• Lessons learned from smaccGOLD – “Bye-bye dogma, hello best practice!”

    by Alan Batt. Last modified: 22/03/14


    So for those of you who are unaware, smaccGOLD took place from the 19th to the 21st March in Australia’s Gold Coast. I was unfortunately unable to attend, but following the conference on Twitter (using the hashtag #smaccGOLD) was just as educational, albeit far less immersive and certainly not as much fun! It also meant staying up until an ungodly hour with only other Twitter friends as company. I mainly followed the hashtag and re-tweeted important points that were tweeted from each session, but I also managed to get involved in live sideline discussions with other Paramedics, nurses and doctors from the USA, Canada, Australia, Ireland, Sweden and the UK on issues such as professionalism, palliative & end-of-life care, airway management, fluid resuscitation, sepsis, education, FOAM and journal clubs! For those of you who weren’t able to make it either, here are some of the major points from what was truly an excellent conference (in no particular order!). All talks will be available from the SMACC website soon (www.smacc.net.au) where you can watch and listen for yourself! *Obvious disclaimer: just because it’s written here doesn’t mean you can now go and do it! Always operate according to scope of practice, local guidelines etc.

    • Trendelenburg position for trauma patients = wrong!
    • Classes of shock related to blood loss = wrong!
    • Permissive hypotension in blunt trauma = caution!
    • Lying patients in collars flat = wrong! (causes extension)
    • Giving oxygen to normoxic patients with chest pain = wrong! (awaiting AVOID trial results)
    • Radial pulse means SBP> 80mmHg = wrong!
    • Decreased GCS a contraindication to NIPPV = wrong!
    • NO CPR if there’s an LVAD in-situ = wrong!
    • Not intubating COPD patients as “they will never get off the vent” = wrong!
    • Do not use ketamine in head injury = wrong!
    • Vasoactive infusions need to go through a central line = wrong!
    • No surgical cricothroidotomy for kids = wrong!
    • Association between gag reflex and aspiration = wrong! (can still aspirate with gag reflex!)
    • GCS <8 – must intubate – wrong! (patients with GCS >8 may also need to be intubated)
    • Ketamine and emergence-10x more people get euphoria vs dysphoria, and delirium probably relates more to larger doses
    • Driving up a “normal” BP in a trauma patient may exacerbate bleeding
    • Obese patients have bad FRC! They cannot breathe properly when supine – put obese patients in ramped up position! Even in trauma!
    • Cricoid pressure (if you’re a user of it) can be released if it’s causing trouble with airway views – Levitan says don’t use it!
    • Prehospital ultrasound is going to be the next big thing
    • Lowest frequency & largest penetration for the bariatric pericardial ultrasound
    • Helmet removal is safe!
    • In motorcyclists – isolated femur = think pelvic injuries
    • Rehab begins at roadside – small things upstream have consequences downstream – the care we provide in the prehospital setting has long-term consequences for our patients
    • Needle crics are a waste of time – Hinds
    • You can improve your intubation success by watching Levitans videos “a million times”
    • There’s a need for international standardisation of Paramedic education, and prehospital care
    • The dynamic nature of ACS makes continuous ST segment monitoring essential
    • Benzos are unequivocally the first line treatment for seizures and you need to get them in quickly
    • Mechanical ventilation should be used for ALL arrests – when your heart rate is up in a resus scenario, you can’t be trusted with a BMV
    • ACLS needs to be replaced with an actual Advanced Resuscitation course – resuscitationists using the same ACLS as dermatologists is wrong!
    • Always read more than just the title & abstract in looking at research (i.e methods)
    • According to a journal editor: most papers are rubbish, peer review does not work, research is hijacked by big pharma, and full-text access is poor
    • According to a journal editor: The “number needed to read” (NNR) of journal articles before you find something useful and valid = 200!
    • Positive attitude is paramount when it comes to airway management
    • Levitan proposes some new terminology: why do we stress ourselves with difficult airways? They should be challenging airways!
    • It currently takes 17 years for published care changes to become routine care!
    • Recognising the septic patient is the most important step in saving lives in sepsis
    • The real power of #FOAMed is to encourage, maintain and inspire learning
    • Learning with simulation? Use Kolb’s Reflective Cycle!
    • Simulation can incorporate all teams – load a mannequin in an ambulance, treat, pre-alert ED and have ED staff join in on sim!
    • Take your learners back to the bedside – clinical teaching is vital
    • Take three attempts to secure the airway with laryngoscopy, if that fails LMA – if that fails cut neck.
    • Too Much Information = ineffective teaching. Bullet points of the important stuff only!
    • Education is rarely described as an intervention – it should be, so that we can then evaluate outcome
    • IM ceftriaxone is quick & effective for kids. It’s a great option if no IV access available.
    • Two attempts at IV access in Paeds – no more! Then IO access!
    • Four things that distress kids: Pain, fever, fatigue, fear – cure each of these!
    • Checklists work, improve safety, and help maintain logical thought process – Leeuwenberg
    • Cricoid pressure may or may not work depending on who you talk to – May/Hinds/Levitan/LeCong
    • Put a PEEP valve on every BVM, and use a bougie for EVERY tube
    • NODESAT technique should be used to prevent hypoxia in all airway management attempts
    • Cervical collars… waste of time? Venous drainage very important for ICP. Collars can inhibit venous drainage if too tight.
    • History & clinical judgement are not helpful in diagnosing ACS, neither are character & radiation of chest pain ACS just as likely with atypical vs typical symptoms – you can’t rule ACS in or out based on these. Need trops, ECG.
    • Every patient is someone’s mum, dad, child, friend, sibling. Not just the ones who are dying. All of them. Don’t ever forget this!
    • Sniffing position with head tilted back is wrong! Ramp the patient up, ear in line with sternal notch.
    • Admitting our mistakes and critically reflecting on them is something we need to get better at!
    • Aortic dissections are difficult to diagnose, commonly missed
    • Weingart tips on not failing cric: go midline, don’t go too high, feel up from sternal notch not down, and don’t worry about blood – they won’t bleed to death!
    • Levitan: blast some O’s in the nose – nasal delivered oxygen is superior to mask delivered!
    • We cannot rely on traditional ALS algorithms or single prognostic tests to decide when to cease resuscitation
    • Future of VF treatment – automatic CPR, double sequential external simultaneous defibrillation, straight to cath lab
    • NEVER cease resuscitation of a cardiac arrest based on blood gas results
    • When to stop resus by Reid: 1. Patient DOES NOT want it 2. No chance of a meaningful recovery 3. Nothing else you can do
    • Weingart on crics: if you can’t feel anatomy, cut until you can. If you still can’t feel anatomy, keep cutting until you hit air. Cartilaginous cage will protect patient.
    • YOU have to be the backup airway solution – if YOU pick up the laryngoscope then you need to be prepared for cric.
    • Weingart: risky airway? Mark the cric with a big black mark. Mentally prepares team: it is not a failure, but part of the plan
    • Passive Leg Raise technique has 94% sensitivity & 100% specificity for predicting fluid responsiveness!
    • CVP is essentially useless for predicting volume status. Stop using it.
    • BP is not a good correlate for preload reserve
    • In trauma, stay away from crystalloid solutions – it’s better to watch a SBP of 70 for 5 mins than risk losing clot formation
    • CRASH-2 study showed TXA should be given as early as possible to bleeding trauma patients – we need more TXA given prehospital!

    Phew! That’s just some of what I took away from this conference! As I said, all talks will be available on the SMACC website in the coming weeks, and I can safely say – watch every last one of them!

    The power of FOAM!

    FOAMed-LOGOAnd I took all of this away without even attending the conference – it really shows the power of FOAM! If you’re not on the FOAM bandwagon yet, you need to be! Check out our posts on

    Tip of the hat must go to the fantastic tweeters on site! In 3 days they produced over 25,000 tweets, with over 25 million impressions (an average of almost 200 tweets per hour)! Truly outstanding work! Honourable mentions (for me) go to Jess, Buck, Robert, Haydn, Aidan, Liz, Mitchell, Salim, Minh, Tim, Leigh, Patrick and Tessa for their hard work tweeting live, as well as all the other tweeters who provided a running commentary of every session – thank you all! Also, thank you to all on the SMACC team, Oliver and Roger, and all the speakers for what was a fantastic conference for a non-attendee! smaccstat3


      Below you’ll find our #smaccGOLD twitter feed, have a browse through it and prepare to unlearn all you’ve learned! smacc2015 is taking place in Chicago, IL, USA from 20-22nd May (hashtag #smaccUS) – I’ll be there, hope some of you will be too!

    Our smaccGOLD Twitter Feed

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    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He is currently completing an MSc in Critical Care in Cardiff University, Wales. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism, immersive simulation and curriculum design.

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