Taking Stock of SMACC

SMACC—the Social Media and Critical Care Conference—is an international conference, founded less than five years ago by Australian intensive care physicians, that combines critical care (prehospital, emergency department and intensive care), social media and the free, open-access medicine (FOAM) movement to create a one-of-a-kind conference with more than 2,000 delegates from more than 30 countries (which, by the way, sells out in one day). There is even a prehospital-specific preconference (SMACCForce) and a unofficial paramedic group (@EMSWolfpack) that holds its own welcoming bar event.^1–5

This was my second SMACC. When you ask why I go to SMACC, my answer is to tell you to stop reading and just go watch this video of SMACC Chicago’s opening ceremony. I like an extravaganza and weirdness,⁶ and I also like beer, and the conference party in Dublin was held at the Guinness Brewery. At 48, I’m also one of the oldest people at the conference.

This is not a conference where paramedics get a pat on the head. Although the conference is physician-centric (about 80% of attendees are physicians), prehospital care is treated like a legitimate part of medicine, and paramedics are treated as clinicians. This is critically important because one of the major failure of EMS in the U.S. is that we think our care is somehow isolated from care in the community and later care in the emergency department, critical care units and hospital. While this alienation may stem from a variety of factors, we have the responsibility to fix it—providing prehospital medicine doesn’t make us, as my daughter would say, “special snowflakes.”⁷ We need to get a lot better at collaboration and stop waiting for our medical directors to initiate every clinical improvement.

Standout speakers this year included intensivist superstar Scott Weingart, of EMCrit fame, talking about meditation in the Dr. John Hinds Memorial Lecture,^8,9 and emergency medicine physician Ashley Shreves, from Mount Sinai Hospital in New York City, talking about the need for better palliative care in the emergency setting—knowing the right questions to ask so we can do the right thing.¹⁰ This session was particularly important for medics because it provided real tools for helping us “be present” in the moment—in contrast to going through the motions—which is so important for EMS when it is one of the most important hours of our patients’ lives. Palliative care is important because we spend a lot of time with dying people, yet receive almost no training in the human aspects of caring for people during the last days and hours of their lives.

Here are some of my thoughts from the conference:

• I was hospital-trained and hospital-employed as a New York City 9-1-1 medic for most of my career, and the relationship between paramedics and physicians was always close. It seems to have degraded in recent years, and I don’t think that is good for paramedics or the care we provide. One of the paradigms you saw a lot at SMACC was that while there are only a handful of prehospital physicians in the United States,¹¹ air medical services in the U.K. and Australia typically work as a physician/paramedic team. As a result you see a lot of respect for paramedics as clinicians.
• At SMACC there was almost universal agreement that we can train anybody to do medical skills in the field, but what really matters is how much judgment is required. For relatively simple procedures like resuscitative hysterectomy (aka perimortem c-section),¹² where there is high level of agreement about the necessity in the setting of cardiac arrest in a full-term pregnancy, paramedics should be performing the skill (with the caveats of good training, ongoing clinical exposure and simulation, ongoing competency validation and good quality oversight). For other medical skills that require more judgment, the question is how we can bring both experience and physician-level clinical judgment to the field, either through physician field response, videoconferencing or traditional online medical control.
• In a similar vein, SMACC and the emergency medicine FOAM community as a whole have spent a lot of time over the past year discussing how to maintain clinical competency for rare-but-necessary skills, particularly the concept of “deliberate practice.”¹³ Paramedics need to begin to take this much more seriously and develop ongoing, hands-on competency processes, including post-licensure clinical exposure (particularly in high-risk/low-frequency areas such as airway management, pediatrics and obstetrics); ongoing competency training using simulation, cadavers or clinical rotations; and ongoing competency validation, including diagnostic (not just skill) competency. We need to get better at this, and we should be the ones shouting about it, because we are not as good as we should be.

SMACC has an ongoing focus on airway management, and one of the things I continuously question as a paramedic professor is our focus on endotracheal intubation rather than airway management. What we should be doing is using the simplest effective process (BVM, laryngeal airway, endotracheal intubation, surgical cricothyrotomy), rather than focusing on BVM-to-ETI with everything else being a rescue process.

American paramedics also seem to still be 20 years behind paramedics in the much of the rest of the world, and if we want to be taken seriously as clinicians, we need to be pushing to keep up with the science of prehospital medicine:

• We’re not universally using bougies or nasal airways that are standard everywhere else in the world (and why would you ever prefer an oral airway over a nasal airway?);
• We’re not universally using high-flow nasal cannula for pre- and peri-oxygenation¹⁴ (you know that partial-rebreather masks only provide 60% oxygen, while mask plus high-flow nasal cannula can provide up to 100%, right?);¹⁵
• We’re not universally using PEEP valves to keep the alveoli open;¹⁶
• We’re not universally suctioning before every intubation;
• We’re not universally mandated to use a difficult airway assessment;¹⁷
• We’re not universally using checklists¹⁸ and ensuring that conditions are optimized to the extent possible to get that tube into the right place at the right time.

Once again, we need to stop putting all the responsibility for clinical improvement on our physician medical directors. If we want to be clinicians instead of technicians, we need to take some of the responsibility to synthesize the research, develop model clinical protocols based on that science, and bring that forward for a discussion about improving the clinical care we provide.

Overall, SMACC is a great conference for paramedics, emergency nurses and emergency physicians who want to see how our peers in other places do things, want a high-energy environment and are not afraid to challenge paradigms. SMACC is an opportunity to meet some of the most celebrated names in emergency medicine from around the world, reinforces the importance of the FOAM movement for paramedics and always energizes me to get to work on improving things.

References

1. Conferences have been held in Australia, Chicago and Dublin. Next year’s will be in Berlin.

2. The hashtag #smaccUS for the Chicago meeting has had more than 35 million impressions on Twitter.

3. Here are some great FOAM resources:

• The SMACC Youtube Channel
• Phemcast
• St. Emlyns
• EMCrit
• PHARM
• Life in the Fast Lane.

4. The SMACC podcast has more than 500,000 downloads.

5. @EMSWolfpack on Twitter and at https://emswolfpack.libsyn.com/ on the web.

6. Another example: Dr. Tim Leeuwenburg (@KangarooBeach) stripped naked on stage last year in his talk about vulnerability in All Alone on Kangaroo Beach, which you can find at www.foamem.com/category/ki-docs/page/4/ (scroll to see Tim wearing just a bag-valve mask; there is audio of the presentation).

7. See https://www.urbandictionary.com/define.php?term=special%20snowflake.

8. Scott Weingart on meditation: https://emcrit.org/wee/vipassana-meditation/.

9. John Hinds was an anesthesiologist and great speaker who died a week after an amazing presentation at SMACC Chicago: https://www.youtube.com/watch?v=GFX_tocJShA; for more: https://en.wikipedia.org/wiki/John_Hinds_(doctor).

10. Ashley Shreves’ references for “Pallative Care Everywhere” included the Palliative Care Network of Wisconsin: https://www.mypcnow.org/; EPEC: https://www.epec.net/; and the Harvard Palliative Care Project: https://www.hms.harvard.edu/pallcare/.

11. Here’s an interview with University of Wisconsin flight physician Mike Abernethy on EMS physicians in the U.S. by Royal Flying Doctor Service physician Minh Lee Cong: https://prehospitalmed.com/2016/02/14/pharm-podcast-133-ems-physicians-in-usa-with-dr-mike-abernethy/. Prehospital physician programs include those of the University of Wisconsin, Cleveland Metro, UC Health Air Care, University of Chicago, Spectrum Health, University of Pittsburgh and Mercy Health.

12. Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation, 2015 American Health Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, https://circ.ahajournals.org/content/132/18_suppl_2/S501.

13. PHEMCAST talking about deliberate practice: https://phemcast.co.uk/2016/06/06/471/. Cliff Reid (resus.me) talking about his lecture from the Royal College of Emergency Medicine Conference in 2015: https://resus.me/rcem15/. Simon Carley’s (St. Emlyn’s) blog post on the subject: https://stemlynsblog.org/the-pursuit-of-mastery-through-deliberate-practice/. Scott Weingart (EMCrit) from SMACC 2013: https://emcrit.org/podcasts/path-to-insanity/.

14. See https://emcrit.org/wp-content/uploads/2011/10/Preox-annals-article.pdf.

15. See https://rebelem.com/is-apneic-oxygenation-overhyped-with-scott-weingart/.

16. See https://emcrit.org/preoxygenation/.

17. Difficult airway assessment: https://lifeinthefastlane.com/ccc/airway-assessment/; https://www.acep.org/content.aspx?id=33992.

18. Airway checklist: https://emcrit.org/podcasts/emcrit-intubation-checklist/.

Scot Phelps runs the Ambulance Science Fellowship Program, which can be found at AmbulanceScience.org. He also teaches in the Emergency Services Degree program at Adelphi University and in the paramedic degree program at the City University of New York/Kingsborough Community College.