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.