Lessons Learned and Take Home Points from dasSMACC – Day 3

30 Jun
June 30, 2017

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 third day of the conference.

The final day of SMACC began with a panel on the future of medical education. Simon Carley served as the moderator for the panel that included Walter Eppich, Jenny Rudolph, Chris Nickson, Victoria Brazil, Daniel Cabrera, and Sandra Viggers.

  • Education techniques will change. You must be deliberate in gaining the needed knowledge
  • We should focus education on critical thinking and the things machines can’t do: empathy and creativity
  • I nice framework is: What did I achieve and not achieve today?  What did I do well and not do well today? What will I do differently next time?
  • Learning how to learn is the missing piece for many people. We also need to learn how to unlearn things that are wrong
  • How do you make the undiscussable discussable? This is true for clinical topics, but more especially true for systems processes
  • Real interprofessional training requires everyone to bring something. It is more than nurses’ education with a few docs in the room
  • Simulation centers should be renamed simulation services that can be staffed by experts to provide consultation to simulation occasionalists of all different specialties
  • Simulation equipment DOES NOT matter, but the ability to deliver effective simulation does
  • Simulation is a “Trojan Horse” to get people together to reflect
  • There are specific skills involved in using simulation for education just like there are skills for putting a patient on ECMO
  • Simulation doesn’t provide outcomes. It is what you do with it that leads to outcomes
  • Simulation is not just for the learner, but it can also helps systems
  • Simulation can provide a safety service for problems that arise in your hospital
  • Regular debriefing creates a culture where you can talk about your clinical practice
  • More data points of evaluation will give a clearer more objective assessment

  • We need to maximize learning from the patients we see short coaching moments are key
  • Assessment and feedback require preparation from both the giver and the receiver of it
  • Resilience training is not the answer when the system is broken
  • You need training to be able to give good feedback in order to make it meaningful and actionable
  • With all of the literature out there, we still rely on and trust expert opinion
  • The best way to predict the future is to create it yourself
  • So what is the future of medical education?
    • Reflective Practice
    • Be a Role Model
    • Leadership
    • Knowledge Networks
    • Adaptive Expertise
    • Professional Learners

Kevin Fong followed up with a talk on how to fail:

  • You can’t see all of the moving parts in a system as complex as healthcare
  • Since failure is inevitable, is there a better way to fail?
  • Given that failure is inevitable, we need to work to ensure we fail in the best way possible
  • “Competence porn” = A mythology of never failing. We like watching hyper-competent people that can do everything. Think James Bond. These people don’t exist
  • Sometimes reliability is more important than performance
  • Failure is an option on a daily basis.  Don’t be afraid to fail.  Learn from your failures
  • Graceful failure = The ability of a system to maintain most, if not all, of its function when part of it fails. (i.e. Degradation of a process that allows the entire system to continue to work)
  • “Forgiveness is the final form of love.”-Reinhold Niebuhr

Jenny Rudolph fooled us all with an impromptu simulation. She then spoke on being able to provide help with harm.

  • In the moments where we should pause and question our judgment, we often ignore this impulse
  • You need a discrete dividing point/line to move on from a bad experience
  • Other people’s stories cease to exist when we get caught up in our own convictions
  • Get curious—become attuned to your colleagues’ frame and perspective

Liz Crowe made an excellent observation while being “interrogated” by Peter Brindley:

  • Telling people they don’t know how to cope, but not offering solutions is like telling someone they have asthma then not giving them albuterol

Vera Sistenich provided some staggering insights into the global refugee crisis.

  • Over 65 million people are displaced. Over 21 million are classified as refugees
  • 50% of refugees come from 3 countries: Afghanistan, Somalia, and Syria
  • “The very best predictor of a state’s peacefulness is not its level of wealth, its level of democracy, or its ethno-religious identity…it is how well its women are treated.” Valerie Hudson
  • False pretenses are often used to determine immigration policies
  • What we do as individuals goes a long way to create social norms

Martin Bromiley followed up the previous talk by Kevin Fong on how to fail.

  • Instead of saying “I wouldn’t do what they did” ask “Why did it make sense at the time?”
  • People don’t speak up. Don’t be afraid to challenge someone when things are wrong
  • We need people prepared to ask questions and then to listen
  • Confident humility—confident you have the skills, but humble enough to know you could be wrong
  • We are often given the error prone situation in medicine and then are expected to be perfect
  • There is a massive gap in healthcare between front line workers and the leader’s perception of their work
  • Leaders need to listen, not comment
  • It is ok if your path to a goal is not a straight line.  That is how life often works anyways

David Menon told us that not all brains are the same.

  • There are different indications to treat elevated ICP with different levels of risk
  • What about cerebral perfusion pressure (CPP)? There is no set target across populations
  • There are no Level 1 recommendations to moderate ICP/CPP…yet
  • Use graded thresholds to escalate treatments on an individual basis while detecting and mitigating harms

  • Hyperventilation to reduce ICP is only a temporizing measure to more definitive treatment
  • There are 2 separate groups: Those with elevated ICP as a consequence of brain injury and those with elevated ICP as a possible cause of brain injury

Margaret Herridge pondered the question “Did Nietzsche know anything about critical illness survivors?”

  • “That which doesn’t kill us makes us stronger.”-Friedrich Nietzsche
  • ICU muscle wasting affects the muscles of the shoulder and hip girdles resulting in real functional disability
  • Other issues survivors deal with: depression, PTSD, economic burden
  • Family members are collateral damage also suffering effects of depression and PTSD
  • Post traumatic growth—subjective experience of positive psychological change after an event
  • Post traumatic growth leads to changes in: 1) perception of self, 2) experience of relationships, and 3) one’s life philosophy. They can still suffer from mood disorders though
  • “He who has a why to live can bear almost any how.”-Friedrich Nietzsche

Jack Iwahyna discussed the concept of persistent critical illness.

  • This is a hypothesis that states there is a point beyond which diagnosis and severity scores are no longer useful. The patient is a new person
  • After about 10 days in the ICU the antecedent characteristics that the patient brought with them to the ICU (age, comorbidities, etc.) better predict morbidity and mortality than the acute characteristics that brought the patient to the ICU
  • These patients are a small percentage of the total number of ICU patients, but own a massive number of ICU days
  • Anchoring bias and diagnostic momentum are bad things. Interestingly, one study found that increased cross-coverage was associated with a decreased mortality (Kajdacsy-Balla A et al. Am J Respire Crit Care Med 2014)
  • If they are still in the ICU, there must be a reason. Find the stupid little thing their physiology is doing and work to fix it

Annet Alenyo Ngabirano provided a touching story of healthcare in Africa:

  • Ubuntu is the belief in a universal bond of sharing that connects all humanity
  • Emergency medicine allows our humanity and compassion to reach and touch people
  • We are healthcare, not the negativity seen in the news headlines

The final session of this year’s SMACC was a panel discussing the effects of life after critical illness. The panel was lead by Liz Crowe and included Carol Hodgson, Martin Bromiley, Margaret Herridge, James Piercy, and David Menon:

  • Doing right and doing no harm often sit on either side of a very fine line
  • What we do creates moral distress due to uncertainty
  • It is so hard to predict individual resiliencies
  • A family suffers prolonged trauma everyday the patient is in the ICU. The patient usually only remembers “I might die” due to the trauma
  • For families, the formal conversations with providers are often lost
  • If a parent and child are hospitalized at the same time, find a way to get them together for a short time
  • There is no good tool to assess quality of life
  • “The ability to show love may be the best quality of life.”-Martin Bromiley
  • Resilience is a dynamic process, not a destination.

That wraps up this rendition of SMACC. We will reconvene in Sydney, Australia February 12-14, 2019

For More on This Topic Checkout:

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

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Matt Astin

Clinical Assistant Professor of Emergency Medicine/Internal Medicine at Medical Center of Central Georgia
REBEL EM Associate Editor and Author
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