This week I attended the Association of North Western Intensive Care Unit (ANWICU) meeting in the lakes for the first time. Having heard great things about it from colleagues, and with the obvious draw of enjoying the Lake District in some scorching summer sunshine (fortunately turning out to be true), I was keen to check it out. Held over 2 days in Bowness-on-Windermere, the meeting brought together some excellent speakers covering a wide range of topics, all supplemented with a great chance to catch up with colleagues from across the region (over the odd refreshing beverage). I have put together a few of my notes on the meeting here, hopefully successfully summarising some of the topics that were covered.
Collaboration
Dr Paul Dean (@D1975P) opened the day on the topic of ‘collaboration’. He was initially going to talk about managing critically ill children on ICU, relating to the ‘Quality standards for the care of critically ill children’ document from the Paediatric Intensive Care Society . As a brief overview, part of the proposed idea was to get more critically ill children cared for on adult units, essentially allowing tertiary centres to provide greater provision for the specialist surgical patients. There has (understandably) been a degree of reticence about this and it is still under review and may be heading towards a trial of implementation in a single region first. However, this led Paul to the topic of collaboration. As he noted, the current system is really struggling with the demands of providing healthcare, and we really need to be optimising our interactions within and between teams, however we may choose to define them. Linking to the topic of children, their care provides some interesting challenges, especially given the current need to transfer for children’s to adult’s services. There is a strong demarcation between being ‘a child’ and ‘an adult’, and the transition, for something which is a completely universal and normal progression of aging, is surprisingly challenging. Comparing other examples, collaboration with our surgical colleagues has historically been successful and perhaps the domain when we have been most effective; examples being NELA and POM. This isn’t really the same with other specialities, particularly medical ones. There is potentially a role for benefitting certain patient groups by admitting more of these groups e.g. liver decompensations, where closer collaboration could potentially allow smoother (and maybe better) patient care.
This is also a feature of the national scale, not just at local hospital level, although some of the other British countries have deliberately focused on achieving better national cooperation in some domains. For example, Wales has a nationwide obs chart and drugs chart - some trusts in the UK don’t even have this at different hospitals within the same trust. There may be some role for the networks here but there is significant difficulty faced by the imposition of external factors; money being the obvious one, but also externally imposed targets. Indeed, this silo working has such visible adverse effects on care, and yet seems so hard to combat. People can be working very hard and diligently towards a goal, but without the collaborative thinking on the right scale, the outcome might not be the sum of its parts. This problem is not just in medicine, and ‘The noble purpose paradox’ summarises it quite nicely - “the more compelling the mission, the more tricky it can be to get the best collaborative behaviours”. Essentially, a part of collaborating in a group involves a degree of sacrifice of the members, and yet the benefits reaped should more than make up for this. GPICS V2, just released that morning may be a great opportunity for this - time will tell.
This is also a feature of the national scale, not just at local hospital level, although some of the other British countries have deliberately focused on achieving better national cooperation in some domains. For example, Wales has a nationwide obs chart and drugs chart - some trusts in the UK don’t even have this at different hospitals within the same trust. There may be some role for the networks here but there is significant difficulty faced by the imposition of external factors; money being the obvious one, but also externally imposed targets. Indeed, this silo working has such visible adverse effects on care, and yet seems so hard to combat. People can be working very hard and diligently towards a goal, but without the collaborative thinking on the right scale, the outcome might not be the sum of its parts. This problem is not just in medicine, and ‘The noble purpose paradox’ summarises it quite nicely - “the more compelling the mission, the more tricky it can be to get the best collaborative behaviours”. Essentially, a part of collaborating in a group involves a degree of sacrifice of the members, and yet the benefits reaped should more than make up for this. GPICS V2, just released that morning may be a great opportunity for this - time will tell.
Innovation
Dr Shond Laha (@shond3) was up next talking about ‘innovation on the ICU’. He introduced this as essentially a story about getting bored and how this has led him through a number of projects. These were generally triggered by specific clinical encounters that had made him think about whether things could be done better. One of these focused on tracheostomy safety, and the other about the challenge of communicating with a patient with a tracheostomy (triggered by a patient trying to tell him to get out of the way of the penalty shootout on the telly). As I am increasingly appreciating myself, the journey is always a bit more complicated than initially anticipated. Hurdles arise from unforseen directions, such as acquiring funding for very early stage idea development, the potential need for patents for newly developed technology, and even the challenging issue of ownership (a big challenge if there are multiple collaborators and invested parties). These were fascinating stories, and again provided inspiration for implementing some of those ideas that we get when we see something that isn’t quite working optimally. Importantly, the challenges that seem so significant at the start are common and not unsurmountable. Finding the right people to talk to and gain advice from initially can be hard, but innovation such as this needs to be a collaborative project, and these sorts of things are worth getting right at the start.
Social Media
Dr Mike Charlesworth (@Miko_Charleswor) was next talking about ‘What makes a paper popular on social media?’. He is one of the editors of Anaesthesia (@Anaes_Journal), and has done a great job with their social media profile. As an example of the power of social media he described the recent case of the potential toxicity of fluid warmers. The use of Twitter served to raise the profile of the topic, promoting extensive discussion around it and even leading to an article in The Guardian. He notes that journals are really catching on to the importance of using social media as a means for interaction and conversation. The problems with a journal’s impact factor as a sole marker of its true impact have been well described, and so the potential use of social media metrics to inform on ‘engagement’ is an interesting concept. I guess it could be argued that the dissemination of information to the frontline of healthcare is a key role of medical journals, and social media platforms have a particularly long reach in this regard. When reflecting on what makes a paper popular, Mike felt the key factors were that it was topical, relatable, and interesting. Scandal was also a factor in peaking interest, much as in the press in general, with the article on data fabrication (their second most popular article) being an example of this. Indeed, Mike noted that it was the interest from the popular press in this that was the main driver for the success of this paper, with it being a particularly newsworthy piece. A big part of getting this initial interest came from the title, with appropriate conveyance of the above factors grabbing that initial attention. Mike noted that a significant proportion of the social media interaction (likes and retweets for example) didn’t actually involving clicking the link to the actual paper, instead being based on the brief text contained in the tweet. The success of Anaesthesia’s “Free for a day” programme, as well as the success of their Tweet Chats (I was listening with great interest) were other great example of the impact social media could have. It’s not all plain sailing though. The recognised problems of social media still exist within the medical bubble. Humour may not translate at all, and context can be lost due to the confines of the medium and the nature in which it is interacted with. With these cautions borne in mind though, the potential seems vast and the benefits to our engagement with the literature very real.
Drugs
The next talk of the morning was from Dr Craig Mckenzie (@itsdrmac), director of the Forensic Drug Research Group. He gave a fascinating presentation on novel psychoactive substances (NPSs) and an eye-opening lowdown on the current illicit drug scene. This is a fast moving area with new substances constantly evolving and significant factors outside the pharmacology itself. These drugs are taken as a cocktail and in an illicit market environment, and so they should be studied and understood that way - a bit of a change from our usual pharmacological approach. In addition, there is also a lot of misuse of prescription drugs now, with certain classes being used in very big doses to ‘get high’. These are completely different from our usual encounters with these drugs, sometimes with dose increases of 10s of times.
The NPSs are a very topical problem. The issue is that a lot of the information around these substances is widely available through the internet, for example through drug patents. These can be easily accessed and the drugs then synthesised by amateur chemists around the world. Current trends in this field are towards a rapid expansion of the synthetic opioids, with the previous trend for novel synthetic cannabinoids decreasing in number (mainly because producers have worked out the good ones and these are being reproduced rather than new ones developed). However, the non-pharmacological factors are still continually evolving with some synthetic cannabinoids having even made it into e-cig liquids, and methods for getting drugs into prisons under constant innovation.
From a clinical perspective, opioids and benzodiazepines are the big killers. Gabapentinoids are also getting involved and it is the interacting effects of the polypharmacy that contribute towards the lethality. A further clinical component is the impact of the illicit market. There is essentially no quality control on the dosing, or even what the actual drug is due to the variable tablet labelling and appearance. Indeed, changes in batches (whilst still appearing the same) have led to epidemics of adverse reactions, including clusters of deaths. Their use really is such a Russian Roulette, and it is likely these patients that we are most likely to encounter in our critical care practice. The specific trends appears to continue to vary; opioids are causing huge numbers of deaths in the US, whilst spice has been the drug of choice in certain UK groups. As such, keeping up to date with trends is useful, and Craig directed us to a number of useful resources:
NEPTUNE - a clinical resource
UNODC world drug report
European drug report
Devastating Brain Injury
Dr Dan Harvey (@criticalinsight) delivered the final talk of the morning on the topic of devastating brain injury (DBI). As one of the authors of the recent guidance on DBI, he wanted to focus on some the challenges it posed for practicing clinicians. To start he recapped the clinical problem: early prognostication of brain injuries in the ED is inherently unsafe. Information is often still being gathered and there is massive scope for confirmation bias in these particular cases. Factors that may not have presented themselves include overlapping drug use, the recent presence of seizure activity, suboptimal physiology, and missing or erroneous information about the background. The result was an individualised approach (to the clinician rather than patient) with geographical variation in practice. Some alarms about this prognostication were indeed first raised by NHSBT who audit a lot of the deaths, with some of the prognostication being found to be suboptimal. In addition, some of the questions being asked have got harder - what makes a life worth living? The ability to preserve life, in a lot of cases, has continued to improve, but actually a functional outcome, rather than mortality, is probably the outcome that is most relevant to people (a significantly dependent, minimally conscious state has fairly universal lack of appeal). It is this breathing space and thinking time which is where the advantages arise from. Clearly, some cases will not need this additional help, as a previously severe baseline is not going to be made better by a DBI. Similarly, there is no prescription on the timeframe of decision making. This will be guided by the physiological and communication trajectories, which may very rapidly provide clear answers. A progressing physiological syndrome of brain stem herniation with a clear family consensus on a patient’s wishes is different from an improving clinical picture. Admittedly, capacity is a big challenge but this remains a tool to help us make better decisions. One example of this benefit (that needs to be interpreted with a little caution) was the Southwest DBI pilot. Although it only involved 21 patients, there were 3 survivors with an acceptable neurological outcome. Food for thought.
Afternoon
The rest of the day involved a chance to break off into smaller groups for different networking activities. The trainees gathered for an al fresco journal club, followed by M&M. The paper of choice for the journal club was the fascinating IRIS study, evaluating cricoid pressure in a RCT format. The paper is probably worth a more detailed review in its own blog posting but the bottom line is that it did suggest that cricoid pressure might not really be offering any benefit. The ANWICU AGM was then followed by an entertaining evening talk from Dr Anthony McClusky. He recounted some of changes that he has seen over his critical care career, with a few bits of advice for those of us just starting down this path (both professional and personal). Such discussions continued into the delicious evening meal, as a packed day finally drew to a close. And given the amount that is still to come in day 2, I think a second blog post is needed. I’ll leave you a few links to some of the topics that came up in the day, and hopefully get the next post up soon.
Tom
Tom
Links & References
- ANWICU. http://www.anwicu.org/
- FICM. GPICS V2. https://www.ficm.ac.uk/news-events-education/news/guidelines-provision-intensive-care-services-gpics-%E2%80%93-second-edition
- PICS. Quality standards for the care of critically ill children. https://picsociety.uk/about-pics/pics-standards/
- Anaesthesia. https://onlinelibrary.wiley.com/journal/13652044
- NEPTUNE. http://neptune-clinical-guidance.co.uk/
- UNODC. https://www.unodc.org/unodc/index.html?ref=menutop
- European Drug Report. http://www.emcdda.europa.eu/edr2019
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