The Critical Debrief

🎞️ Episode Synopsis (AI) Shreyas launches Ask Pramod, a new series under The Critical Debrief in which we walk through Pramod's research and discuss clinical application. In this first episode we discuss sedative drug overdose and evaluate if there are features of the early clinical assessment that can reliably predict the outcome? Keen to learn more from Pramod? Pre-order his new book " Clinical Examination in Critical Care Medicine " - a gamechanger for teaching clinical assessment skills in the critical care disciplines! All proceeds go to our emergency medicine education charity Network Five Emergency Medicine! ⏱️ Episode Timestamps 00:00 — Disclaimer and intro 00:28 — Welcome — introducing the Ask Pramod series 00:50 — The paper: why the question, the cohort, and the findings 05:51 — Interpreting the pH 7.20 threshold 08:49 — The NICO trial, the six-hour observation strategy, and Australian practice 16:38 — At the bedside: airway mechanics, blood gases and drug factors 20:51 — Next steps, and sign-off 📚 References & Resources (in order of discussion) Chandru P, Schriber K, Brasted HBF, Butler E, Gunja N (2026) — Risk Factors Associated with Deterioration in Sedative Drug Overdose. Journal of Medical Toxicology. 2026;22(2):296–304. 🔗 doi.org/10.1007/s13181-026-01120-0 ⏱️ ~00:50 The paper under discussion. Retrospective cohort of 374 patients referred to a district toxicology service with suspected sedative overdose, November 2022 – November 2023. Common agents: benzodiazepines 32.1%, opioids 29.1%, GHB 20.6%. In-hospital complications 35.8%, ICU admission 17.9%, intubation 13.6%. ICU admission independently associated with lower venous pH and non-benzodiazepine GABA-ergic ingestion (adjusted OR 3.35, p = 0.04); in-hospital complications with opioid ingestion (adjusted OR 3.81, p < 0.001) and lower GCS. Modelled probability of intubation rose from 8% at pH 7.35 to 66% at pH 7.20. PMID 41792544. Agency for Clinical Innovation, Emergency Care Institute — The Australian and New Zealand Emergency Department Airway Registry (ANZEDAR). 🔗 ACI Emergency Care Institute — Airway Registry ⏱️ ~01:32 The multicentre ED intubation registry referred to on air. Collects indication for intubation, first-pass success and complication rates across Australian and New Zealand EDs. Note: the specific proportion of ED intubations attributable to poisoning quoted in the discussion could not be verified against a published registry output and should be treated as the speaker’s recollection. Freund Y, Viglino D, Cachanado M, et al. (2023) — Effect of Noninvasive Airway Management of Comatose Patients With Acute Poisoning: A Randomized Clinical Trial (NICO). JAMA. 2023;330(23):2267–2274. 🔗 doi.org/10.1001/jama.2023.24391 ⏱️ ~08:49 The French trial discussed. Multicentre randomised trial across 20 emergency departments and 1 ICU, comatose patients with suspected acute poisoning and GCS < 9, May 2021 – April 2023. 225 patients (mean age 33); intubation 16% in the conservative arm vs 58% with routine practice; no in-hospital deaths. Primary outcome was a hierarchical composite of in-hospital death and ICU and hospital length of stay, favouring the conservative strategy (win ratio 1.85, 95% CI 1.33–2.58). Two corrections to the on-air description: this was a superiority trial using a win-ratio composite, not a non-inferiority study; and alcohol was the implicated toxin in 67% of cases, higher than the 40–50% recalled. The trial also excluded single-agent opioid and benzodiazepine ingestions, which strengthens rather than weakens the generalisability argument made in the episode. Pellatt RAF, Isoardi K, Keijzers G (2023) — Intubation for patients with overdose: Time to move on from the Glasgow Coma Scale. Emergency Medicine Australasia. 2023;35(4):702–705. 🔗 doi.org/10.1111/1742-6723.14254 ⏱️ ~10:28 The Emergency Medicine Australasia piece credited with prompting the study. Authors are from Gold Coast University Hospital, LifeFlight Retrieval Medicine and Princess Alexandra Hospital; Katherine Isoardi is a clinical toxicologist. It is an Opinion article rather than a letter to the editor. It proposes observation where toxicity is suspected to be short-lived — under 6 hours, or 8–12 hours depending on setting and resources — with airway reassessment if there is deterioration or coma persists beyond 6 hours. Note: the article text does not state an explicit pH 7.20 cutoff as a red flag; the speaker hedged on this point on air and it should not be attributed to this paper. Background reading (not cited by name on air) Schaffer AL, Busingye D, Chidwick K, Brett J, Blogg S (2021) — Pregabalin prescribing patterns in Australian general practice, 2012–2018: a cross-sectional study. BJGP Open. 2021;5(1). doi.org/10.3399/bjgpopen20X101120 Context for the PBS listing point raised in the episode: pregabalin was subsidised on the PBS for neuropathic pain in 2013, after which prescribing and related harm rose substantially. No specific source was named on air. Also mentioned ‘GCS 8, intubate’ — the traditional teaching the episode argues against; no single source cited on air. Pramod Chandru’s forthcoming book on clinical assessment in critical care — pending publication, no citation available. The local clinical toxicology service now available to Nepean Hospital clinicians. Victorian epidemiological data on rising sedative overdose rates — referred to in general terms; no specific study was named and none has been cited here. 📬 Contact the Team We value your feedback and would love to hear the questions you want put to Pramod. Email us at hello@n5em.com

(AI) What is clinical event debriefing, how does it differ from the simulation debriefing we all know, and how do you actually make it routine in a busy ED? Emergency clinicians Prof Walter Eppich and A/Prof Andrew Coggins join host Kit Rowe and the team for a deep dive. The panel works through what "clinical event debriefing" (CED) really means and how it differs from simulation debriefing: it follows a real patient event, is rarely planned, and often happens when the team is most emotionally activated. A central thread is aligning intention with impact — distinguishing debriefing to learn, to manage, and to treat, and the risks of drifting into psychological treatment without the training for it. The bigger missed opportunity, they argue, is reserving debriefing only for catastrophic events, when routine, brief, learning-oriented debriefs build the skills and psychological safety a team needs before the critical case arrives. Along the way: who should facilitate (and why it shouldn't default to the team leader), end-of-shift check-ins, "coffee and cases," M&M as after-action review, retrieval-medicine debriefing, and the support gap facing senior clinicians — "who debriefs the debriefers?" The consistent takeaway: pick a simple framework and use it, keep it short, lead with shared understanding and humility, and just start debriefing. Host: Kit Rowe | Panel: Pramod Chandru, Caroline Wilson | Guests: Prof Walter Eppich (University of Melbourne), A/Prof Andrew Coggins (Westmead) ⏱️ Episode timestamps 00:00 – Disclaimer 00:13 – Intro music 00:30 – Welcome and panel introductions 02:08 – Opening question: what is clinical event debriefing? 03:04 – CED vs simulation debriefing; the after-action review and its origins 04:36 – Key differences: a real patient, usually unplanned, compressed time 09:09 – Is CED only for "sinister" events? Reconciling experience with its potential role 11:05 – Learning vs caring for traumatised staff; aligning intention and impact 14:51 – Support at 3am without a psychologist: psychological first aid (look, listen, link) 16:59 – The learn–manage–treat spectrum; the COVID-era genesis of the BMJ paper 21:46 – Who should lead a debrief? Charge-nurse facilitation; self-led teams 27:34 – Debriefing the shift rather than the single event; translational simulation 30:16 – The STOP5 hot-debrief tool 30:47 – What to ask in a routine end-of-shift debrief 32:08 – Pramod's case (fat embolus, cardiac arrest); "who debriefs the debriefers?" 33:21 – Andrew's observational study; check-ins and building psychological safety 35:44 – Peer support and the loss of community on becoming a consultant 38:53 – Making sense of an event with a trusted colleague 41:28 – Preparing peers to debrief each other; ongoing research collaboration 43:46 – Community of practice; separating coaching/mentorship from debriefing 46:03 – Walter's case story: an overnight paediatric tragedy and an informal debrief 48:35 – Structure and frameworks: use one, keep it simple; humility as a leader 51:01 – Shared understanding and ground rules as the core of a safe debrief 52:00 – M&M as after-action review; "outcome review" and ground rules 54:11 – Debriefing in retrieval medicine; "coffee and cases" 56:02 – "Just start debriefing"; systematic review of tools; the INFO tool; the seatbelt analogy 58:56 – Wrap-up: take-home messages from the panel 59:47 – Briefing and debriefing synergy; team reflection research 1:01:14 – Sign-off 📚 References & resources (in order of discussion) Kolbe M, Schmutz S, Seelandt JC, Eppich WJ, Schmutz JB (2021). Team debriefings in healthcare: aligning intention and impact. BMJ . 2021;374:n2042. https://doi.org/10.1136/bmj.n2042 (~11:05) Keiser NL, Arthur W Jr (2021). A meta-analysis of the effectiveness of the after-action review (or debrief) and factors that influence its effectiveness. Journal of Applied Psychology . 2021;106(7):1007–1032. https://doi.org/10.1037/apl0000821 (~11:44) Keiser NL, Arthur W Jr (2022). A meta-analysis of task and training characteristics that contribute to or attenuate the effectiveness of the after-action review (or debrief). Journal of Business and Psychology . 2022. https://doi.org/10.1007/s10869-021-09784-x (~11:54) Rose S, Cheng A (2018). Charge nurse facilitated clinical debriefing in the emergency department (the INFO tool). CJEM . 2018;20(5):781–785. https://doi.org/10.1017/cem.2018.369 (~22:24) Walker CA, McGregor L, Taylor C, Robinson S (2020). STOP5: a hot debrief model for resuscitation cases in the emergency department. Clinical and Experimental Emergency Medicine . 2020;7(4):259–266. https://doi.org/10.15441/ceem.19.086 (~30:16) Coggins A, De Los Santos A, Zaklama R, Murphy M (2020). Interdisciplinary clinical debriefing in the emergency department: an observational study of learning topics and outcomes. BMC Emergency Medicine . 2020;20(1):79. https://doi.org/10.1186/s12873-020-00370-7 (~33:21) Petrosoniak A, Gabriel J, Purdy E (2022). Stop asking if it works, start making it happen: exploring barriers to clinical event debriefing in the ED. CJEM . 2022;24(7):673–674. https://doi.org/10.1007/s43678-022-00396-9 (~56:28) Phillips EC, Smith SE, Tallentire VR, Blair S (2024). Systematic review of clinical debriefing tools: attributes and evidence for use. BMJ Quality & Safety . 2024;33(3):187–198. https://doi.org/10.1136/bmjqs-2022-015464 (~57:14) Schmutz JB, Lei Z, Eppich WJ (2021). Reflection on the fly: development of the Team Reflection Behavioral Observation System (TuRBO) for acute care teams. Academic Medicine . 2021;96(9):1337–1345. https://doi.org/10.1097/ACM.0000000000004105 (~59:47) Background reading (referenced in planning; not discussed on air) Kessler DO, Cheng A, Mullan PC. Debriefing in the emergency department after clinical events: a practical guide. Ann Emerg Med . 2015;65(6):690–698. https://doi.org/10.1016/j.annemergmed.2014.10.019 Gillen J, Koncicki ML, Hough RF, et al. The impact of a fellow-driven debriefing program after pediatric cardiac arrests. BMC Medical Education . 2019;19:272. https://doi.org/10.1186/s12909-019-1711-y Also mentioned INFO attitudes study — Rose SC, Asna Ashari N, Davies JM, Solis L, O'Neill TA. Interprofessional clinical event debriefing—does it make a difference? CJEM . 2022;24(7):695–701. https://doi.org/10.1007/s43678-022-00361-6 Victoria Brazil (Bond University) — translational simulation Rebecca Szabo — end-of-list debriefing in operating theatres Paul Mullen — structures and logistics for debriefing Frameworks named in passing: PEARLS, TALK, REFLECT; and the "advocacy–inquiry" technique

Three rapid clinical updates — tenecteplase for stroke, the danger of overshooting blood pressure after ICH, and the new Surviving Sepsis guidelines ACEP won’t endorse — then The Pitt S1E03 on death, grief, hot debriefs and caring for culturally diverse patients in the ED. Hosts: Dr Shreyas Iyer, Dr Caroline Wilson, Dr Pramod Chandru, Dr Mariez Gorgi 🎞️ Episode Synopsis (AI) The team opens with three rapid clinical updates. Caroline covers the shift in acute ischaemic stroke care towards tenecteplase as the preferred thrombolytic in place of alteplase, prompted by the NSW ACI clinical practice guide, and discusses the extended 4.5–9 hour and wake-up stroke windows, the role of perfusion imaging, and the value of the Telestroke service in regional NSW. Pramod presents a recent paper showing that overshooting blood pressure targets after intracerebral haemorrhage is associated with worse outcomes, using it as a springboard into a broader, sceptical discussion of evidence standards, trial design, and the harms of overzealous blood pressure lowering. Pramod closes the updates with breaking news: the release of the 2026 Surviving Sepsis Campaign guidelines and ACEP’s decision not to endorse them, unpacking the three stated concerns. The conversation then turns to The Pitt’s third episode, which the team uses to explore death and grief in emergency practice — first deaths, the weight of decision-making as a junior, and the experiences that stay with clinicians for years. They examine the role and limits of the hot debrief, how senior and junior staff draw different value from it, and practical ways to look after a team after a difficult case. The episode finishes on the show’s portrayal of an interpreter transforming care for a culturally and linguistically diverse patient, and the team’s reflections on advocating for diverse communities in a time-pressured ED. ⏱️ Episode Timestamps 00:00 — Disclaimer & intro 00:28 — Welcome & introductions (first-time guest Mariez Gorgi) 01:06 — Update 1: Stroke thrombolysis — Tenecteplase replacing alteplase (Caroline) 11:43 — Update 2: Blood pressure control after ICH — overshooting and harm (Pramod) 21:30 — Update 3: 2026 Surviving Sepsis guidelines & ACEP non-endorsement (Pramod) 25:48 — The Pitt S1E03 — episode recap (Mariez) 27:51 — Death & grief in emergency medicine 42:31 — Hot debriefs: value, pitfalls, and looking after staff 57:12 — Interpreters & culturally and linguistically diverse patients 62:20 — Wrap-up & what’s coming 📚 References & Resources (in order of discussion) NSW Agency for Clinical Innovation (February 2026) — Intravenous thrombolysis for adult patients with acute ischaemic stroke: clinical practice guide. 🔗 ACI clinical practice guide (PDF) ⏱️ ~01:06 Names tenecteplase as the preferred first-line IV thrombolytic; alteplase remains an effective TGA-approved alternative. Also addresses the extended 4.5–9 hour / wake-up window (beyond 4.5 h is outside TGA approval and reserved for specialist-led decisions). Primary source for Caroline’s update, including the small functional-outcome benefit cited from its underpinning evidence base. Shi AC, Taylor T, Huang C-C, Singhal AB, Goldstein JN, Bevers MB, Hou PC (2025) — Early Intensive Blood Pressure Reduction After Intracerebral Hemorrhage Is Associated With Worse Functional Outcome: The Risk of Overshooting Blood Pressure Goals. Annals of Emergency Medicine. 🔗 Annals of Emergency Medicine ⏱️ ~11:43 Retrospective cohort (two academic centres, 2017–2023). Overshooting to <120 mmHg systolic associated with worse functional outcome — the paper Pramod presents. Anderson CS, et al. (2013) — Rapid Blood-Pressure Lowering in Patients with Acute Intracerebral Hemorrhage (INTERACT2). New England Journal of Medicine. 🔗 NEJM ⏱️ ~15:24 Foundational RCT on early intensive BP lowering in ICH. INTERACT3 (Lancet 2023) and the Moullaali et al. preplanned pooled individual-patient-data analysis (referenced as “a pooled analysis”) extend this evidence base. Préterre C, Gaultier A, Obadia M, et al. (2025) — Intravenous alteplase versus oral aspirin for acute central retinal artery occlusion within 4·5 h of severe vision loss (THEIA): a multicentre, double-dummy, patient-blinded and assessor-blinded, randomised, controlled, phase 3 trial. The Lancet Neurology. 🔗 The Lancet Neurology ⏱️ ~16:40 The trial Pramod uses to illustrate trial-design and power pitfalls. Visual-acuity improvement was 66% with alteplase vs 48% with oral aspirin — an ~18-point difference that did not reach significance, in a trial the authors judged underpowered (improvement in both arms ran well above the ~40% vs ~10% the study was designed to expect). Surviving Sepsis Campaign (2026) — Prescott H, Antonelli M, Alhazzani W, et al. International Guidelines for Management of Sepsis and Septic Shock 2026. Critical Care Medicine / Intensive Care Medicine. 🔗 Surviving Sepsis Campaign 2026 (SCCM) ⏱️ ~21:30 The new SSC guidelines; for the first time, separate adult and paediatric documents — central to the discussion. American College of Emergency Physicians (2 February 2026) — ACEP Will Not Endorse New Sepsis Guidelines from the Surviving Sepsis Campaign. 🔗 ACEP statement ⏱️ ~21:48 ACEP’s formal statement citing three concerns: conflicting adult vs paediatric guidance, guidelines not reflecting the reality of emergency care, and the absence of emergency-physician governance in the SSC. The Pitt — Season 1, Episode 3 (Max, 2025). ⏱️ ~25:48 The episode under discussion; basis for the death/grief, hot-debrief and interpreter themes. 📬 Contact the Team We value your feedback and would love to hear from you! Email us at hello@n5em.com

🎙️ The Critical Debrief – The Pitt S1E02 Debrief Duration: ~65 minutes Hosts: Shreyas Iyer, Pramod Chandru, Caroline Wilson Topic: Clinical updates in cardiology, antimicrobial stewardship, and febrile infants, followed by a case-based discussion of The Pitt Episode 2. Show notes generated with AI assistance. 🎞️ Episode Synopsis (AI) In Episode 2, the team explores ACS updates, AI ECG interpretation, antibiotic stewardship, and febrile infant risk stratification. The second half applies these principles through a discussion of The Pitt Episode 2, focusing on ethical decision-making, paediatric toxicology, mandatory reporting, and airway management in trauma. ⏱️ Episode Timestamps 00:00 – Intro / housekeeping 02:04 – Cardiology update: ACS, OMI concepts 10:28 – AI ECG (Queen of Hearts) 18:42 – Antibiotic duration 26:10 – Febrile infants (61–90 days) 35:23 – The Pitt Episode 2 recap 39:50 – End-of-life care 46:30 – Paediatric THC ingestion 54:40 – Mandatory reporting 1:02:10 – Airway management in trauma 📚 References & Resources (in order of discussion) 1. Heart Foundation & CSANZ (2025) – ACS Guideline - https://www.heartfoundation.org.au/for-professionals/acs-guideline-overview - Referenced during ACS discussion; outlines modern troponin and risk pathways. 2. Meyers HP et al. (2025) – Accuracy of cath lab activation decisions for STEMI-equivalent and mimic ECGs: Physicians vs. AI (Queen of Hearts by PMcardio) - https://pubmed.ncbi.nlm.nih.gov/40763602/ - Validation study of Queen of Hearts AI detecting occlusion MI. 3. Zahavi A et al. (2025) – Short vs. long antibiotic treatment for pyelonephritis and complicated urinary tract infections: a living systematic review and meta-analysis of randomized controlled trials - https://pubmed.ncbi.nlm.nih.gov/40228579/ - Short-course antibiotics non-inferior for pyelonephritis. 4. Aronson PL et al. (2025) – Prediction Rule to Identify Febrile Infants 61–90 Days at Low Risk for Invasive Bacterial Infections - https://publications.aap.org/pediatrics/article-abstract/156/3/e2025071666/203219/Prediction-Rule-to-Identify-Febrile-Infants-61-90?redirectedFrom=fulltext - Low-risk stratification for febrile infants. 5. Aronson PL et al. (2025) – Risk of Bacterial Infections in Febrile Infants 61 to 90 Days Old With Respiratory Viruses - https://publications.aap.org/pediatrics/article-abstract/156/1/e2025070617/202105/Risk-of-Bacterial-Infections-in-Febrile-Infants-61?redirectedFrom=fulltext - Lower bacterial infection risk in viral-positive infants. 6. Pantell RH et al. (2021) - https://publications.aap.org/pediatrics/article/148/2/e2021052228/179783 - Foundational AAP febrile infant guideline. 7. Wang GS et al. (2016) - https://jamanetwork.com/journals/jamapediatrics/fullarticle/2534480 - Paediatric cannabis toxicity data. 8. NSW Mandatory Reporter Guide - https://dcj.nsw.gov.au/children-and-families/protecting-our-kids/mandatory-reporters/mandatory-reporters--what-to-report-and-when/the-mandatory-reporter-guide--mrg-.html - Framework for reporting child safety concerns. 9. Difficult Airway Society Guidelines - https://das.uk.com/guidelines/das_intubation_guidelines/ - Principles of difficult airway management. 10. ATLS – American College of Surgeons - https://www.facs.org/quality-programs/trauma/atls/ - Trauma airway management principles. 📬 Contact the Team 📧 hello@n5em.com We’d love your feedback or suggestions!

🎙️ Episode 1: The Pitt Debrief Duration : ~74 minutes Hosts : Shreyas, Pramod, and Caroline Topic : Podcast relaunch, clinical updates, and our review and take-homes from The Pitt , Episode 1. Show notes generated with AI assistance. 🎞️ Episode Synopsis In this debut of The Critical Debrief , the team reflects on personal changes and the transition from Network 5 to a more independent, creative podcasting approach. The core of the episode unpacks the clinical realism and challenges featured in The Pitt , using it as a springboard for nuanced discussions about real emergency medicine, ethics, teamwork, and clinical procedures. ⏱️ Episode Timestamps 00:00 – Intro 14:00 – Updates segment: Staff turnover and patient mortality 23:00 – Chance fractures in children 38:00 – NGT insertion in children – NSW Health policy 45:00 – Main segment: The Pitt – Is it real? 50:00 – Involuntary detention – ethics and law 57:00 – Hyperkalaemic arrest 1:05:00 – Tamponade and pericardiocentesis 1:12:00 – Rhabdomyolysis and renal failure 📚 References & Resources (in order of discussion) 1. BMJ Open (2023) – Nurse and doctor turnover and patient outcomes in NHS acute trusts in England 🔗 Nurse and doctor turnover and patient outcomes in NHS acute trusts in England: retrospective longitudinal study | The BMJ ⏱️ ~14:00 2. Meta-analysis: Intra-abdominal injuries in Chance fractures 🔗 A meta-analysis of the incidence of intra-abdominal injuries associated with thoracic or lumbar flexion-distraction injuries - PubMed ⏱️ ~23:00 Summary of 8 retrospective studies (no direct source linked) Key figure: 55% intra-abdominal injury rate in paediatrics 3. NSW Health Policy (2025) – Nasogastric and Orogastric Tube Insertion and Management in Neonates, Infants and Children 🔗 Nasogastric and Orogastric Tube Insertion and Management in Neonates, Infants and Children ⏱️ ~38:00 Confirm NGT position based on pH < 4 with approved strips X-rays not routinely required 4. The Pitt – TV Series ⏱️ ~45:00 Used as a case-based teaching tool for this episode Discussion includes realism, pace, portrayals of ED culture 5. NSW Mental Health Act (2007) 🔗 https://legislation.nsw.gov.au/view/html/inforce/current/act-2007-008 ⏱️ ~50:00 Discussed in the context of involuntary detention criteria 6. NSW Capacity Toolkit 🔗 Capacity Toolkit | Communities and Justice ⏱️ ~50:00 7. ACI Emergency Procedures App 🔗 https://app.emergencyprocedures.org/ ⏱️ ~1:05:00 Referenced during the pericardiocentesis segment Contains guidance, videos, and checklists 8. Press Ganey Patient Satisfaction Scores 🔗 https://www.pressganey.com/ 🔗 JAMA Study – Fenton et al. (2012) ⏱️ ~47:00 Debated as a metric for quality care Study showed association with increased hospitalisation and mortality 📬 Contact the Team We’d love your feedback or suggestions! 📧 hello@n5em.com Want to hear about a paper? Have a topic that you want us to discuss? Let us know — your ideas shape this podcast!