Abstract
Video killed the Macintosh star
L Scott
The abolition of the post ward round tea and toast break
D Murray
What can ICM do without? The randomised controlled trial
A Scott
ICM in the time of Jeremy Hunt
N Shah
Superbugs. Rude managers who have no idea. Rubbish coffee. The media. Easy right?
D Hutchins
Video killed the Macintosh star
L Scott1
1Gloucestershire Hospitals NHS Trust, Gloucestershire, UK
In the last 50 years, we have witnessed the remarkable evolution of our scientific and medical capabilities. Intensive Care is a prominent demonstration of how we successfully combine scientific and technological progress, a state-of-the-art forum in which we employ the latest innovations to challenge traditional boundaries of life and death. Yet everyday in intensive care units (ICUs) around the country, we routinely find ourselves beholden to an archaic and inadequate specimen of life-saving equipment. Commandeered from our anaesthetic predecessors, it’s a relic of resuscitation that has evaded technological evolution since before the birth of intensive care itself – the Macintosh laryngoscope.
The development of video laryngoscopes signals a paradigm shift in emergency airway management, and numerous studies now confirm they consistently outperform the traditional Macintosh. They make intubation faster and increase first-pass success rates (especially in inexperienced hands);1,2 they allow team members to see and anticipate what’s happening within the larynx; they make predicted ‘difficult’ airways easier to intubate;3,4 they are a powerful teaching tool and have been shown to decrease the intubation learning curve.5,6
I should clarify some terminology, for I’m not arguing against the utility of ‘direct’ laryngoscopy itself (where the glottis is viewed directly by the operator). The most versatile video laryngoscopes – i.e., those with standard-geometry blades – allow both ‘direct’ and ‘indirect’ laryngoscopy (where the glottis is viewed on a screen). Videolaryngoscopy itself merely denotes the presence of a camera mounted on the blade and doesn’t necessarily imply the hyper-angulated blades found on early models. The antiquated Macintosh laryngoscope remains capable of providing only direct views, and this limited specification compared to its contemporaries ensures it now pales in comparison. Furthermore, my argument is specifically restricted to critical care settings. Here, we routinely deal with unwell, unstable patients who risk serious harm by prolonged or multiple attempts at intubation. Waking the patient if intubation fails is usually not an option. In the ICU population, we are therefore compelled to optimise our primary intubation attempt; the present-day availability of video-assisted devices means it’s now untenable to justify the ongoing use of traditional Macintosh scopes. (There will of course remain a place for the humble Macintosh in anaesthetics, where it may continue to have a role in intubating the uncompromised, slim, fasted patients with straightforward airways!)
Many ICU clinicians, particularly those from an anaesthesia background, may be resistant to the wholesale abandonment of the Macintosh in intensive care. Yet the counterarguments are unpersuasive. The size, cost, portability and availability of newer devices continue to improve. Yes, the camera or screen may fail – in which case you’re no worse off than when using a traditional Macintosh. A standard-blade video laryngoscope on a bad day becomes no worse than a traditional scope on a good day! So why should your best device be your ‘backup’ device? Why should you ever need a traditional Macintosh again? Video laryngoscopes make critical care intubations safer, faster and more efficient. The Macintosh is a museum piece and has no place in a modern ICU.
References
The abolition of the post ward round tea and toast break
D Murray1
1Whiston Hospital, Merseyside, UK
It is a common tradition when working on the intensive care unit that each ward round will end with a discussion over a cup of tea, served with slices of toast, made from thick white bread, lathered in butter.
Eating just three slices of white bread a day increases the odds of becoming overweight by approximately 40%, when compared with eating white bread just once a week. Those who eat two or more portions per day, or 60 g, are 40% more likely to be overweight or obese 5 years later compared with those who have one portion or less per week. White bread is made with highly refined flour which is rapidly absorbed as sugar, and this sugar is rapidly transformed into fat.1 Omitting butter is an easy way to lower our intake of saturated fat to lower our risk of heart disease. Small amounts every day add up to large amounts over time. By switching butter for margarine on your morning toast and sandwiches at lunch, you can remove almost 3 kg of saturated fat from your diet in a year. Butter is around 50% saturated fat and 4% trans fat – the unhealthy fats that raise our cholesterol levels.2
A study from the University of Glasgow found that men who are heavy tea drinkers had 50% higher risk of prostate cancer,3 and a study in Iran found a link between drinking extremely hot tea and developing oesophageal cancer.4 The caffeine in black tea is also believed to contribute to stiff arteries,5 and research has suggested that too much tea could cause brittle bones and teeth.6
According to the Office of National Statistics, the average cost of a loaf of white bread is £1.35. Omitting the post ward round toast break could save each unit at least £492.75 per year. The British Medical Association estimates that the investment cost to train a consultant is at least £564,112. Maintaining healthier intensive care consultants with their many years of expertise will be extremely cost effective in this era of austerity in the National Health Service.
References
What can ICM do without? The randomised controlled trial
A Scott1
1Calderdale and Huddersfield Foundation Trust, UK
The recent history of Intensive and Critical Care in the United Kingdom is a story of triumph. Year on year, we have delivered improvements in outcome despite the ageing population, worsening public health, ever-tighter financial constraints and a savage medicolegal environment. We have saved lives in the syndromes of Sepsis, acute respiratory distress syndrome (ARDS) and polytrauma and we are at the centre of the best-rated healthcare system in the world.
In all this time, we have delivered despite one of the lowest Critical Care capacities in the western world. We cope with the lowest ratio of beds to population and beds to hospital capacity, and we deliver excellence.
However, our excellence is not founded on the cornerstone of most modern medical research, the Randomised Controlled Trial. Intervention after intervention has either failed or flowered spectacularly and fallen away in a clarified picture of inefficacy, confusion or outright harm. An Intensive Care Medicine trainee completing their Certificate of Completion of Training (CCT) this year may have seen Tight Glycaemic Control, Xigris, Nitric Oxide, Early Goal Directed Therapy, Oscillation and many others rise and fall away in one short training career.
We test our fascinating interventions against a matching syndrome and hope that this time, this trial will show an effect. The numbers improve, the outcome remains stubbornly unaltered. Our syndromes are neither fully characterised nor completely understood, drawn from a list of diagnoses who share no pathophysiology, no commonality apart from a final, descriptive vignette that is recognised, coded and treated. So disparate are our causative factors that our descriptive labels are vanishingly unlikely to share one stem. Yet, we approach the syndromes with our best tools for testing, unknowing whether we are in the same nascent stage of understanding that might lead a 1950s oncologist to treat every solid tumour with methotrexate, but despairing of an unpublishable p value, discard the drug forever.
Many thousands of patients have been recruited to trials large and small without any clear understanding of the disease process investigated. It may be that we have harmed and continue to harm many, and it may be that sitting in a dusty cupboard is the machine, the agent that would salvage survivors. It may be we must repeat these trials and experiment with human lives again in the light of new and clearer understandings of their pathologies.
We now face a dark time of austerity. Our efforts, and most of all, our money should be targeted on providing our excellent service to as many appropriate patients as possible, gaining the information we need to target our services precisely to those who will receive the most benefit, and our research must move to understand the syndromes to make them the diagnoses that our future colleagues can simply treat, whilst telling stories of the days back when no-one really knew what ARDS was.
ICM in the time of Jeremy Hunt
N Shah1
1St George's NHS Trust, London, UK
The National Health Service (NHS) has been asked to make an additional £22 b in savings over the next 5 years, despite currently being forecast to end the current financial year up to £2.5 b in deficit. In the current financial climate, we are increasingly asked to do more with less. Bearing this in mind, intensive care is likely to come under greater financial pressure in the near future.
When considering what Intensive Care Medicine can do without, it is important to start by considering the costs. Staffing is always a significant cost in the NHS. Whilst the various allied health professionals who provide care on the intensive care unit (ICU) all add value to the care we provide, some of that care may not be essential to survival (although it is important in terms of outcomes/holistic care). Psychotherapy is an example of an Allied Health Profession (AHP) that is seen as increasingly important on post-ICU outcomes, but not survival. Similarly, while Speech and Language Therapy (SALT) has an important post-ICU role in patients who have had tracheostomies, swallow assessments on the ICU do not necessarily require a formal SALT review.
Another important area of cost is in the tests we do. There is a tendency to blindly carry out a full ICU panel of blood tests daily – yet there is unlikely to be a benefit from daily clotting screens in the stable patient. This can potentially be extrapolated to include liver/bone screens, etc. When specialty opinions are sought, the immediate reaction can include a vast range of (often very expensive) tests, without consideration of the likelihood of the conditions being looked for. As many of these tests are done at national centres, there may be no record locally of them being sent. Hence, they may be duplicated, incurring further cost.
Another area of the ICU budget that many units are looking at is the drug budget. This is an area where marginal gains may be magnified by scale. As well as the obvious target of using generic pharmaceuticals rather than branded ones, perhaps we should further review the appropriateness of many of the drugs we use. Many doctors prescribe nebulisers, analgesics, antipyretics, Proton Pump Inhibitors (PPIs), etc. for all their patients without necessarily considering need. Routes of administration are often left intravenous well past the point at which they could be converted to cheaper oral alternatives.
Finally, we may need to become increasingly selective with regards to the patients we admit to the ICU. In a time of increasingly limited resources, we might have to focus our care on the patients who have a greater chance of survival either to hospital discharge or home. This may require a greater emphasis on frailty scoring or use of the Sabadell score to predict likelihood of meaningful recovery prior to admission to ICU.
Unfortunately with the increasing pressure on the ICU to accept more patients, and do more for them, the abovementioned options are likely to be increasingly difficult to implement.
Superbugs. Rude managers who have no idea. Rubbish coffee. The media. Easy right?
D Hutchins1
1Torbay Hospital, Devon, UK
Think again. I guess what the above question is asking in stealth is how does one make Intensive Care Medicine (ICM) safer for our patients? How can we achieve continuing advances in patient care and safety in a resource-limited service? These are the important ‘million dollar questions’ that form the foundations for the future of ICM for the next century, especially with reference to increasing healthcare austerity.
With all seriousness, I believe the wisdom of the meerkat; the answer is ‘simples’.
Poor communication. Communication is critical to the safe and effective care of our patients. Research illustrates how inter-clinician handover is one of the most dangerous times for our patients within a 24-h period. A large evidence base exists informing clinicians of our shortfalls in the area. However, it still remains a ‘black sheep’, ostracised to the corner of the room whilst time and resources are allocated to, for example; the latest transthoracic ECHO machine purchase. Why is something so seemingly simple, so difficult?
In my 29 bed ICU, the recent addition of a Registrar-held handover book has vastly changed practice by ensuring important details are not forgotten, misinterpreted or misremembered. This simple initiative has qualitatively improved patient handover, information sharing and ultimately patient care. It illustrates that simple changes within a very complicated system can often reap the greatest rewards.
Non-evidence-based practice. Evidence-based medicine is one of the cornerstones of medical practice. However, due to a variety of reasons ICM has to care for the most unwell patient cohort with arguably the least-rich evidence base. This is an issue which groups such as the Intensive Care Society (ICS), European Society of Intensive Care Medicine (ESICM) and others are working hard to change. The future is bright, but that light is at the end of a long tunnel and without increasing commitment, we will never learn our past mistakes to inform our future care. Generic treatment strategies for a ‘one-size fits all’ when actually there are many different sizes (both philosophically and physically). Care must be individualised to each patient to facilitate positive outcomes. Single-unit mentality. This inhibits accurate information sharing and knowledge base. Barriers must be removed and professionals must work closer as a unified team. Poor technology – This can and does inhibit patient care enormously through incorrect data gathering, presentation, misinformation and wasted time.
In conclusion, in something as intricate as critical care medicine where the most complex machine known to Man (a human) is failing, we need to get back to doing the simples well, before the clever stuff. Akin to Florence Nightingale in the Crimean War when spawning the genesis of ICM over 150 years ago.
Forget the red tape, politics, media and managers. Being too keen to look to the future without learning lessons from the past and doing simple things to the highest standard is everything that ICM can do without.