EMS Gathering in Killarney

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I was lucky enough to get to Ireland a bit before #smaccDUB for the #EMSG16 in Killarney, which is one of the most beautiful places I’ve been. I got there from Dublin by driving, which was an adventure in itself. Surprisingly, switching seats and sides of the road was not a huge challenge and I got used to it pretty quickly.

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The EMS Gathering has been held in Killarney three times since its start in 2013. It is special in that it brings together EMS from throughout the country in a way that is meant to inspire progress in their system. I think this year was unique because providers from all over the globe attended, most before going to SMACC. I only knew about the gathering because the SMACC organizers were kind enough to mention it in their registration process. Despite not knowing about it before, the EMSG became one of the most valuable experiences of my Ireland trip.

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We made a ton of new friends!

To start, Killarney is beautiful. One of the most scenic spots in Ireland, or so I hear.  The downtown area is full of activity and it is a fun place to be. It turned out to be a perfect spot for the gathering. One of the best parts about the EMSG was getting to meet EMS providers from around the world. Many were from Ireland but probably half of the people I met were not.

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Great pubs too

On Wednesday night the gathering staff hosted an EMS symposium at The Malton, which was a spectacular venue for the conference. They served a great meal and there were a few talks given that night. Paul Gallen and others spoke about the EMS system in Ireland. It was interesting to hear the similarities and differences. It seems that Irish EMS is working to become more professionalized and gain more respect in the medical industry. This seems to be a theme worldwide.

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Dr. Mark Forrest gave an entertaining promo on Penthrox, an inhaled analgesic designed for prehospital use. It sounds like it could have great value once it become more widely recognized.

The two most striking talks were from Gerry McCoy and John McManus. They each had unique talks about trauma in their settings. Mr. McCoy spoke about trauma in Belfast before the trauma system became what it is today. They were seeing a massive influx in firearm injuries which helped form the trauma programs that exist now. Prof. McManus gave a talk about the trauma experience he has gained working in Iraq in the military setting. Both were accompanied by incredible stories and great images.

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Very comfortable seating arrangement

The conference officially ran on Thursday and Friday. The days were divided into didactic sessions in the morning and and hands-on/breakout sessions in the afternoon. The morning session on Thursday was a spectrum from birth to end  of life care. The first talk was from Dr. Mairead O’Riordan who made assisting with delivery sound easy. In reality, most babies will do well with little intervention. Mom will put herself in whichever position is most suitable to deliver the baby so always let her move as she needs to.

Professor Tony Ryan spoke about the Helping Babies Breath program which was launched in Africa. He put on a short skit which demonstrated the typical process of a baby being delivered in an impoverished setting. He then showed the differences in the care that can be provided after implementation of the program. In most of the third world access to medical care is nonexistent. However, many of the medical providers in small villages are there to help mothers deliver. Despite the effort many babies die because of lack of basic neonatal care that can be provided by almost anyone. The program is designed to train the providers in basic ventilation and airway techniques that can help a baby survive through its first few minutes of life. This is often all that is needed to improve outcomes in this population.

The next talk was from David Hennelly who is the clinical development manager for the Ireland National Ambulance Service. He spoke about the One Life Project which is working to improve cardiac arrest outcomes in Ireland. They have made great strides in improving access to rapid care throughout the country and they have seen increasing survival rates as a result.

The final morning talk was about end of life care from Prof. Will Molloy. The topic is one that is poorly known throughout EMS, emergency medicine, and critical care. There is often little thought given to what is truly the right thing for a patient at the end of their life. The focus should often be comfort and allowing the patient to die in a way that they want to, rather than being artificially supported for long periods of time.

The afternoon activities were similar both days and unfortunately you can’t do all of them! The feedback from all the sessions was very positive. Most of them involved leaving the venue and participating in some sort of outdoor activity. There were a wide variety of activities including bicycling, motorcycle riding, and a boat tour all of which had a different medically related topics incorporated. One of the most popular sessions was the farm injuries course. This was held on a real farm and there were multiple immersive, high-fidelity simulations of farm injuries that are commonly encountered. There were also indoor activities which included ultrasound, EKG interpretation, and simulation.

Both of my afternoons were spent helping as an instructor for EMS Pocus in the point-of-care ultrasound programs. I have a strong interest in ultrasound and our group is working to get the technology into the prehospital setting. Our sessions provided education on some of the most common and useful exams to perform in an critically ill patient. These included: basic cardiac ultrasound, lung ultrasound, and the RUSH exam. For more information click here.

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On Thursday night another social event was held. It was set in the picturesque Irish countryside. Dinner and drinks were served and a Helicopter EMS and Search and Rescue panel was the featured event. There were providers from some of the world’s leading helicopter programs including Sydney HEMS, London HEMS, Travis County STAR Flight, and many more. There was much discussion about some of the unique challenges that face prehospital providers. As always, there was some debate about how to ideally staff a medical helicopter. In the end, it comes down to the mission profile to determine the right crew configuration.

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The talks on Friday were primarily all about trauma care. We heard from experts about
their individual trauma programs and ones they had worked in. Adrian Murphy spoke about his experience at London HEMS and Mike Abernethy gave an informative talk on farm injuries which carried into his SMACC talk.

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Ashley Liebig sat on the couch, kicked her shoes off, and gave a talk on human factors. She spoke about how stress influences us as providers and how patients are affected. She used swift water rescue as an example, describing how she has to balance the patient’s life with her own stress while rescuing a distressed swimmer. As always, she gave an impactful and meaningful talk.

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He definitely hit the ball

Friday night was the Grande Finale final event sponsored by the EMSG organizers. It was held at the scenic Muckross Farms. We were fed like royalty and got to experience some Irish entertainment. There were kids Hurling and Mike Abernethy and others became expert hurlers. There were also falconers there with a variety of rare bird species that were fascinating to see in person. Overall, an incredible night of fun and socialization.

 

 

 

The EMS Gathering was an amazing precursor to SMACC. My Ireland experience would not have been the same without it. It demonstrated that Ireland is a leader in EMS worldwide and has a progressive outlooks for their EMS system. I would encourage anyone to attend this event if it is held again and to visit Killarney as it is a truly beautiful place.

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Found this wall of mostly U.S. patches in a pub in Killarney

 

EMS Gathering in Killarney

#smaccDUB reflection

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Where does one start after a week like that?

The #FOAMed community is unique. Anyone who uses it regularly or contributes to it knows that. For most of us the knowledge we gain through social media and free sources drives our practice heavily. The format and environment helps us to stay motivated and always wanting to learn more. This passion that we have is what drives us to attend SMACC in the first place.

This year was my first SMACC experience.  I couldn’t make it last year when it was in my own country. However, I think being in Ireland provided a unique aura. Ireland had a special meaning for FOAMed; it was born there, in a pub in downtown Dublin. In addition, one of the greatest FOAMed contributors and visionaries lived there. This of course was John Hinds. I won’t say much about him because anyone in this community must know who he was and I could never do him the justice he deserves. The conference this year had a certain feel too it. It seemed very appropriate to be there in honor of John. This was especially true at #SMACCforce.

There were many incredible pre-conference sessions offered. It was almost impossible to choose which to attend. The reputation of SMACCforce, the prehospital workshop, brought me there.

 A full day of education from some of the smartest, most motivated prehospital providers in the world. One of my favorite talks, an empassioned rant really, was from Per Bredmose (@VikingOne_). He spoke about the difficult situation of intervening when care is not appropriate or not aggressive enough. It really embodied the SMACC and FOAMed mantra of patient advocacy.

“For fuck’s sake stand up for your patient!”

-Per Bredmose, The Viking

SMACCforce brings the importance of good prehospital critical care to the forefront. It is often overlooked, especially in the United States.

Monday night was also quite notable. During the trip I became quite involved with the EMS Wolfpack (@EMSWolfpack) and EMS Pocus (@emspocus, http://www.emspocus.com). The two groups collaborated to throw a pub night. We rented out an entire bar, The Trinity Inn, for a night of informal point-of-care ultrasound education, socialization, and alcohol consumption. We had no idea what to expect, nor did we know what was coming.

It started off with a few people learning the basics of POCUS (echo, RUSH, vascular access). But, before we knew it, the bar was full. It was impossible to even walk through it. In addition, Jim DuCanto (@jducanto) was there with his SALAD vomiting airway mannequin. This is probably the only documented instance of SALAD being performed in a bar; we are very proud of this. People were learning difficult airway techniques all throughout the night until the bar kicked us out.


However, the learning that was done was not the most remarkable point of the night. We had providers of all levels, from every continent, and from all specialities of critical care attend. People  networked and collaborated with each other in a format that I believe is unique to SMACC. As was spoken about in SMACCforce, there was a true flattening of the heirarchy where paramedics were engaging physicians, and vice versa, in relevant and important conversation. The night was an overwhelming success and next year we will need a bigger pub.

Tuesday was the first day of the main conference. There were so many incredible talks that it would take me days to summarize them so I will focus on the ones that impacted me the most. The conference started with an incredible opening with a light show and the new smaccDUB soundtrack. This was followed by the John Hinds plenary, a series of speakers with topics designed to commemorate John.


Perhaps the most inspirational was Scott Weingart’s (@emcrit) talk where he encouraged us all the meditate. Scott has recently focused a lot on the psychological aspects of critical care and this is one way he believes that we can all improve our mental health and resuscitation abilities. There was also a video commemorating John’s life and a talk from his partner. I think there were tears throughout the auditorium.

“I will not leave you.”

-John Hinds to all of his patients

“Don’t be a resus wanker.”

-Also John

The rest of day one consisted of concurrent sessions. First I attended the Oxygen and Stress session where we learned from geniuses, including John Myburgh (@JAMyburgh) and self-proclaimed sex god Mervyn Singer that supplemental oxygen is probably a bad thing in most cases and patients do well without it.


The second half of the day was the How I Do It session. Providers spoke on specific practices they use regularly. Casey Parker (@broomedocs) discussed the importance of using evidence based values such as pretest probability when performing tests. In general many of the tests done in the emergency department are not helpful and difficult to interpret. Per Bredmose spoke on his use of inhaled nitric oxide in Norwegian helicopter critical care. Their use focuses primarily on bridging ARDS patients to ECMO but also in any cause of pulmonary hypertension such as pulmonary embolism. The day concluded with a panel discussing how medical knowledge and new data should be disseminated. There was argument about peer-review, journal bias, and the high cost to access new studies. The broad consensus was that we need a centralized, open access location to put all new data which has a publicly viewable peer-review process.

Day two started with a plenary called Slaying Sacred Cows. This was a series of four incredible talks which truly all deserve individual recognition. Resa Lewis (@ultrasoundREL) spoke inspirationally about women as leaders. She taught lessons that are designed to help both men and women succeed as leaders in medicine.

The talk that may have been the most impactful and lacrimation generating of the entire week was Ross Fisher’s (@ffolliet) Things That Scare Me, which he gave with no slides as the audience sat in intent silence.


Ross is a pediatric surgeon in the UK and he described some of the times during his practice that he has been most scared. This included operating on a 600 gram neonate with NEC. A patient this size has a blood volume of about 60 mL and they tend to bleed. He said that fear is the emotion that ends careers of excellent providers. The most important factor in dealing with fear is support from colleagues. In the right environment, fear can be overcome. This talk took such courage to give to a room of 2,000+. It is a must hear for everyone once it is released.

The next was from Reuben Strayer (@emupdates) who spoke about treatment of agitation. The most important part of the talk was this: we want droperidol back in the U.S.! It is a safe and effective drug for the significantly disruptive patient. If the patient is combative, or a threat to themselves or others, IM ketamine is the agent of choice.

The last talk of the morning plenary was from the amazing Liz Crowe (@LizCrowe2). She spoke about love in critical care and how it really impacts patient outcomes and provider health. As expected the talk was full of laughs and sexual enuendo. Remember your patients, patient families, and colleagues all need love.

The morning concurrent for me was All Heart. There were awesome talks on pediatric heart conditions, cardiac surgery patients, and the RV.


Haney Mallemat (@CriticalCareNow) intrigued the audience by proposing a modern approach to PEA arrest. Not all are the same and underlying causes must be identified and treated if ROSC is to occur. PEA is really an umbrella term, much like SVT. Ultrasound should be used to distiguish between pulselessness with rhythm and echo motion (PREM) and pulselessness with rhythm and echo standstill (PRES).

The afternoon of day two featured three different forums, of which I attended Bare Knuckle EM. There were four sessions which included an EM literature update. It turns out bacon can be used to treat epistaxis! Who knew? (http://www.ncbi.nlm.nih.gov/pubmed/22224315) Actual relevant topics were also discussed. The three following sessions were pro/con debates about important topics in EM. The topics were: EM is a failed paradigm, POCUS is a problem, and thrombolysis in submassive PE. Check these when they are released. The day concluded with SONIC BOOM, an entertaining and educational display of POCUS techniques.

We can’t get through day two without mentioning the incredible gala. The event was held at the Guinness Storehouse, the five floor venue where Guinness is made and sold in large quantities. Around 2,100 people attended and it was an awesome time.


The last day started off interestingly. The auditorium was about 1/4 full as a result of gala activities the night before. It gradually filled throughout the morning. The plenary talks were themed Beyond the Ivory Towers. The first two talks were from Kath Maitland (@KathMaitland) and Nikki Blackwell. They both discussed topics regarding their work in Africa providing care for critically ill patients with few resources. Kath focused on oxygen and its potential overuse.

Next, EM physcian Ashley Shreves discussed the immensely important topic of palliative care in the ED. This is done poorly pretty much everywhere. Incredible talk that will inspire you to do better.

“The treatment for death is probably not CPR in many cases!”

Ashley Liebig (@ashleyliebig) stole the show with her talk The Golden Fleece, The Golden Hour, and The Golden Rule.


In critical care, pre-hospital and in-hospital, providers carry a massive burden. Clinical responsibility paired with emotional trauma often leads to the downfall of incredible people. Ashley gave an emotional and honest talk with essentially no slides. I encourage everyone to listen to this when it is released.

Brining Sexy Back was the theme of my morning session. Weingart spoke about post-intubation sedation and analgesia. Remember: analgesia always and FIRST. The most notable talk though was from Alex Psirides (@psirides) on Why Your Hospital is Broken.


This talk was a reality check but true for most places. The focus of most hospital systems is often not truly the patient, it is the providers. Another must-hear.

My last concurrent of the conference was A is for Airway. Four great talks here. Reuben Strayer presented a somewhat novel approach to laryngoscopy designed to make providers slow down and not rush. Listen to the lecture and see what its all about.

The finale was a ton of fun. Two teams of four were pitted against eachother in contests testing knowledge, teamwork, and skills. All the participants earned half price admission to SMACC next year!

So in summary: epic. This post does not even scratch the surface. The talks were incredible. But what really makes SMACC special is the people you meet. And I can’t quanitify that in words. If you have not been to SMACC, go! Also, if you are not involved in #FOAMed and the twitter world I encourage you to start. Go to http://www.smacc.net.au and listen to the previous talks. Also, go to http://www.lifeinthefastlane.com, the original FOAMed site which has thousands of articles. Get on twitter, search #FOAMed, #smaccDUB, and get involved.


#dasSMACC 2017

Next year SMACC will be held in Berlin, Germany.

Venue: Tempodrom

June 26-29, 2017

#smaccDUB reflection