10th Annual Critical Care Symposium: A Trainee’s Perspective

Having attended last year’s Symposium and found it extremely insightful, I was keen to attend this year’s expanded 10th anniversary meeting. As always, the faculty list contained some of the most renowned names in critical care. With a bigger meeting and parallel scientific sessions has come a bigger venue. The Palace Hotel hosted the meeting this year, with the grand architecture being a reminder of the role of Manchester at the heart of the industrial revolution. It was fascinating and useful to hear both the general consensus and occasionally contrary views about current intensive care practice. It was invaluable for a trainee learning the specialty to hear the latest thinking in a number of areas in which the textbooks are already out of date. A new innovation for this year was the ability to interact via twitter which many delegates took advantage of.

The plenary session was opened by Prof Jean-Louis Vincent leading a tribute to the late Prof Dan Traber, describing his tremendous contribution to critical care research. Dr Steven Streat from New Zealand gave us an insight into ‘21st century thinking’, arguing that many interventions persist by the perceived need to do something. He questioned how evidence is interpreted and that it is done under the influence of our pre-existing beliefs. For example, the SAFE study has been interpreted as supporting differing fluid strategies. The fluid you receive for resuscitation depends on where you are in the world. The fact that albumin is free to Australian hospitals is not unrelated to its high frequency of use there.

Dr Manu Malbrain followed, dissecting the Surviving Sepsis guidelines with regards to fluid resuscitation, particularly with regards to the use of a CVP target. He argued that chasing a CVP often leads to over-administration of fluid and that static filling pressures are not useful in predicting fluid responsiveness. In a whistlestop review of cardiac output monitoring (with over 120 slides in 15 minutes!) we learned of the utility of volumetric techniques. Dr Farhad Kapadia continued the theme, arguing that ‘less is more in improving critical care outcomes’. Since we do not fully understand the body’s adaptive response to illness, he suggests that we should let it get on and do it. There is little evidence for adrenaline in CPR. High levels of oxygen increase mortality post cardiac arrest and in COPD yet we seem unable to give it up. He argues that we need to change beliefs. The fact that most trials in critical care have negative results underline that it often more appropriate to do nothing rather than something.

Prof Vincent then outlined the ICON audit which looked at the care of 10069 patients in 84 countries, demonstrating differences in age, outcome and the use of organ support. A smaller proportion of patients on intensive care units are being ventilated than previously.

Dr Paul Barach from the United States then talked about human factors in preventing adverse events in intensive care. He argued that the high rate of avoidable adverse events in intensive care units, possibly occurring in up to 35% of patients, represents a form of ‘normalised deviance’ by which we accept poor care. The importance of process to outcome was underlined by fact that mortality is 36% higher in the United States if you have surgery on a Thursday or Friday compared to Monday to Wednesday. The processes of high reliability industries such as nuclear have a thousand times more reliability than intensive care. A sobering thought.

I decided to attend the ventilation session next with Prof Kathy Rowan presenting data which suggested that there is a clear relationship between the volume of patients ventilated on a unit and outcome. This potentially has implications for policy. Dr Richard Beale then presented a review of high frequency oscillation ventilation since the disappointing results of the OSCAR and OSCILLATE trials. He suggested that the higher mortality seen with oscillation in OSCILLATE may be due to the more aggressive ventilation strategy with higher pressures used. Dr Beale suggested that oscillation may still have a place in expert hands. Prof David Linton then explained adaptive support ventilation, a new form of ‘intelligent’ ventilation which automatically detects whether patients are ready to wean and then does so automatically. It may be coming to an ICU near you.

Lunch followed and I joined 21 others in presenting a poster to the judges. This is a new departure for this meeting and gives an excellent opportunity for trainees to present at a major meeting and have their abstracts published in an international journal. I hope this innovation continues in years to come.

The afternoon brought a session on haemodynamic monitoring with Prof Michel Slama outlining the role of echocardiography in sepsis. Prof Azriel Perel argued against protocolised haemodynamic management in septic shock, with a critique of the Rivers study, again arguing that CVP is not a useful parameter by which to guide resuscitation. The message is that protocolised care should leave room for therapeutic judgement.

After more coffee, Dr Kuiper from the Netherlands told us of the difficulties of prognostication post cardiac arrest, particularly with the advent of therapeutic hypothermia. Prof Walsh from Edinburgh discussed transfusion thresholds. The conclusion seems to be that 7 g/dl is acceptable for most people but in acute coronary syndrome 8 g/dl may be more appropriate. More work is however needed.

A workshop on fluids then followed. Prof Teboul reminded us of the fact that a fluid challenge cannot (by definition) be used to predict fluid responsiveness and is only successful in 50%. Dr Malbrain explained the concept of ‘de-resuscitation’. He underlined its importance with the fact that on average, non-survivors are 8 litres positive by the end of their first week on ICU compared to survivors who are only 3 litres positive. Dr Roop Kishen explained the deleterious metabolic effects of chloride rich fluids. This brought to an end the first day.

I particularly enjoyed the lung ultrasound workshop with Dr Ranier Gatz and Marek Nalos the next morning. After some case presentations, it was very useful to be supervised actually doing some hands on scanning. I will certainly be more comfortable in using this technique in clinical practice in future.

An update on neuro-critical care provided an insight into the future. Prof David Crippen described nano-robots which he believes will be used to clear subarachnoid haemorrhage in years to come. He also believes that organs may be preserved by cryogenics. Two intriguing prospects for the future. Prof Joe Lex cast a sceptical eye on the evidence for thrombolysis in acute stroke. Prof Bala Venkatesh outlined the possible neuro-protective effects of ketones in brain injury. Prof Polderman reviewed the maintenance of homeostasis in brain injured patients. This included a striking slide showing large areas of brain which were hypoperfused after hyperventilation in a brain injured patient. Tom Bleck then provided an update on the evidence on treatment of status epilepticus.

After hearing Dr Orton from Oldham discuss the mechanism of propofol and its effect on the endocannabinoid system, I was keen to head to the education session. Dr Anna Batchelor explained the changes to the training system in intensive care medicine in the UK. It was useful to hear the background to the changes and the future direction. Trainees were very keen to ask her about what will be happening in the future and the questions continued into the coffee break. As a contrast we heard about ICU training in Brazil from Dr Fredrico Bruzzi de Carvalho.
Prof Mervyn Singer from University College London then took to the stage to decry the new religion of ‘bundlism’. He added to the criticism of the basis of some of the Surviving Sepsis guidleines. He also critiqued the evidence for the ventilator acquired pneumonia bundle used in the UK. He advised that ‘guidelines should be guidelines not rules written in stone’. He argued the case for what he described as EBID, evidence based individiualised decision making. In the last session, we learned that hypothermia is feasible in awake patients with Prof Polderman. Prof Fang Gao Smith explained the evidence behind the unpalatable idea of enteral faecal infusion for recurrent clostridium difficile infection, however there is no evidence yet for probiotics. Associate Prof Don Chalfin argued the case for dedicated intensivists in ICU and Prof Mitch Fink described organisational models for critical care services. Prof Mervyn Singer then talked about ‘suspended animation’ and explained that sulphide is a treatment of potential in ischaemia-reperfusion injuries, with the effect of decreasing metabolism.

To summarise, key themes included the importance of thinking about interventions rather than following bundles or protocols without questioning, and criticism of the use of CVP to guide fluid resuscitation. I found it valuable to reflect that sometimes, the most appropriate treatment may be to do nothing rather than intervene in a way which could potentially harm the patient. This includes blindly giving fluid. I left feeling thoroughly up to date on many of the latest topics. Having recently sat the FFICM examination, I would recommend this meeting to anyone planning to sit an examination in intensive care. Examiners expect more up to date knowledge than that in found text books and attending a conference such as this would be ideal preparation. Perhaps a specific session for an exam knowledge update for trainees could be considered for future years. Trainees will find this meeting beneficial for exam preparation, the opportunity to present an abstract, as well being inspired by key thinkers across intensive care medicine. It is also a chance to be able to meet and socialise with other trainees. I would like to thank Dr Veerappan for organising the event and I am looking forward to next year’s Symposium.

Redmond Tully, Specialty Registrar in Anaesthesia and Intensive Care Medicine, Manchester, United Kingdom

Review of the 2007 Critical Care Conference

As usual, the 4th Annual Critical Care Symposium put on by Veerappan in Manchester, UK was superb. There were around 200 attendees this year, and my biggest concern is that the meeting will “catch on” and get too big. The faculty which Veerappan manages to assemble for these meetings is astonishing, and a wide range of clinical and basic science topics are always discussed. Unarguably, at least to me, the most valuable aspect of this meeting is that it really doesn’t matter if the specific topic or development you are interested in is on the program or not, because it is nearly certain that among the faculty or attendees there will be someone there who knows what you want to know – and, just as importantly, will have both the time and the inclination to talk to you at length about it. With likes of Bleck, Fink, and Singer to chat with, anything I wanted to know about current developments in the pathophysiology and experimental treatment of sepsis, ischemia and shock is only a question or two away from being answered.

Professor Sheldon Magder gave an excellent presentation on the Stewart Approach to acid & base management and presented the strong ion dissociation (SID) approach in a concise and lucid manner. Sheldon’s slides are a treasure since they provide the teaching tools necessary to make SID comprehensible and clinically applicable. I had previously asked if anyone on CCM-L had any slides on SID and (apparently) no one did, aside from Farhad, who had one. Thanks to Sheldon, and the Manchester meeting, I now have a great set of slides – including some case presentations illustrating the importance of SID which Sheldon did not have time to present.

Dr. Roop Kishen gave a good overview of RRT and lead off a “mini-block” of related topics including a presentation on drug dynamics in RRT by Professor Jeff Lipman and a review of anticoagulation in RRT by Dr. Claudia Teles. It goes without saying that Claudia, being a hematologist obsessed with clotting, platelet activity, and all things affecting formed elements of the blood provided insight into the effects of various anticoagulation modalities in RRT on the immune inflammatory response and blood cell integrity in response to extracorporeal manipulation in the presence of different anticoagulants.

Kishen addressed the controversy over which RRT modality to use, and noted that currently the evidence seems to be leaning towards CRRT over hemodialysis. He discussed the US ATN and the Australia & New Zealand RENAL studies, both of which are designed to answer the question as to which modality is superior, if any (results likely late this year or early nesxt). I asked, as I invariably do, if anyone was yet paying attention to the GOOD things removed by all RRTs, and the likely very adverse effect this could have on critically ill patients. As one of the faculty noted, “I noticed your question either was not understood or ignored.” I’ve been interested in this issue since I started doing hemodialysis in the late 1970s. Despite several research proposals and countless times raising this issue, no one has ever responded in ANY way to this question and the literature in this area is poverty-stricken. I was a back-up speaker this year, so I did not give my proposed presentations. I am so frustrated over lack of attention to this issue that I am reproducing several slides from one of my unpresented presentations here:

As you can see, removal of amino acids (the only thing studied extensively) is enormous and relentless during HD. Keep in mind this is just amino acids! Many, many other molecules are no doubt removed as well. It must be far worse during CRRT modalities in that circulating concentrations are probably continuously lower, particularly with hemodialfiltration. How critically ill patients can heal, let alone thrive, under conditions where circulating arginine, glutamine, ascorbate, nitrite (and many other) critical molecules are continuously depleted is amazing in and of itself. We know RRT is “good” at removing wastes, why would it be any less effective at removing nutrients and vital regulatory molecules?

Jeff Lipman reviewed antibiotics in RRT and listed those most commonly underdosed and discussed the importance of the unique pharmacodynamic characteristics of these drugs to their bacterial killing ability. He noted that with beta-lactamases it is important to maintain the blood concentration at 4 to 5 times the MIC for the majority of the dosing interval and that his work had recently demonstrated that resolution of infection is faster with continuous, as opposed to bolus dosing, with ceftriaxone. One reason Veerappan selected Jeff was because he perceives a problem with many clinicians failing to take into account the need to adjust dosing of non-protein bound antibiotics based on the patient’s wet (as opposed to dry) weight. Unfortunately, Veerappan failed to tell Jeff about this, and the topic was not a focus of the talk. So, my bet is that Jeff can count on being invited to speak at Manchester sometime in the future ;-).

Tom Bleck was very well used and gave four talks: Neurological Causes of Difficulty in Weaning, Steroids – Are They Doing Harm, Neurogenic Pulmonary Edema, and Sub-Arachnoid Hemorrhage – What is New? All of these talks were excellent. The Neurogenic pulmonary edema talk laid out the mechanics as currently understood, and provided a good overview of treatment options.

Bleck is probably the only man on earth who can get up before an audience of critical care professionals and say something positive about steroids in the setting of neuroinjury. He provided very insightful discussion about the pharmacology of various steroids and (to me) invaluable insight about the failure of the clinical trials of the Lazardoids (21-aminosteroids), a class of drugs which shone in animal models of neuroinjury, but failed (as all such drugs have) in the clinic. Perhaps some day it will be understood that drugs can be invaluable while being utterly useless when given alone. IMHO, the Lazaroids probably have an important role to play in neuroprotection when used in combination with other molecules.

And that brings me to Professor Mitch Fink who gave three riveting presentations on basic science advances in sepsis: The Role of HMGB-1 in Critical Care, Epithelial Dysfunction, and Novel Pharmaological Agents for Mitochondrial Protection. I’m only going to discuss the HMGB-1 and mitochondrial protection talks. High mobility group box protein 1 (HMGB-1) is a ubiquitous protein in nucleated mammalian cells which is released in response to, and as a result of, injury. In rodent models of sepsis, inhibition of HMGB-1 release or its neutralization by polyclonal antibodies rescues the animals even late in sepsis (day 2). Interestingly, HMGB-1 levels remain elevated in animals and humans long after recovery from the septic or traumatic insult. Dr. Fink noted that levels were still at or near their acute phase peak in community acquired pneumonia patients even after discharge from hospital. This suggests that HMGB-1 has a complex signaling role and that its mechanics will be sophisticated. Inhibition of HMGB-1 will probably be critically related to timing, and it may be the case that inhibition of downstream signaling could be more effective. Dr. Fink noted that HMGB-1 is probably like TNF in the complexity of its actions and that it should not be seen as the” magic bulle”t in sepsis or shock. However, as he pointed out, while TNF antibodies did not prove useful in sepsis, they have virtually revolutionized the treatment of rheumatoid arthritis, and may do so for Chron’s disease as well.

The mitochondrial protection paper reviewed his recent work on targeted delivery of the SOD mimetic TEMPOL to the mitochondria. TEMPOL is water soluble and does not penetrate cell or mitochondrial membranes rapidly. One solution to this is to attach TEMPOL to mitochondrially transported moieties from the old antibiotic Gramicidin. I had two slides dealing with these molecules in my “Ideal Fluids” presentation so it was very rewarding to get to talk at length with Dr. Fink about these compounds and his related work with the free radical scavenger ethyl pyruvate (EP). Dr. Fink noted that ethyl pyruvate failed an initial clinical trial to reduce inflammation in cardiopulmonary bypass and that the intellectual property rights had been returned to UPMC, making near-term further development of EP for clinical application in resuscitation solutions much less likely.

Also of great interest was the emphatic assertion by Dr. Fink that the much touted media results of pharmacological induction of metabolic inhibition by hydrogen sulfide and carbon monoxide were very real and very likely to have a revolutionary impact on emergency and critical care medicine. Sabo Czabo (of PARP and NOS fame) recently left Inotek Pharmaceuticals in Cincinnati to take a position with Mark Roth’s Ikaria, the company Roth helped create to exploit application of pharmacological metabolic inhibition (i.e., hypothermia in a molecule) in CCM. Mitch noted that Ikaria has raised almost $700 million dollars and has major support from DARPA (Defense Advanced Research Projects Agency Defense Advanced Research Projects Agency) the US military’s agency aimed at making warfare 100% survivable (for “us” not “them). Ikaria now controls most of the IP related to pharmacologic induction of reduced metablolism, including acquisition of Scanlan and Grandy”s thyronomines — molecules capable of inducing a hibernation like state. A number of my slides dealt with H2S and they are included below:

What matters most to many people attending a conference is the added value of the locale. The experience of the cultural, culinary, and social life of the target city is the big attraction. Manchester is certainly not London, and thank heavens it is not San Francisco, either. So, while there are good restaurants, a fine air and space museum, and one of the largest collection of Alma Tadema’s paintings anywhere (I have a soft spot for Tadema) it not the place to come for a sophisticated night on the town.

What unarguably matters to everyone who attends a conference is that the venue be accommodating, and the food be good. Bad service, logistic failures, and above all bad food and drink, can devastate a meeting. So far, Veerappan has done well above average in this respect, with truly excellent conference planning and execution (none of the usual ghastly failures such as bollixed slide projectors, clueless hotel staff, screeching sound systems, etc.). Service was very good, and the luncheon food was delicious and varied – vastly better than the usual hellish over-cooked vegetables, macerated chicken, and starchy-sauce-drenched fare served at meetings the world over.

Britain has changed more than I dreamed possible. I hosted two conferences in Britain (London) in the mid-1980s and they were the single worst meeting logistic and dining nightmares I’ve ever experienced. The food was (literally) inedible, the staff was rude at worst, and completely uncaring at best. Finding hospitable restaurants with edible food was a chore. All that has changed. Even the basic supermarket food at Tesco or Sainsbury’s is a religious experience, compared to what is available in the US outside of major, cosmopolitan cities like New York and San Francisco. There is actually edible bread here in England (everwhere in England), good cheeses, and truly wonderful (not frozen) heat and eat meals which are better than most of the best restaurant fare in what has become the vast culinary wasteland that is now America. The evening dinner at the Palace Hotel was above average, and the wine flowed liberally, as did the conversation. So, if you want a seamless meeting experience where good food and accommodation substantially enhance the experience, come to the Manchester meeting.

I was blessed to sit at the dinner tables with CCM luminaries (Tom Bleck, Mitch Fink, Mervyn Singer, Jean Louis Vincent, and Christaain Boerma, among others) and now can say I’ve broken bread with someone who had tea with the Queen (quite a good story from Mervyn Singer from his medical school days). However, a real highpoint of the meeting for me was the two dinners Veerappan and his wife Mina hosted in their home. Veerappan and Mina are ethnic Tamil, and the region he and his wife come from in India was formerly known as Madras. Need I say more? If you have never heard the words “Madras Curry,” then, sadly, you have not yet eaten the food of gods. Both nights the fortunate guests were served home made Indian cuisine and allowed to mix and mingle in relaxed surroundings. Conversation was heavily oriented towards “shop talk” and it was apparent that most of the guests were very intellectually engaged. BTW, at least for me, lunches were the same, with my fellow diners showing both enthusiasm for, and preoccupation with, the medical topics of interest to them.

Alas, A. Liolios was not at this year’s meeting, so I spent my nights in the hotel instead of on wild expeditions around the city. Sadly, even a good book cannot compare with a 4-hour foot search for a good sushi restaurant and a up-end digital video camera retailer on a Saturday night in Manchester.

One lunch, regrettable hurried, was with Christiaan Boerma who did a beautiful presentation on the microcirculation. Christiaan is using orthogonal polarization spectral (OPS) imaging to create real-time motion pictures of the microcirculation f the intestine and sublingual mucosa of high resolution and clarity.

He has been able to do this on septic patients undergoing bowel resection, so, for the first time, we have been able to get a look at the microvilli in human sepsis.

The pictures were breathtaking. It is possible to see the arterioles, venules and capillaries as they dynamically perfuse the villi, and no still picture can even begin to do justice to the numerous video clips Christiaan showed during his presentation.

Indeed, the still photo above can be misleading if it is not understood that microcirculatory flow in septic animals (and the humans observed so far) is very heterogenous — some areas show normal or slightly aberrant autoregulation and flow whilst they situated only a few tens, or hundreds of microns, away from other areas where flow is severely compromised, or dysfunctional. Similarly, sublingual and intestinal mucosal blood flows, and blood flow patterns, may be very different from those observed in the microvilli of the same patient.

This microcirculatory dysfunction can be virtually abolished by administration of 0.5 mg of nitroglycerine (NGT) after appropriate fluid/pressure resuscitation:

This strongly suggests that the sludging and autoregulatory disturbances observed are NO mediated. Dobutamine had a dramatic negative effect on microcirculation, whereas, by contrast, Dobutrex (5 micrograms/kg/min) improved microcirculatory flow almost as much as NTG (De Backer,Crit Care Med 2006; 34:403-408.):

Clearly, being able to miniaturized this imaging system and deploy it endoscopically and laprascopically to dynamically monitor end organ perfusion/resuscitation could be invaluable. Not surprisingly, there is a strong correlation with outcome (survival) in successful versus unsuccessful resuscitation of the microcirculation (Trzeciak, Ann Emerg Med 2007; 49:88-98):

Review of the 2006 Critical Care Symposium

The Third Annual Critical Care Symposium sponsored by the Royal Oldham Hospital and organised and chaired by Dr. Chithambaram Veerappan and Dr Tracey Watt respectively was held on 27-28 April in Manchester, England. I have gone to countless conferences and meetings (as have most of you) and while most offer some reward, they are usually frustrating, and often intellectually lonely. Invariably you must choose between topics that interest you, and find yourself in a cavernous room with people you will not see again, and who have not shared your conference experience. The very best speakers are there just for a few minutes after their presentations (if you are lucky), and you must hurriedly think of, and ask, any questions you have.

This conference was a pleasure from start to end. The character and knowledge of the speakers was incredibly diverse and the topics covered could be explored in whatever tangent the attendees were interested in. The luncheon food was, without reservation, the best food I’ve ever had at any conference or meeting anywhere (and it was very good besides!). This food was great, the service superb, the coffee and tea hot and endless, and venue comfortable and welcoming. This was important because if you are annoyed with the venue or the food you may commiserate with other attendees, but you are less likely to be relaxed, comfortable, and ready for some serious and enjoyable conversation. This is the first conference I’ve attended where I was able to talk at whatever length I desired with all of the presenters and, not just about medicine, but also about everything. This was remarkable because the presenters were vastly experienced clinicians and researchers. All of the presenters were no-nonsense people with a profound respect for EMB.

The conference, as Dr. Stephen Streat, FRACP, (Clinical Director, Organ Donation, New Zealand) noted, was a marvelously diverse array of really interesting topics. In fact, Dr. Streat”s presentations, particularly his presentation on End of Life (EOL) and organ donation was fascinating and made me, and clearly many others, think of the issues surrounding obtaining consent for donation, and the ethical positions that underpin these processes in new ways.

Dr. Streat dissected the practice of repeatedly soliciting consent for donation using social, moral, ethical, and religious persuaders whose approaches are orchestrated in what can be interpreted as a coercive manner to “persuade” the next-of-kin to change their minds and give consent. Dr. Streat’s description of this tactic and the ethical assumptions that underlie it was very restrained. However the take-home-message was clear: organ donation should be a personal choice that respects the values of the family and the potential donor. Organ donation is not a moral duty and consent should be approached by offering it as an option not as moral or social imperative with shame and guilt attaching to a decision not to donate. Dr. Streat argued convincingly that it is the Intensivists’s role to ensure that coercive tactics are not brought to bear on grieving next-of-kin to pursue a social agenda.

There was basic science too, including a very accessible and useful talk by Professor Charles Hinds (Consultant/Lecturer at the William Harvey Research Institute at Bart’s and the London Hospital) on genomics in sepsis. Professor Hinds opened his presentation with a photograph of a rifle round the point being subsequently made that there is no magic bullet in sepsis.

This presentation explored the achievements and limitations in contemporary sepsis genomic research and detailed the programs under-way to systematically evaluate possible genetic makers that predispose patients to sepsis and may profoundly influence both survival and morbidity in patients who become septic. Professor Hinds has helped to establish the UK Critical Care Genomics Group, which is undertaking a large National investigation (GAinS www.ukccggains.org), as well as being National Coordinator for the European GenOSept study (www.esicm.org.) The GenOSept project involves 14 European countries and is targeted at four discrete kids of sepsis: fecal peritonitis, necrotizing pancreatitis, community acquired pneumonia, and meningitis. Focusing on well characterized subgroups of sepsis will allow for more meaningful interpretation of the data since the pathophysiology of sepsis is by no means uniform. These studies will serve as a tool to probe the mechanics of sepsis, understand the role of molecules elaborated during sepsis, and serve as a platform for development of rational, multimodal therapies. Professor Hinds is actively recruiting for centers for participation in both studies, welcomes new participants, and my be contacted at: c.j.hinds@qmul.ac.uk.

Dr. Antonios Liolios of Kos, Greece, had the most electric presentation of the conference, “Internet for the Intensivist” and surely the most sought after slides. Dr. Liolios must have had close to 180 slides which he covered in rapid succession. This slide set was invaluable as it provided links to dozens of not merely useful, but vital URLs. Almost everyone in the audience really wanted at least one of these slides/links. Dr. Liolios’ other presentation “Combat Critical Care and Transport” on battlefield critical care medicine was fascinating, grim, and showed a lot of things you don”t see or hear about on major news outlets. The images were incredible and reminded me powerfully of the images of the US Civil War, which also represented a paradigmshift in battlefield medicine. Every time medicine rises to the challenge of the lethality of the weapons in use, the weapons become even more horrible and deadly. Amboise Pare created the modern paradigm of rational surgery in response to the introduction of explosive shell into warfare (much more lethal and more injurious than arrows, pikes, lances and swords). The same increase in mutilation and lethality is driving medical technological innovation in this war.

A significant insight gleaned from Dr. Liolios’ presentation is that it seems likely intraosseous (IO) infusion will become a commonplace clinical modality in emergency and critical care medicine as the current generation of battlefield clinicians returns and brings this modality into common and often first-line. As Dr. Liolios’ noted, IO works, works well, saves lives that would otherwise be lost, and is simple and cost effective.

If you don’t have dedicated echocardiography in your ICU, be prepared to lose your first malpractice suit on this point in the very near future. Dr. Bernard Cholley, M.D., Ph.D., delivered an elegant talk on the “Role of Echocardiography in Shock Patients. This presentation served not only as a good introduction to the utility of echocardiography in making a rapid and accurate diagnosis (high or low CO? hypo or hypervolemia? Right or left heart? Adequate CO, location of infarcts, regional wall motion abnormality) but also powerfully brought home the point that minimally trained operators were consistently able to recognize and correctly characterize abnormalities. Dr. Cholley presented data showing that the risk of minimally trained operators making errors was less than that of errors resulting from relying on clinical data alone.

Because virtually all of the attendees were at virtually all of the talks it made for great cross-pollination and conversation and I found myself learning as much or more from talking with many of them as I did from the presenters.

Next year’s line up of speakers is simply stellar and this is a meeting not be missed, especially considering its uniquely intimate structure and unparalleled access to the speakers. Here are a few of the speakers: Dr. Tom Bleck (one of the world’s greatest neurointensivists), Professor David Crippen (pioneer of Internet medicine and critic of donation after cardiac death), Dr. Gordon Doig (with whom the acronym EMB is synonymous), Mitch Fink (new molecules for shock and sepsis), Dr. Can Ince (microcirculation and mitochondrial dysfunction), Dr. Mervyn Singer (one of the most influential and innovative investigators into the role of the mitochondria in the pathophysiology of sepsis), Dr. Claudia Teles ( international expert on coagulation and its role in sepsis),and Dr. Jean Louis Vincent (legend in critical care medicine with achievements and accolades too numerous to list). The 2007 conference should be the best yet.