Mastering Intensive Care

Our ICUs might be growing larger in size but there seem to be the same number of very sick patients to care for overall. All of which means we seem to be admitting a greater proportion of less unwell patients to our ICUs, especially in the larger tertiary ICUs. Given we also suffer from “bed block”, where there are no available beds in the hospital to transfer patients to, when they are no longer critically ill, our ICUs can become holding bays for effectively "ward-level" patients. This may be great for the patients but it means longer ward rounds, and a level of frustration for intensive care teams, who may feel like they are not making a significant enough difference for these less sick patients. When A/Prof Michael O’Leary started out in Intensive Care nearly 30 years ago, he remembers being enthusiastic and busy, performing many interventions on mostly sick patients. Having now moved across the world and gained a few decades of experience, he has a great perspective on some of the challenges our larger I

What number of patients should an intensivist simultaneously care for to optimise outcomes? Is a system with different day and night intensivists best for all? These are two of the questions discussed during the latest episode of Mastering Intensive Care in which Hayley Gershengorn shares her research and personal thoughts about resourcing our Intensive Care Units. There is no easy answer to matching supply and demand in our workforces, not least because it is very different between the different health professionals that work in the ICU. The current resources available and the average daily demands seem to be the key decision-making drivers in many institutions and we probably have a lot to learn from analysing big data in this area. Doctors could learn a lot from how nurses staff themselves, and likely vice versa. It is also vital that we find ways to delicately balance the needs of clinician wellness and job satisfaction with the obvious requirement for optimal patient outcomes. Turning up the screws on ou

How did your patient feel that time you took several attempts to place a CVC? What might happen after a dose of haloperidol for delirium?   In this compelling episode, Professor Paul Wischmeyer, shares some of his experiences as a patient in the ICU. Since he was 15 he has endured multiple hospitalizations and ICU stays for his inflammatory bowel disease. This has given him an excellent vantage point to notice what we as ICU professionals do and say to our patients. And from Paul’s perspective we could do much better. Some of the procedures we might think are simple (like placing intravenous or intra-arterial cannulae) can cause significant suffering. And if we treat these procedures as something just to tick off on our list we may diminish the person-centred care we should all be attempting to deliver. Paul’s passion for helping patients recover from illness and surgery arises from his personal experiences as both a doctor and patient in the ICU. As a trained intensivist, anaesthetist, clinical pharmacologis

Do you have too many career interests outside of your basic clinical practice? Are your daily focus areas as few as three? Family, clinical and perhaps one other thing?   In this episode Australian intensivist, Marianne Chapman, speaks about how she keeps her life under control by focussing on her big three - family, clinical and research. This allows her to manage the stresses of an intensive care career. She sometimes has to say no very deliberately, and although she finds this hard, it helps her manage the workload. She notices that some of her colleagues seem to want to be experts in several areas, and whilst this may be important at the beginning of our careers, this can be a recipe for disaster for some of us over the longer term. Marianne is a Senior Staff Specialist in Intensive Care Medicine at the Royal Adelaide Hospital and a Clinical Professor of Acute Care Medicine in the School of Medicine at the University of Adelaide, both in Adelaide, Australia. Her clinical research interests include gastroi

Do you spend time finding out what the “why” is for your patient? Have you considered it’s not what is the matter with the patient but what matters to the patient? What the patient thinks their purpose is? Or at the very least, what they wish for during the next part of life, however short that may be? In this episode American intensivist, Dr Wes Ely, tells us how he deeply cares about the whole patient – the body, the mind and the spirit. He is passionate about really getting to know his patients. And to do that he thinks we need to be heavily focused on both ICU liberation and good listening. The ICU liberation bit sounds easy. It's removing the patient from the sedatives, the ventilator and whatever other harmful interventions are no longer needed when their situation is improving. But it's harder than we think. And to help with this, he has led the development of the ABCDEF bundle. With the assistance of many colleagues, and based on high quality science, he has progressively developed a simple 6 factor a

What is it like to witness an intensivist struggle?   And what can we learn from the shocking death of an intensivist?   This special Mastering Intensive Care episode is on a difficult and important topic. Rather than focusing on bringing our best selves to work, the focus of this episode is the ultimate tragedy of our profession, doctor suicide. I warn you that this is a sad and confronting story about the troubling situation intensivist Richard Harding went through, including dealing with a mental health condition as well as a medical complaint made against him, before ultimately taking his own life 8 months ago in New Zealand. Richard’s death is still under investigation by the New Zealand Coroner and the findings as to the final cause and circumstances of his death have not been released. In this podcast, his wife, Kate Harding, describes her observations and perspectives on what happened to Richard. I didn’t know Richard. I only came to know of his death when Kate wrote a blog piece in the British Medica

Is your ward round stimulating and educational?   Do you help learning by creating debates on the ward round for and against the simple interventions we use?   In this week’s episode, Belgian intensivist, Professor Jean-Louis Vincent describes what happens in his ICU, on a daily basis, and indeed on the ward rounds. He tells us how he enjoys going several times a day to see what is happening in his ICU, the schedule of ward rounds there, the importance of a single conversation on the ward round, and how much we can learn from our patients, especially about their physiology. Jean-Louis is perhaps the most well-known intensivist in the world. He is a major leader of his generation and in fact a pioneer of the large international conference, having run the Brussels International Symposium of Intensive Care and Emergency Medicine (ISICEM) for a staggering 38 consecutive years. Jean-Louis is a Professor of Intensive Care Medicine at the University of Brussels and an intensivist in the Department of Intensive Care

In this week’s episode you’ll hear an invigorating conversation with Francesca Rubulotta. This power-packed, enthusiastic, passionate, water polo-playing, Italian doctor, now living and working in London, UK, is seriously ambitious to help patients other than those in her ICU, mostly by advancing education using technological innovation. Francesca is a Consultant and Honorary Senior Clinical Lecturer in Anaesthesia and Intensive Care Medicine at Imperial College Medical School. She studied medicine and anaesthesia in Italy and intensive care in Belgium, but also worked in the USA and the Netherlands on a journey that arrived in London 10 years ago. Francesca has been the Chair of the past division of professional development of the European Society of Intensive Care Medicine (ESICM) and is currently the Chair of the ESICM’s CoBaTrICE project. She leads and has led many other committees and organisations, and is presently the first ever female Presidential candidate in the ESICM general election (with the ball

This week is International Nurses Week culminating in International Nurses Day on Saturday May 12th, the date on which Florence Nightingale was born. To celebrate this, my special guest this week is an intensive care nurse, Claire Davies. Claire is my wife. To me, she is intelligent, caring, kind and compassionate, as both a nurse and a person. So after struggling for a while with the choice of who I should have as my first nurse guest on the podcast, it gradually became obvious that it should be Claire. Claire began as an intensive care nurse back in 1999 as a Critical Care Course student at the Alfred Hospital’s Intensive Care Unit in Melbourne. After rising to become an Associate Nurse Unit Manager there a few years later, Claire took time off to rear our 2 beautiful daughters before reestablishing herself as a Critical Care Liaison Nurse at the Epworth Hospital, also in Melbourne. Whilst Claire is definitely an excellent nurse, with a keen focus on developing healthy and valuable nurse-doctor relationship

Does each bedside decision you make actually help your patient to feel, function or survive? Have you considered how frightening and intimidating the Intensive Care Unit environment is to your patients and their families? Do you feel empowered by the people you work with and the culture in your ICU?   Simon Finfer loves telling a tale. In this episode you’ll hear the story of the serendipitous and multi-national route Simon took to end up working for 25 years in one of Australia’s premiere Intensive Care Units. An Intensive Care Department where his colleagues and the culture they developed has fostered him to become one of Australia’s prominent intensive care researchers. You’ll also hear how he teaches his junior colleagues to question everything they do at the bedside to ensure their decisions truly help the patient. Simon is a Professorial Fellow in the Critical Care and Trauma Division at The George Institute for Global Health, a Senior Intensivist at Royal North Shore Hospital and Director of Intensive

How well do you understand what happens to your patients after they leave the ICU? Do you find out how they go and feed this back to your ICU team?   Most of you give excellent care to your patients whilst they are in the intensive care unit. No doubt this will be compassionate, appropriate, diligent, information-driven, holistic, team-based and communicative care. But when they leave the ICU, do you know what happens to them? Do you know if they actually leave the hospital? Do you know how they sleep, how long they remain confused for? What their final diagnosis on hospital discharge was? This is what A/Prof John Santamaria genuinely cares about. This is what he endeavours to find out. He is curious. John wants to know these things so he can better inform his patients before they leave the ICU and so he can keep his team up to date with what happened. Of course much of it is straightforward. The lady with pneumonia gradually got better and went home. The old man who had the laparotomy remained confused for 1

How do you balance the use of your clinical experience with the literature-based evidence? Are you a good enough listener? Is the clinical handover in your ICU the best it could be?   I’ve been reflecting on these questions since I talked to A/Prof Peter Kruger for this week’s Mastering Intensive Care podcast. Peter is Deputy Director of Intensive Care at the Princess Alexandra Hospital in Brisbane, Australia and an Associate Professor at both the University of Queensland and Monash University in Melbourne. He holds specialist qualifications in both Anaesthesia and Intensive Care and has experience in both laboratory and clinical research. He is the immediate past chair and a senior examiner for the first part examination of the College of Intensive Care Medicine of Australia and New Zealand and a primary examiner for the Australian and New Zealand College of Anaesthetists. He is a board member of the College of Intensive Care Medicine and of The Intensive Care Foundation. In addition to his clinical and teac

What are the biggest challenges when beginning as a fully-fledged intensive care clinician? How do you best use your senior colleagues when your experience bank is still small? What can you do to help achieve gender equity in intensive care medicine?   These are some of the questions you’ll ponder as you listen to the latest Mastering Intensive Care podcast guest Dr Sarah Yong from Melbourne. Having started off 2018 with two “Best of 2017” episodes on the podcast, today allows you the opportunity to hear a new interview. I am enthusiastic and passionate about bringing you some further valuable perspectives on improving how we do our jobs in intensive care units around the world. And this year I’m hoping to branch out a bit and try some new things and some new types of guests. Mastering Intensive Care is not just about interviewing older and experienced intensivists. It’s also about hearing some of the challenges from less experienced intensivists as they traverse the early days of their careers. So in this ep

A year ago there was no such thing as the Mastering Intensive Care podcast. Now there are 21 separate interviews, each of which have helped me and seem to have helped many of you to make improvements at delivering more compassionate, thoughtful and patient-centred intensive care. Without fail my guests throughout 2017 were excellent and I really enjoyed doing the interviews. And I promise to bring you the best content I can over 2018 too. Here are the final five of the best 2017 guests, to follow on from the first five in the last episode. This has been difficult as I have seriously enjoyed every one of my guests. I will upset some guests by not including them and I will upset some of you for not including your favourite guest. But nevertheless I have taken the five most downloaded episodes and mixed them with the five I enjoyed the most. Then I took what I considered the best excerpt of the conversation and put them in no particular order over two episodes. So enjoy listening to the best excerpts of the best

A year ago there was no such thing as the Mastering Intensive Care podcast. Now there are 22 episodes with 21 separate interviews, each of which have helped me and seem to have helped many of you to make improvements at delivering more compassionate, thoughtful and patient-centred intensive care. Without fail my guests throughout 2017 were excellent and I really enjoyed doing the interviews. And I promise to bring you the best content I can over 2018 too. Given the Christmas/New Year break is a time for reflection, I thought this was the time to slow down and relive the best of what was heard on Mastering Intensive Care in 2017. Here are the first five of the best 2017 guests, with a further five to follow next episode. This has been difficult as I have seriously enjoyed every one of my guests. I will upset some guests by not including them and I will upset some of you for not including your favourite guest. But nevertheless I have taken the five most downloaded episodes and mixed them with the five I enjoyed

This week’s Mastering Intensive Care podcast features Dr Felicity Hawker who is one of the true female pioneers of Intensive Care in Australia and New Zealand. I had the privilege of working with Felicity for over a decade from when I began as a brand new intensive care consultant over 20 years ago and I came to admire her greatly. Mainly because I witnessed first hand someone who was a master clinician – astute, careful, diligent, systematic, thoughtful, compassionate and knowledgeable. Felicity always handed over the patients in a considered and packaged patient-focused manner. She was a pleasure to work with and I learnt so much from such a high quality role model. Felicity grew up and went to medical school in the Australian state of Tasmania, before completing specialist training in Melbourne, Glasgow and Sydney. She became the Co-director of the ICU at Royal Prince Alfred Hospital in 1985 before moving to Melbourne to be the Director of the Cabrini Hospital ICU from 1995 until 2008, during which time sh

Are we truly making healthcare safer? Do we adequately understand human factors in how we work in hospitals? How would you respond if your partner died from a “routine operation”?   These are just 3 of the questions you are likely to ponder as you listen to this interview with Martin Bromiley OBE from the United Kingdom on the Mastering Intensive Care podcast. Whilst many people that we care for in our Intensive Care Units receive excellent care, sadly there are some who end up in our ICUs after something goes unexpectedly wrong during a routine operation. Tragically some of these people die. Not due to anything they did, but from medical error. In the final DasSMACC special episode, I speak to Martin Bromiley, who became a widower when his wife, Elaine, died in such circumstances 12 years ago. In what has been described as “the direct result of human factors and failings in non-technical skills, created by systemic failings in the healthcare system”. Martin didn’t blame, shame or complain. He did his best to

Do you play the role of the exemplary leader in the ICU? Are you charming, funny, friendly and extroverted – even when these aren’t your natural personality characteristics? Do you throw yourself into your series of consecutive days in the ICU like you are going away to adventure camp? Do you outline specific objectives that a patient should meet over a timeframe of a few days to decide whether treatment should continue? And how regularly do you talk to your patient’s family when you are pretty sure the patient is dying? These are some of the questions you may ask yourself after listening to this episode of the Mastering Intensive Care podcast with American intensivist Jack Iwashyna. This is the fifth in a series of DasSMACC special episodes, where I interviewed speakers from the recent DasSMACC conference held in Berlin. Jack is Associate Professor of Pulmonary and Critical Care Medicine at the University of Michigan where he is a practicing medical intensivist at both the University of Michigan and the VA A

Are you receiving elderly intubated patients where someone else says they want “everything” done? Are the doctors who refer patients to intensive care finding out what their patients really want towards the end of life? Does this frustrate you on a daily basis?   This is a huge topic in intensive care. Finding out the wishes of our patients before they end up on a ventilator with no one to speak for them is vital if we wish to deliver optimal healthcare. Yet so often we intensivists are left to deal with this situation. And whilst in most cases we do this very well, many of us like Dr Alex Psirides, a UK, New Zealand and Australian-trained intensivist, feel the despair as we hold another lengthy meeting with a patient’s family. In this episode I spoke with Alex about this topic, which he had just delivered a brilliant TED-like talk on at the DasSMACC international conference in June. Alex has a great perspective to share as two of his specific clinical interests are managing dying patients and rapid response

Are your ICU patients ever in a holding pattern? Do you aim to liberate your patients from ICU as soon as possible? Is your caution about moving things forward harmful to our patients?   I don’t think we talk often enough about the dangers of conservatism in intensive care. About how if we are cautious in thinking the patient is not quite ready to be extubated, or have the sedation turned off, or stop the antibiotics, then we sometimes don’t realize the harm our inaction may cause. A topic you will enjoy hearing about in this interview with Professor John Marshall on the Mastering Intensive Care podcast. John is a Professor of Surgery at the University of Toronto, and a trauma surgeon and intensivist at St. Michael’s Hospital in Toronto, Canada. John has an active clinical research interest in sepsis and ICU-acquired infection, and in the design of clinical trials and outcome measures. He has published more than 325 manuscripts, and 85 book chapters, and is the editor of 2 books. He is the founding chair of t