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‘The Big Sick’ 2023 Conference Review


Dr Ffyon Davies is back with a second guest blog, this time reviewing the "Big Sick" conference that recently took place in Zermatt, Switzerland.


"If it’s possible to feel starstruck at a medical conference, then that was me."


“The sickest patients, the first hours.”


Many readers may not have heard of ‘The Big Sick’ (TBS) conference, held annually in Zermatt, Switzerland. That’s because it’s a well-kept secret, by those in the know, requiring an application with your credentials and formal invitation to attend the conference. TBS is about ‘the sickest patient, the first hours’. It incorporates pre-hospital emergency medicine, emergency medicine, critical care and anaesthetics.


Due to this exclusive guest list, this is a relatively small conference of around 200 of the world’s top clinicians in these fields, which means it has an intimate and exclusive air to it.


It felt like the crème-de-la-crème of the critical care and PHEM worlds attended this conference, and the networking opportunities were immense.

But what’s the point of the exclusivity? A point that was made again and again during the conference was the high-level discussions and debates that can be had as a result of the experienced conference attendees and speakers.


“Quality medical conference meets skiing paradise.”


Not only is this an invite only medical conference. It’s a medical conference combined with skiing in one of the world’s top ski destinations in the shadow of the infamous Matterhorn. The conference is hosted by Air Zermatt, who operate a helicopter rescue and critical care service in the region, and whom you may recognise from the Netflix documentary ‘The Horn’.


With speakers such as Hugh Montgomery (OBE for his work in climate change campaigning), Richard Levitan (airway guru, @airwaycam), Mike Tipton (renowned physiologist), Sara Crager (EMRAP educator extraordinaire), Ross Fisher (P3 cubed website) and Jean Louis Vincent (ex-president ESICM, editor critical care) speaking on a variety of provocative and cutting-edge topics. 


At a Glance:

Location: Zermatt, Switzerland	Duration: 3 days	Cost: €900	CME: 27 CME hours

Topics: pre-hospital emergency medicine, critical care, emergency medicine, anaesthetics, medicine at the extremes, helicopter rescue, mountain rescue, the difficult airway, trauma, circulatory shock, medical presentations & education, major haemorrhage control, resuscitative thoracotomy, cold water immersion, training astronauts using extreme environments, climate change, crevasse rescue, avalanche rescue, hypoxic adaptations

Format: Mixture of lectures, workshops and demonstrations

Highlights: Air Zermatt dynamic winching demonstration, difficult airway workshops, networking and learning from practice around the world

Drawbacks: Cost, cost, cost. Zermatt is an expensive place!

Day 1 – Airway and Critical Care


MORNING

  • Hypoxic Adaptation. Prof Hugh Montgomery OBE

  • Microvascular Oxygen Delivery. Prof Knut Kvernebo

  • Early resuscitation of the septic patient. Jean Louis Vincent

  • Precision Vent Management. Sara Crager

  • Stop Complaining and Train. Domagoj Damjanovic

  • RSI in the adult patient: what about ventilation. Alexandre Jeleff

AFTERNOON

  • Workshops in Ultrasound in critical care

  • Skiing and networking.


The day continued with evening lectures and workshops on ‘The Difficult Airway’ from some of Europe’s and North America’s experts. Workshops included:


  • Cuirass ventilation (using a negative pressure chest cage to ventilate a patient)

  • SALAD approach to intubation (suction assisted laryngoscopy and airway decontamination)

  • The bloody bleeding airway awake intubation

  • Ultrasound guided chest drain

  • Finding the cricothyroid membrane (CTM) using Ultrasound

  • Inserting REBOA using VR headsets

  • Front of Neck Access and the worlds first……..female front of neck access model!


Day 2 – Circulation and Trauma


  • Rescuing the Right Ventricle – Sara Crager

  • Technologies for the Assessment of Circulatory failure – Knut Kvernebo

  • Misunderstanding the Pelvic Fracture – Gunnar Sandesjoo

  • Emergency Airways: Priorities not Algorithms – Richard Levitan

  • The Timeline of Lifesaving Interventions – Stacy Shackelford.

  • Presentations – the science of why we fail. Ross Fisher

  • The Place of Resuscitative Thoracotomy in Pre-Hospital Care. Zane Perkins

  • The importance of REBOA/Aortic clamp as a method of Cardiac Perfusion. Robbie Lendrum

  • The Wales Air Ambulance Perspective – Mike Palmer

  • The importance of Clinician-Led Dispatch – Joe Steer

Ross Fisher's session with the mountains providing a fantastic backdrop for some important lessons

https://en.wikipedia.org/wiki/Fondue
In the evening, we had a fondue shared with new friends! The first rule of Fondue club: lose the bread and you buy the next round!

Day 3 – Extremes

  • The Future Emergency Room. Jean Louis Vincent

  • Extremes of oxygen delivery in children. Jacob Karlsson

  • Sudden death and prolonged survival on immersion in cold water: lessons for rescue and resuscitation. Mike Tipton

  • The Pilots Perspective Air Zermatt,

  • Simulation as an Extreme Environment to Train Elite Providers: Using cave environments to practice simulation and team bonding in elite astronauts. Luca Carenzo

  • The End of the Thread. Changing our attitudes about when your patient is too sick to transfer Vahe Ender

  • A Climate to Fear. Hugh Montgomery.


We then relocated to Air Zermatt Base for some workshops and demonstrations.

  • Dynamic winch demonstration with their Bell helicopter

  • Crevasse rescue tripod

  • Avalanche rescue aerial to attach to a helicopter and search strategy

  • Medical Kit review

  • PAX stretcher review (this weighed only 14kg, with chemical heat pads and a vacuum mattress built in, ready to be hoisted with mechanical CPR ongoing)

  • Look around the rescue helicopter

  • Mechanical CPR with Corpuls (similar to a LUCAS device)


The Best bits and Key Learning Points

  1. Trauma surgeons can and do intubate in the US, and run the trauma team.

  2. Air Zermatt routinely RSI in flight, and employ dynamic winching to rescue the casualty.

  3. Ketones change your body’s metabolic pathways as part of our body’s adaptations to hypoxia.

  4. The right ventricle is the "princess ventricle" and needs to be treated as such.

  5. Individualise patient care and move away from algorithmic approaches.

  6. Severe hypoxia outweighs the risk of regurgitation in adult RSI.

  7. Kids are robust and will tolerate hypoxia well.

  8. Cold is protective in drowning and immersion.

  9. Resuscitative thoracotomy has a much greater success rate if done to relieve tamponade versus to control haemorrhage.

  10. A combination of microscope and spectroscopy may give us a much better idea of tissue hypoxia and may be used as a prognosticating tool in critically ill patients in the future.

  11. You can ventilate someone using negative pressure without intubation!

  12. Pelvic binders have never been shown to reduce pelvic bleeding…..patients die from bleeding, not pelvic fractures!

  13. If we fail to effectively deliver our presentation, we fail to educate our audience and we change nothing.

  14. The first 15 minutes is the most important in resuscitating a patient.

  15. The most important aspect of a crevasse or avalanche rescue is buddy rescue.


Conclusion

One of the most educational and enjoyable medical conferences I have ever attended, and a complete bonus that the schedule allows for a good amount of skiing. The main drawback was the cost – you’ll struggle to find beer for less than £8 in Zermatt! That being said, I will certainly be attending next year.




UPDATE: YOU CAN WATCH PRESENTATIONS FROM THE CONFERENCE FOR FREE BY FOLLOWING THIS LINK: https://scanfoam.org/tbs23/ 




Dr Davies is an A&E and expedition doctor based in Herefordshire. You can follow her on Instagram @ffyondavies





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