Delayed, transient quadriplegia; the importance of spinal cord perfusion.

Transient quadriplegia developed in a man, a short time after, he sustained a cervical spinal fracture in a surfing mishap. The neurological deficit appeared complete, and developed some 30 min after the initial injury in the presence of moderate hypotension. It resolved over a further period of 1-2 hours following restoration of normotension. This case highlights the importance of the maintenance of spinal perfusion pressure in the acute management of traumatic spinal injury.

Successful emergency management of a bleeding tracheoinnominate fistula.

In this case, we describe a novel approach to achieving temporary haemostasis in acute massive haemorrhage from a bleeding tracheoinnominate fistula. We report the case of a 42-year-old man admitted to hospital after suffering 80% body surface area burns. Thirty days following the percutaneous insertion of a tracheostomy, spontaneous massive haemorrhage occurred via the tracheostomy stoma, the tracheostomy tube and the mouth. After hyperinflation of the tracheostomy cuff which controlled airway contamination, effective tamponade was achieved using a hyperinflated balloon on a Foley catheter that was introduced by direct laryngoscopy into the upper larynx above the tracheotomy stoma. This provided temporary control of the bleeding until definitive management through ligation of the innominate artery via median sternotomy.

Assessment of the College of Intensive Care Medicine's capacity to train: a survey of trainees and directors.

BACKGROUND: In Australia and New Zealand, the numbers of intensive care medicine trainees have increased significantly over the past 15 years. This has implications for supervision, clinical and procedural experience, and availability of rotations. The College of Intensive Care Medicine of Australia and New Zealand (CICM) decided to estimate the current training resources using several domains. METHODS: An online survey was sent to all CICM trainees (n = 528) and all directors of intensive care units (ICUs) (n = 106), using the SurveyMonkey tool. RESULTS: The overall response rate for the survey was 44% (trainees, 38%; directors, 72%). Most trainees had a 1:1 day-night roster system. Experience among trainees with common ICU procedures appeared limited. Fifty-six per cent of trainees reported spending more than 20% of their time attending medical emergency team calls. Difficulty accessing anaesthesia, medicine, paediatric and rural terms were reported by 35%, 26% 46% and 40% of trainees, respectively. Thirty-seven percent of trainees reported having to wait at least 1 year and 10% waited up to 2 years over and above their required training time to secure an anaesthesia term. Owing to gaps in experience in certain modules, one-third of final-year trainees felt underprepared to take on a role as a specialist, an observation shared by 15% of directors. CONCLUSION: This report has provided an assessment of the available resources within Australia and New Zealand for training doctors in intensive care medicine, and has identified significant limitations and concerns among trainees and ICU directors regarding the capacity to train. The findings call for a review of the training program, including a determination of optimal numbers of training positions.

Prevalence of bullying, discrimination and sexual harassment among trainees and Fellows of the College of Intensive Care Medicine of Australia and New Zealand.

BACKGROUND: Anecdotal reports about bullying behaviour in intensive care emerged during College of Intensive Care Medicine (CICM) hospital accreditation visits. Bullying, discrimination and sexual harassment (BDSH) in the medical profession, particularly in surgery, were widely reported in the media recently. This prompted the College to formally survey its Fellows and trainees to identify the prevalence of these behaviours in the intensive care workplace. METHODS: An online survey of all trainees (n = 951) and Fellows (n = 970) of the CICM. RESULTS: The survey response rate was 51% (Fellows, 60%; trainees, 41%). The overall prevalences of bullying, discrimination and sexual harassment were 32%, 12% and 3%, respectively. The proportions of Fellows and trainees who reported being bullied and discriminated against were similar across all age groups. Women reported a greater prevalence of sexual harassment (odds ratio [OR], 2.97 [95% CI, 1.35-6.51]; P = 0.006) and discrimination (OR, 2.10 [95% CI, 1.39-3.17]; P = 0.0004) than men. Respondents who obtained their primary medical qualification in Asia or Africa appeared to have been at increased risk of discrimination (OR, 1.88 [95% CI, 1.15-3.05]; P = 0.03). Respondents who obtained their degree in Australia, New Zealand or Hong Kong may have been at increased risk of being bullied. In all three domains of unprofessional behaviour, the perpetrators were predominantly consultants (70% overall), and the highest proportion of these was ICU consultants. CONCLUSIONS: The occurrence of BDSH appears to be common in the intensive care environment in Australia and New Zealand.

Current use of preoperative intra-aortic balloon counterpulsation in high-risk cardiac surgery: a cohort study.

OBJECTIVE: To determine whether preoperative introduction of intra-aortic balloon counterpulsation (IABC) reduced mortality in high-risk patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: This was a retrospective cohort study of prospectively collected data on all patients who underwent cardiac surgery at a university hospital in Sydney, New South Wales, between 1 January 2002 and 20 August 2007. High risk was defined as the presence of two or more recognised risk factors. We compared the observed mortality to the mortality predicted by the EuroSCORE, and conducted a logistic regression analysis to determine the effect of preoperative IABC on mortality. RESULTS: Among 358 patients deemed high risk, 36 underwent preoperative IABC. This group had higher EuroSCORE-predicted mortality than the group that did not undergo IABC (38% v 18%, P = 0.008). Despite this, observed mortality was similar for those with and without preoperative IABC (both 2.8%) and was significantly lower than predicted in both groups. This equates to a riskadjusted reduction in mortality associated with the use of preoperative IABC (hazard ratio, 0.47; 95%CI, 0.26-0.84; P = 0.005). This result was not confirmed in the logistic regression analysis, with an adjusted odds ratio for mortality of 0.85 (95% CI, 0.09-7.6; P = 0.88). Rates of postoperative complications, including limb ischaemia, were low and similar in both groups. CONCLUSIONS: In this study of high-risk CABG patients, the use of preoperative IABC in the group with higher predicted mortality was associated with a relative reduction in observed mortality. These data provide cautious support for the use of preoperative IABC in selected high-risk patients.

Equitable resource allocation in the intensive care unit: a descriptive ethical case.

A patient with respiratory failure due to undiagnosed tuberculosis in the presence of HIV infection presents to the ICU in a foreign country. This raises many ethical questions, quite apart from the medical management issues raised by the patient's serious condition. Six of these ethical questions have been presented to leading physicians and an ethicist, from a range of national, cultural and religious backgrounds, for their comment.