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Emergency Medicine Australasia (2014) 26, 426–429

doi: 10.1111/1742-6723.12287

SOCIAL MEDIA

The dry season is coming Rory SPIEGEL,1 Michelle JOHNSTON,2 Tor ERCLEVE3 and Christopher P NICKSON4 1 Department of Emergency Medicine, Newark Beth Israel Medical Center, Newark, New Jersey, USA; 2Emergency Department, Royal Perth Hospital, Perth, Western Australia, Australia, 3Department of Emergency Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia, and 4Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia

‘Two litres of normal saline stat!’ was the battle cry of early 21st century resuscitation. However, this Dispatch from the FOAM Frontier suggests that it was sadly misguided. In a missive examining the early history of FOAM, Professor Rimak, Head of the Federation’s Aquatic Conservation Unit, confirms that the inklings seeping through in those early days were more important than could have ever been imagined. The consequences would prove to be galactic.

Dispatch from Professor Rimak As far as I can see from this miserable office, where I sit day after long day, there is vast, endless, dry land. The view is punctuated by yellowing mounds, where most inhabitants have exiled themselves underground, but for the mainstay the vista is empty and covered with century old dust. This is the parched legacy our forebears have left us. This planet, like many others in the godforsaken outer rim, is desiccated and withered, partly because of the way our predecessors squandered fluid. I like to look at images from Old Earth, stuck up on my dusty wall, where there are green valleys, waterways, moss and sparkling pools, but when I turn to look outside, there is nothing but a desolate expanse, leathery and thirsty. This was, I guess, inevitable. Towards the dying days of Old Earth, before the Federation, fluids were frittered away – wasted and Rory Spiegel, MD, Emergency Medicine Resident; Michelle Johnston, FACEM, Emergency Physician; Tor Ercleve, FACEM, Emergency Physician; Christopher P Nickson, FACEM, Intensive Care Fellow.

discarded with lavish improvidence, not only on that planet, but across the bounds of interstellar space. It was only around the time of FOAM’s origin that questions began to be asked about the appropriateness of such profligacy. Too late, those of us living in the barren landscapes of today opine, too late. It is one thing to resuscitate a living organism, but it is another thing entirely to attempt to resuscitate a dying planet. A planet self-regulates, that is, evolves in somewhat of a steadystate, with its organisms and nonorganic matter developing in harmony, keeping the biosphere in equilibrium. This is, of course, disrupted when socalled intelligent beings tip the balance, hoiking it this way and that, wrenching the milieu about. With respect to the profligate dispensing of fluid, culprits have come in all shapes and sizes, yet among those most guilty were the emergency physicians and critical care practitioners of Old Earth. Their actions triggered an unforeseen chain of events. Yet it is so easy to see now, from here, in this wasted geosphere, how we have upset the balance. The story of where it all went wrong reveals itself when we revisit the key accusations that triggered a flurry of important conflicts during The Dogmalysis Wars.

Were we drowning the victims of trauma? Since the inception of the ATLS/EMST style of trauma management algorithm, a standardised 2 L of normal saline was de rigueur for any degree of hypovolemia, prior to shifting gears into blood and factor replacement. Although penetrating trauma was given a leave pass from this knee jerk reaction, it was still the fashion in blunt

trauma. However, these manuals, and this style of teaching, were eventually superseded by FOAM friendly, reactive and responsive courses for the management of trauma, such as @edexam’s Emergency Trauma Management (ETM) course1 and the Anaesthesia, Trauma and Critical Care (ATACC) course2 (whose manuals were freely downloadable in the true spirit of FOAM). The catch cry of fluid replacement by the ATACC team was ‘Preserve, don’t replace.’ These courses reacted quickly to the waves of thinking regarding over-resuscitation in trauma, and were able to absorb the most advanced understanding of the period. The leading edge of research at the time suggested that outcomes for acutely bleeding trauma patients were better or equivalent with lower volume resuscitation. One of the Hipsters of the FOAM movement (who was FOAMed before it was cool), was Karim Brohi, founder of Trauma.org.3 He was an authoritative voice on the role of excessive crystalloid in the induction of acute traumatic coagulopathy.4 The Eastern Association for the Surgery of Trauma (EAST) was also vocal, stressing that the evidence behind Old Earth’s bountiful use of crystalloid fluid was lacking.5 It seemed that the days of large volume crystalloid infusion in trauma, replacing blood with salt water, with its incumbent cold, coagulopathic, inflammatory, destructive, volume/ pressure spiking properties, were numbered. Yet, beyond the reaches of FOAM, word spread too slowly. Paradoxically, it took a fluid shortage to awaken many of us to the virtue of frugality. It was on the planet of Tatooine, that infamous and wretched hive of scum

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and villainy, where the fluid shortage first became apparent. Despite this distant rock having shrivelled, roasting under the uncoordinated passage of dual suns, for eons, it was always assumed that fluid for resuscitation would be available. However, an epidemic of blaster injuries, with the exceedingly rough spaceport bar of Mos Eisley at its epicentre, exposed the scarcity of fluid created by the licentious prescription of times past. This led to a Universal panic, which drove up the price of fluid, causing most thinking planets to reassess their wanton use in trauma and a long overdue and considered frugality. Trauma patients across the galaxies reaped the benefits.

Were we drowning the victims of sepsis? Early Goal Directed Therapy (EGDT)6,7 changed the face of sepsis management (this is what it was called in most of Old Earth, with variants known as Earl Grey Directed Therapy in parts of Virchester, 8 and SFAF on other planets in the Orion–Cygnus arm: Simultaneous Fluid, Antibiotics and Fruit). It introduced many concepts to emergency medicine, not the least of which were the early recognition of sepsis, bundled care and timely interventions. One facet of EGDT was abundant fluid administration, mainly in the form of crystalloid. Those charged with managing sepsis were encouraged to ‘turn on the taps’. What was interesting was that all inhabited planets used strikingly similar goals in the management of sepsis, despite the heterogeneity of causation (compare the humble E. Coli of Old Earth urosepsis with the metatoxinogenic Aurolactogrub species of Beta Centauri, the implications are obvious). More enlightening still, was the proof that no single race or species was able to accurately measure how much fluid was required by those struck with sepsis. All means of measurement, from the most primitive, to the most advanced machines, were faulty, leading to grievous overuse and wastage of fluids, not to mention significant morbidity, and one or two minor interplanetary wars. The interventions and goals themselves were also unproven. A number

of aspects were questioned following the introduction of EGDT (or SFAF if you prefer), and several large trials were conducted in their wake to further delineate which were the meaningful interventions. These are beyond the scope of this Dispatch. However, when the first of these Old Earth trials, the American ProCESS trial was published, denizens of the FOAM world lit up within hours,9–11 all contributing opinion and dissection of the results and their implications for practical day to day use. The consensus reached by the Federation following ProCESS was that overall mortality rates had plummeted in sepsis since the heady days of the landmark Rivers trial. However, this was most likely a result of using aggressive ‘bundled’ care, as opposed to specific interventions and targets encapsulated by a rigid protocol. Furthermore, some of the Rivers interventions (early central venous catheters and central venous saturation monitoring) might not be necessary at all. Old Earth still awaited the outcomes of the Australasian and British trials – ARISE and ProMISE, with the expectation that they would contribute further to this debate. Regarding fluid management, in the Rivers trial, the average 0–6 h fluid administration was a whopping 5 L, whereas in the ProCESS trial, it was reduced to an average of about 3 L in all groups. Historians take this as indicating that some much needed restraint was being shown as the policy of highly liberal fluid treatment fell away. At the time of my PhUD I was contacted by the critical care guild of the planet Arrakis, who were suffering the consequences of a rapidly dwindling fluid supply. Sandworms were on the rise, and any remaining fluid reservoirs were being encysted by Sandtrout. They expressed concerns that the excessive use of fluids on distant planets was contributing to their own inexorable drought, and wished for their distant cousins to show restraint in their crystalloid use. I was able to reassure them, that thanks to FOAM, knowledge translation was exponentially accelerating, and that best practice would soon spread like wildfire. It is a small Universe after all.

Is FEASTing on normal saline dangerous? The FEAST trial 12 set the critical care world buzzing, and FOAM flared like a supernova. 13 Although the generalisability of this study was questioned due to lack of ‘First World problems’ among its participants, the fact remained that the group of shocked children (just a type of diminutive human apparently) who were given crystalloid boluses had higher mortality. There are many postulated reasons, and many waterlogged pages of discussion and dissertation, but somewhere within is a dry kernel of uncertainty – can giving rapid fluid boluses of normal saline to shocked patients kill them? Other similar trials have been conducted in several of the other spiral arm planets (as a result of fluid supply failure, rather than good planning). The results thus far have been mixed and difficult to interpret, although some studies conducted on species less alien than children have replicated the results of FEAST. Until a definitive study is performed on latte-drinking adult Game of Thrones addicts, external validity will continue to be questioned.

Is it really all about the Glycocalyx? Although some worried about the potential for the Ebola virus to spread beyond its African confines, a more terrifying contagion began to ravage the primordial FOAM populace. The infectious agent was just a word, ‘Glycocalyx’, yet it brought with it frightening flashbacks to cellular physiology and First Part Days. The glycocalyx concept took a foothold in many FOAM outposts,14–16 which attempted to distill down the extraordinarily relevant first principles and explain why saline might sometimes be harmful. In essence, if the protective para-endothelial layer that is the glycocalyx is stripped away – by fluids, vessel stretch, electrolyte changes and stress, among many things – it might allow precious intravascular fluid to leak away, among other disruptions. This came as quite a shock to many, who had relied on the dogma

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that fluids simply filled up the intravascular space, and that the Starling mechanism for fluid shifts at the capillary level was sacrosanct. More disturbing was the fact that the Revised Starling Model was hardly a new concept,16 but come on, can it really all be about the glycocalyx?14

Is chloride a poison? The early days of FOAM saw the repropagation of the term ‘Abnormal Saline’, reminding us that chloriderich, nonbalanced electrolyte solutions might be more malign than benign.17–19 Of particular concern were the microcirculatory and renal effects of hyperchloremic acidosis. Some of the excitement was triggered by a study in JAMA 20 showing an association between chloride-rich fluid administration and acute kidney injury. However, some21 cautioned that there was still more to be known, and that this JAMA study was confounded by the complete absence of gelofusin in the chloride poor group . . . and every FOAMite knows that synthetic colloids hurt kidneys. The answer was, at this point, still years away. Meanwhile, back in Virchester, the St Emlyns crew reviewed the NICE guidelines, which put some of these issues into perspective.22 This looked not only at the use of crystalloids in the resuscitation setting, but all use of fluids in the ED. The message, waving its hands out of the sea to gain notice, was that greater attention needed to be paid to type, amount and monitoring of fluid administration, in all settings, in order to reduce harm.

Denouement The flood of normal saline, like a waterfall after the wet season, was beginning to dry out. All over Old Earth, critical care practitioners were questioning and rationing the deluge of crystalloids that was the hallmark of previous decades. But, for some of us here in the Outer Rim, and beyond, it was too late. Like climate change on Old Earth, an inexorable warming and dehydration of the continental interiors, things had been set in motion. Gaia’s tears had dried up.

As I turn around once more to look across the baking lands of my home, I can see the crumbling pipes of the moisture vapourators. They are ineffective, and ill-maintained. If only I could find a droid who understands the binary language of vapourators, but alas, they are in short supply. I often muse upon those days long ago, when fluids were bandied around, gushing with abandon, and wonder, would we have ended up this way, if the use of crystalloid had been tempered earlier? Is there an alternative universe out there, which took heed of the burgeoning global discussions and conversations, and saved itself from this dehydrated fate? Professor Paubro Rimak, PhUD Hydropaleontologist Aquatic Conservation Unit Federation of Outer-rim Allegorical Migrants, Academic Division Dispatch complete.

Competing interests RS, MJ, TE and CPN are section editors for Emergency Medicine Australasia.

References 1. Emergency Trauma Management (ETM) course. [Cited 4 Aug 2014.] Available from URL: http:// etmcourse.com 2. Anaesthesia, Trauma and Critical Care (ATACC). [Cited 4 Aug 2014.] Available from URL: http://www .atacc.co.uk/ 3. Trauma.org. [Cited 4 Aug 2014.] Available from URL: http://trauma .org/ 4. Brohi K. Not all bleeding stops: acute coagulopathy of trauma. Intensive Care Network. [Cited 29 Aug 2014.] Available from URL: http:// intensivecarenetwork.com/bleeding -stops-acute-coagulopathy-trauma -brohi/ 5. Cotton BA, Jerome R, Collier BR et al. Guidelines for prehospital fluid resuscitation in the injured patient. J. Trauma 2009; 67: 389–402. [Cited 4 Aug 2014.] Available from URL: https://www.east.org / resources / treatment-guidelines/prehospital -fluid-resuscitation-in-the-injured -patient

6. Rivers E, Nguyen B, Havstad S et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N. Engl. J. Med. 2001; 345: 1368–77. 7. Nickson CP. Early goal directed therapy in septic shock. LITFL [Cited 4 Aug 2014.] Available from URL: http://lifeinthefastlane.com/ccc/early -goal-directed-therapy-in-sepsis/ 8. Carley S, May N, Grayson A et al. The mess in Virchester. [Cited 4 Aug 2014.] Available from URL: http:// www.smacc.net.au/2012/12/the-mess -in-virchester/ 9. Weingart SD. Podcast 120 – the ProCESS trial with Derek Angus. EMCrit. [Cited 4 Aug 2014.] Available from URL: http://emcrit.org/ podcasts/process-trial/ 10. Milne K. SGEM#69: cry me a river (Early Goal Directed Therapy) ProCESS trial. [Cited 4 Aug 2014.] Available from URL: http:// thesgem.com/2014/04/sgem69-cry - me - a - river-early - goal - directed -therapy-process-trial/ 11. Robillard J, Nickson CP. The ProCESS trial. INTENSIVE. [Cited 5 Aug 2014.] Available from URL: http://intensiveblog.com/process -trial/ 12. Maitland K, Kiguli S, Opoka RO et al. Mortality after fluid bolus in African children with severe infection. N. Engl. J. Med. 2011; 364: 2483–95. 13. Senthi A. The FEAST study. [Cited 5 Aug 2014.] Available from URL: http://www.emergucate.com/the -feast-study/ 14. Cohen J. Is it really all about the glycocalyx? LITFL. 2014. [Cited 5 Aug 2014.] Available from URL: http://lifeinthefastlane.com/is-it-reallyall-about-the-glycocalyx/ 15. Weingart SD. Podcast 111 – fluids in sepsis, a new paradigm – Paul Marik. EMCrit. [Cited 5 Aug 2014.] Available from URL: http:// emcrit.org/podcasts/paul-marik -fluids-sepsis/ 16. Nickson CP. Glycocalyx in critical illness. LITFL. [Cited 5 Aug 2014.] Available from URL: http:// lifeinthefastlane.com/ccc/glycocalyx -in-critical-illness/ 17. Story D. Is chloride a poison? Intensive care network. [Cited 5 Aug 2014.] Available from URL: http://

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intensivecarenetwork.com/story-is -chloride-a-poison/ 18. Myburgh J. Resuscitation fluids: which, when, and how much? Intensive Care Network. [Cited 5 Aug 2014.] Available from URL: http://intensivecarenetwork . com / 633 - smacc - john - myburgh - fluid -resuscitation - which - when - and -how-much/ 19. Reid C. What’s with all the salt? An assault on chloride. Resus.ME. [Cited

5 Aug 2014.] Available from URL: http://resus.me/whats-with-all-the -chloride-an-assault-on-salt/ 20. Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA 2012; 308: 1566–72. 21. Nickson CP. Chloride and kidneys. FOAMcc G+ Community. [Cited 5

Aug 2014.] Available from URL: https://plus . google . com/ + Chris Nickson/posts/5iBDyMgTbs3 22. How is this relevant to EM? St Emlyns. 2014. [Cited 5 Aug 2014.] Available from URL: http:// stemlynsblog.org/new-nice-guidance -intravenous-fluid-therapy-adults -hospital-relevant-em/

From the Editor Many of you may be wondering why the Social Media section is called just that, when all we have published to date under this banner are messages arriving from deep space from our intergalactic colleagues. Social Media was selected for the title (and not FOAMed) because it is a signal of intent that more material (digital or hard copy) will be published here. This month we start this expansion with a video link (see below) – the title and theme of which need no explanation from me. We want to encourage you to contact us if you wish to submit some material which you think may fit here, be it a video link, a blog or a podcast. There is nothing whatsoever new in this approach in the world of 21st century publishing – but the journal does need material to develop it further. We look forward to hearing from you. Link: https://vimeo.com/101121845, password: foam Geoff HUGHES Editor-in-Chief doi: 10.1111/1742-6723.12310

© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

The dry season is coming.

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