Vasoplegia is defined as refractory low diastolic blood pressure. Treat the etiology. A new aortic catheter is being studied. There are also come case reports on using methylene blue

When the protocol provides no solution, do what you can, whether there is evidence or not

For refractory VF, consider dual sequential defibrillation. If you don’t have two machines and multiple shocks have not worked, consider moving the pads to a different location

Patients in refractory VF can be taken to the cath lab with mechanical CPR in progress

Cardiologists need to get over patients dying on the cath table. The panel felt this is an ethical question and concern over their mortality stats should not be the concern of the cardiologist

Esmolol is another option for refractory VF

ECMO in refractory VF is about preserving the brain

If the cath lab won’t take the patient in refractory VF, the panel felt that thrombolysis was indicated

Monitoring during cardiac arrest in the prehospital should include the basic monitoring as on all patients, plus end tidal CO2 monitoring if available. In the ED, EtCO2 and the placement of a femoral arterial line were recommended

Personalized epinephrine doses were discussed. Some people need more than 1 mg, while others need less the 1 mg. To make this decision, an arterial line needs to be in place

There is some evidence for the use of ketamine, and perhaps fentanyl, during CPR induced consciousness. At the very least, talk to the patient to let them know what is happening and you have a plan

The use of mechanical CPR brings calm to the scene and allows cognitive off loading as well as an overall more controlled code

It is extremely rare to survive out of hospital cardiac arrest after 40 minutes of high quality CPR. Use ultrasound to assist in making the decision to stop resuscitation

The question of “Stay and Play” vs. “Load and Go” for EMS was addressed. The panel mostly agreed that “Stay and Play” is the way to go, unless there is a reason to move (i.e. cath lab)

There is some preliminary data on the Heads Up Resuscitation. This is mechanical CPR being performed with the head of the bed elevated to 45 degrees. The optimal angle has yet to be defined

The thought behind this method is that if provides increased venous drainage from the brain

Most of the panel is still using 32-34°C for cooling post arrest. 1/3 of patients cooled to 36°C developed fever, which is the outcome to be avoided. There is also a lot of shivering at 36°C. These patients will require paralysis

Should EMS bypass small hospitals to take arrest patients to cardiac arrest centers? ILCOR says yes, but the panel states that it depends on the location

For More on This Topic Checkout:

Post Peer Reviewed By: Salim Rezaie (Twitter: @srrezaie)