Blog

J Doyle from United Kingdom wrote 06-16-2016 07:18:27 am
Day 2 smaccdub by Dr Monica Minardi

Resa Lewiss
Leadership not (just) for men

Identify your unconscious bias. Pregnancy is not a disability..
Do your homework, read about gender inequality.

Why is it so difficult to enable women into leadership jobs despite the change in the agenda.
What can a junior doctor do when seeing a senior misbehaving with regard to gender discrimination?

Ross Fisher
Paed surgeon
Things that scare me
Preterm 26 wks with severe acidemia and NEC. Bleeding in a neoonate is a real problem everything bleeds. Circulating blood is 60 ml in a 600 gr neonate. I stood there about to operate.
I was operating on a Wilms tumor. The tumor was very big what scares you? What are the things which we are afraid about. It is ok to be afraid because this is recognising that there are limits.fear is different from stress. Stress is part of what we do, we need a degree of stress to maximise our performance. Fear is different. When we are afraid the pounding in your head , the breathing is fast, you are unable to think properly. You cannot make decisions. Fear lives in the amigdala. Medical fear is something we have learned is not the kind of fear we have in other situations.
Fear affects us acutely but also affects people around us. The reasons the things go wrong is not because of lack of training or knowledge. It is because of fear. Whatever job we do there are things we are afraid of. In recognising what I’ve done in the past has helped me not to be afraid any longer. Hippocampus moderates the fear from the amigdala, but it is also the place where we remember how bad it was that experience of fear. Fear is bad if we don’t recognise it. If you are afraid the best thing is someone standing up with you. We recognise the brutality of what we do and the humanity of what we do. I m no longer afraid of the neonate who can bleed to death because of people who stood with me. 'I m no longer afraid'. Great talk, many thanks Mr Fisher.

Reuben Strayer
Disruption, danger and droperidol: EMergency management of the agitated patient.

What patient defines Emergency Medicine? Undifferentiated acute agitation is a very challenging situation, which can be dangerous for the patients and the staff.
3 types: 1- agitated but cooperative no concern for dangerous condition. They respond to the sandwich treatment
2- disruptive without danger: no delirius. You can engage with them but they need to be sedated. There are no dangerous conditions. This is very common. They are usually observed in an unmonitored bed. Safety a priority so haloperidol 5 mg Droperidol is the most effective agent for undifferentiated agitation. Is the safest. The QT black box: is nonsense.
Droperidol is no longer available in the US: it was too effective, too cheap, too safe.
The second best is probably Midazolam. 5-10 mg. dosing midazolam is tricky, we have to be wary of respiratory depression. Midazolam is less effective than droperidol and you can have a paradoxical response.
3- Excited delirium: is rare. Delirium and danger. Sometimes the line between disruptive vs delirius is difficult to draw.
How to manage? You need adequate force and make sure it’s safe to approach. Put face mask oxygen on the patient. Relieve dangerous restraint holds.
The next step is chemical restraint.
Chemical sedation should be given IM not IV unless they have already an IV line. You need a rapid single shot success and the ideal agent is ketamine. If the patient has elevated HR and BP no problem the ketamine will help with that. 4-6 mg/kg IM. Head of bed up to reduce aspiration risks. Then its time to resuscitate, take vitals, place vascular access, identify the cause. In practice there is a continuum from agitation to delirium.

Liz Crowe is a social worker and PHD student.

Where is the love in critical care?
Love can revolutionise critical care. There is science to demonstrate that this approach would improve care.
What sustains us is the love for what we do because it’s not always hot and spicy as the beginning!
Love or fear as leader? Good leaders do everything to demonstrate they know what your job is. Good leaders create a trustworthy enviroment. What makes people stressed is feeling underappreciated, undervalued, when people feel loved the brain capacity grows. Everyone needs a work wife or work husband.
Love builds innovation and Creativity not the brain.
Love and patients: we see people in their most vulnerable time.
The more we care about our patients the less we burn out.

Critical care without walls

Sarah gray
Disaster management

Most days we don’t have enough beds. How you decide who gets what.

What do you do if you have only one bed and many red patients. Very few places have a written plan on that situation. You need something which your hospital’s signed off. People don’t want to raise that issue, people are afraid by legal issues, afraid that we could face a situation when we cannot offer the patient what we would usually offer.
If you had a plan this will optimise outcomes and help us. We need: guiding principles , inclusion and exclusion criteria, defining the process.
Not everyone is going to get what they really need: this is scary for people.
Developing these plans should be a public process, we need to engage the public.
Inclusion & exclusion criteria: difficult to find papers on these issues. Inclusion: mechanical ventilation, vasopressor need. These are really recognised criteria. Exclusion criteria: CA, severe trauma, severe burns, metastatic malignancy, DNR, severe end organ failure.
You need a team- multidiscilinary - to decide who will get the bed.
The literature recommends you have a board to review the process

@Mjslabbert


Christina Hernon
Emedtox
The disaster gap and disaster management

There is a gap in knowledge, understanding, we need a new word to describe that.

J Doyle from United Kingdom wrote 06-16-2016 08:11:08 pm
SMACCDUB Day 2 PM – By Dr Monica Minardi



Christina Hernon

Emedtox

The disaster gap and disaster management



There is a gap in knowledge in knowledge, understanding, we need a new word to describe that.

'Did I do enough, did I make a difference, did I do the right thing.

'I was Drowning in the acute stress reaction'

Help define the minimum essential curriculum in order to deal with these situations as first responders.

Be compassionate. Help immediate responders to connect.



Ross Hofmeyr

Confined space airway



There isn’t a definition for that! Its where access to your patient or position or use of equipment is confined by the setting.

There is a steady increase in patients rescued after mountain accidents.

Even in hospital we can have problems in accessing the patient as well as we would like.

Unexpected difficult airway in theatre 0.05- 0.35%. Serious adverse events intubating out of theatre 35%

Abnormal access and position of the patient is the main difficulty in managing airways.



First rule get yourself out of the situation before managing the airway (if you can oxygenate!)

Studies demonstrate that changing the position changes the time to intubation.

Ice pick Aussie intubation: study showing it might be better for novices.

Airtrack vs non channeled view. Immediate learning effect with the videolaryngoscopy.

Using Supraglottic devices will work.

A team in the US uses a transillumination technique but it takes time to learn it in a very controlled setting.

In summary: try to get the patient into a situation where you can have 360 degree access, if you cannot do it consider supraglottic, if you need to tube the patient in confined settings channeled systems give better results.



When PHARM meets the farm. Mike Abernethy



Fascinating story about farmers and how 'he loves tractors as a fat boy loves cake'.

Then talked about a trauma case of a farmer (his friend) with severe leg injuries.

In the trauma center they panscan his a*** and also assessed the leg! He ended up having the leg amputated and managed very well.



The boot sign. Sign of severe injury. the only worse sign is when they leave their foot on the scene.

Old farmers and old tractors: this is what you deal with. You can also find very young people driving tractors. These are the age groups involved. What kills farmers: tractors.(we see many of these injuries in the italian countryside! They have terrible complicated injuries. Monica). Roll over trauma, backflips, run over. Family and neighbours usually are first attenders and it’s very useful because they can dis assemble the equipment.



After a good lunch here we are for the afternoon session. I’ve chosen the bare knuckle EM

Chaired by Resa Lewiss

@smaccfight



EM year in review



Ashley Shrevesvand, Ryan Radecki



Trim sulfa vs placebo for skin abscess.

Irrigation of cutaneous abscesses do not improve treatment

Gout: oral prednisolone in the treatment of gout no difference pred vs indometacine

A RCT non-inferiority trial of single dose of oral dexamethasone vs 5 days in adult acute asthma.

Pain relief in renal colic Lancet IM diclofenac vs IV morphine vs IV paracetamol. IM diclofenac and paracetamol are both superior to morphine. Consider IM diclofenac.



Acute back pain naproxene with cyclobenzapine, oxycodone acetaminophen or placebo for treating acute back pain. No evidence for opioid to be the cure for the pain.

Medical expulsive therapy in adults with ureteric colic multicenter: no general benefit. Possibly if you have a distal stone, which is big, there might be some benefit.

Antibiotics in diverticulitis: no difference. Outpatient non-antibiotic treatment of diverticulitis. 97% have no complications.

Management of appendicitis with abx and no surgery: still needs more evidence.

REVERT trial on modified Valsalva.

LP in negative CT for acute headache. We need to do 250 LP to find 1. Sensitivity of CT in first 6 hours is very high so if the CT is within 6 hours of onset of pain let the patient go!



Idarucizamab for dabigatran reversal the evidence is very low.

Andexanet alfa for the reversal of factor Xa agents.

Review of thousand of patients admitted to hospital with low risk chest pain. So if we can do a quick protocol to discharge low risk chest pain please do it!

Platelet transfusion vs standards care after acute stroke due to bleed associated with antiplatelet (PATCH study). A randomised open label phase 3 trial.

The safety and effectiveness of droperidol for sedation of acute behavioural disturbance in the ED: it is safe!! Incidence of QT prolongation of 1% (equal to general population) and no torsade.

Ketamine for chemical sedation in the ED: about 90% works as second line. The doses are big!

RCT on 3 sites for central lines: just get good at 1 site and not be dogmatic on that.

Overdiagnosis of PE by CTPA: we do far too many CTPAs! Little PEs are as likely to be false pos as neg PEs.

In these small PE the experts suggest to. Do a doppler and if it’s negative just observe them! No evidence but seems like common sense.





SMACC FIGHT

Bare knuckle EM

Emergency medicine is a failed paradigm

Yes:scott weingart

No:simon carley



Scott

Which boxes do we identify with? The sick patients box? The not so sick or the non sick at all?

Which boxes does the system wants us to deal with?

They tell you patients wait times matter...

Patient satisfaction...going to the ed should be the worst day of your life it should suck.

What do the hospital think we are expert in?

we can change the system or we can change the doctors.

The metrics should be sickest patients first.

Initially we were called ER doctor. It should be EDM. emergency department medicine. Recruiting doctors for what they will actually be doing.

Create a new specialty the Resuscitation specialty.



Simon Carley

Close your eyes and take yourself back when you were 18. Watching MASH. What kind of Doctors did you want to be? Weren’t you inspired by this model of a doctor taking care of the patient regardless from what the problem the patient had.

Maybe what we need is a revolution a socialist approach.

The number of people attending ED is higher and higher.

We can perform at our best with all groups of patients. The skill of the EM physicians is to spot the serious patient even when people look fine. The ability to work with uncertainity, with probabilities..

US, bedside tests is all in our ground.

Emergency revolution!

People know we are there to serve them.

We need a new faculty.



Bare knuckle pit fight

POCUS is a problem



Maxime PRO.



Pocus. GURU effect, esoterism. US is very attractive. the erotics of US are very seductive. But is it the best way to use our time or ptient’s time to use US all the time.



Fox

The doctor fox lecture: paradigm of educational sedation.

Paper of immediate vs delayed pocus in the ED.



Submassive PE should be thrombolysed.



Swaminathan Vs Con



5-7% of patients with submassive PE will die.

We are preventing them from developing pulmonary hypertension.

Literature: the literature is not too clear. We can probably save them from long term problems.

In the group under 65 there is no increase in major bleed.

Young healthy patients with RV strain should receive thrombolytics. It should be a shared decision. Patients already with COPD or pulmonary hypertension shouldn’t have it!



Dr Beardsell.



Sonic boom! The smacc ultrasound extravaganza.



How to train people on basics for US

Fluid is like Guiness on US.



Understanding US is pattern recognition.



Amazing US teaching with on scene simulation.



And Next year smacc will be in Berlin 26-29 June.

See you there!

J Doyle from United Kingdom wrote 06-18-2016 07:11:52 am
Day 3. By Dr Minardi

"Beyond the ivory towers"

Critical care in difficult contexts. Nikki Blackwell MSF

Managing sick patients in a limited resource setting is extremely challenging.
It is a very big decision to ventilate someone - if you are lucky enough to have a ventilator!
Between 40-50% of cases will be obstetric, wherever you work (eclampsia, bleeds, malaria).
About malnutrition, since the invention of pumpinut most malnourished children have been treated in the community.
You can treat 60000 kids in the community with the pumpinut, and this has hugely affected the care and outcome of those kids.
The local staff should have the credit of the achievements, they are the ones who live and stay in that context, expats come and go. 'Must of the work is done by my African colleagues'.
Another very low cost highly effective project is the involvement of mothers in detecting malnutrition with the arm bracelet.
Teaching the mothers to use the bracelet to detect malnutrition is possible with basic training. A paper has been published on this project. The study demonstrated empowering the mothers does work.
Questions.
What about the training needed if someone wants to embrace that career.
There are Diploma / Masters on Tropical medicine and Hygiene and specific courses on procedures in limited resource settings (like the airway course)
MSZf is the kind of university where we all train to get prepared to working in these contexts.
Monica’s take home message: doing the basic staff can save lives in limited resource settings. And in our hospitals too I believe.
--------------

We need Palliative care everywhere

Ashley Shreves
Case presentation of a 93 year old patient with heart block and comorbidities who died after care was escalated up to an ICU admission including mechanical ventilations and central line, measures which she believes were inappropriate for the patient and the patient did not seem to want.
Specific challenges in these end of life situations are:
-Identify dying trajectory
-Capacity assessment
-Advance directives / difficult communication
-Withholding treatment
-Spiritual competency
-Ethics
'I recognise I had a knowledge gap about palliative care and I was not prepared.'
The literature shows that this kind of end of life conversation are bad brief or nonexistant.
Dying patients are often 'neglected' in the ED.
'We all suck with this, it’s not only me'. We have never been taught how to deal with end of life treatment.
Australia: 65% patients with serious illness die in hospital. Same in US.
So what should we do?
Consult palliative care?
Some hospitals don’t have a palliative care service and there is a shortage of people working in palliative care.
The solution is with us. We should have basic palliative care skills to manage those patients. Clinical training, encourage doctors to get the fellowship and change the curriculum from within. There are also mid career courses like EPEC a specific course for EM doctors.
There are online courses: PC network of Wisconsin is a great website.
It is so important to care for those patients appropriately.
One tip: screen if the patient or the family is ready. 'I m so worried for your mom because she is so sick' and then you explore.
Monica’s take home message: assisting the dying patient is another skill we need to learn and we cannot always delegate to other teams.

Ashley Libieg

Ashley Started her talk with a 'powerful' video of her working in the helicopter.
The golden fleece. We are here not for money or glory because these are nearly inexistent. We are here for the passion, the love, the altruism.
She described a case of paediatric resuscitation which caused her post distress syndrome, due to a lack of communication with the receiving in-hospital team, for which she felt responsible for having done the wrong thing in prolonging resuscitation efforts in that child. Compassion should be applied to each other and not only to our patients. She became so focused on what happened that she stopped sleeping and she started having lots of negative feelings about that.
The golden rule: rude behaviour in our teams affect the ability to perform procedures.
Be mindful to the people working with you, because what we say can have a huge impact in other people’s career and personal life.

Monica's take home message: rude behaviour is contagious and can be destructive. Be mindful to patients and staff.

11:00

Bringing the sexy back.
Scott Weingart

Standard ED post tube sedation.

Patients get paralysed after intubation! This drives Scott mad. Now please put your index and midring finger up and stuck them in your throat, not nice is it? This is what we do to our patient, the tube is painful, the NGT is painful. How do we fix it? Sedation doesn’t blunt pain. Sedation without analgesia equals delirium. And delirium is associated with death.' I’m an emergency intensivist, I look after patients in their first 24-48 hours, EM physician looks after the first hours. Deep sedation is related to death see Critical care paper.
A1 sedation: analgesia first.
Then you won’t need very much sedation. Fentanil stat and then drip. Hydromorphone push or fentanyl push. Logistic is a critical point: don’t assume things are done because you asked for it. I highly recommend adopting a pain scale. Only when the pain is controlled give sedation, but you’ll need small doses (propofol at smaller doses); stay away from benzodiazepine as they have been associated with bad outcomes.
Propofol and dexmedetomidine is the combination I prefer. This allows me to have a patient who is still not too deeply sedated. If you control the pain very few patients will have delirium.
ICU delirium is becoming more frequent.
So standard critical ill patient: as said before.
Neuropatient: fentanyl (remifentanyl) and propofol (or dex).
Haemodynamically compromised: pain cannot be a pressor! The pain becomes their vasopressor, this is unacceptable. Fentanyl/ or ketamine. Fentanyl does not affect the BP. Ketamine in dissociative bolus 0.4-4 mg/kg. if you like rocuronium you better use post intubation sedation and analgesia. The only sign would be tears from the patient.
ECASH: early comfort using analgesia. Have a look at the paper. Let s care for our patient lets treat the pain the agitation and their misery.

PAD stands for pain analgesia delirium. Treat all of them.
Monica’s take home message: plan your strategy, know your environment and protocols, primum non nocere so treat pain even if the patient cannot scream and shout.

Katrin Hruska
Biomarkers: useful or useless?

Trisaq company founded by 2 medical professors 'soluble urokinase receptors and chronic kidney disease. Published on NEJM and quotes as a simple test would do for kidney disease what cholesterol does to cardiovascular disease.
Looking at conflict of interests, The Dr. had quite a few!!
This is not an isolated case..
SuPAR and HIV..
Study on APACHE II and suPAR correlation with survival in sepsis.
SuPAR: a future prognostic biomarker in Emergency Medicine.
Similar things happen to s100B.
They look at a paper on differences in interpretation of cranial CT in ED traumatic brain injury patients. There was and acknowledgement to a Company ('brainscot?).

What is a biomarker? A clinical endpoint is a characteristic or variable that reflects how the patient feels, functions or survives. A surrogate endpoint is a biomarker that is intended to substitute for a clinical endpoint. Finding out relevant good biomarkers is important.
Unfortunately Conflict of interest are not easily disclosed (and when disclosed not dealt with Monica adds!).
intellectual conflict is even more dangerous and more difficult to spot than financial conflicts.
Monica's take home message: be very skeptic when new magical biomarkers are introduced, particularly if the person promoting them has got the patent! Unresolved point if we are good enough to spot COI then how to fix them?

Alex Psirides
Why is your hospital broken

Quote from Nightingale 'first thing the hospital should do to sick, is no harm.
Story of Zoe. **

Henry Marsh quote. 'Hospitals are horrible places like prisons. When you go to prison you're given a number. Your clothes are taken away & you are made to wear a uniform. Then you’re put in a confined space not allowed to leave & have to obey orders. Finally you're subjected to a rectal exam. What' s the difference?'

Patients fall into 3 categories: hard to kill, hard to keep alive and might actually matter category.

SOD vs MOD single organ doctors vs multiorgan organ doctors.

Medical education needs to evolve: patients who were admitted to ICU 20 years ago are now managed in wards, where Junior doctors deal with them most of the time. Medical education needs to address this, to look after patients who were looked after in ICU 20 years ago.
We all work in silos the sickest patients are in the wards!! And we don’t know those patients, as intensivists we might not know where these patients are and how sick they are.
We are in solar powered silos. When the sun goes down the senior doctors go home. The silos are created around us not patients.
Importance of MET in order to get there before patients are pre MET. But sometimes the MET team is not alerted even when clear signs of deterioration develop.
Met decision tree.
'The treatment for dying is probably not CPR'
Monica’s take home message: EM and critical care physicians need to be proud to be MODs and generalists!


13:40
Keeping your patient alive

Simon Finfer

Life after sepsis

The data is that the mortality rate is decreasing. A hidden public health disaster? Hidden. JAMA 2014.
The price for success
Significant disability is common. Long term cognitive impact is less obvious. Paper on JAMA saying that cognitive impairment is increased by 10% in survivors.
Health and retirement study on JAMA 2010 on functional disability: 3 fold increase in moderate severe cognitive impairment, 3 fold increase in physical impairment.
We really need to pay attention to people who survive.
Is there something specific for sepsis which makes the outcome compared to other diseases?
The brain structure is altered by sepsis according to some functional brain studies but we still don’t know and we need more research on it.

There isn’t a coordinated programme for patients post sepsis in Australia. Nobody owns these patients, there are no coordinated actions.
What can we do in the ED to improve these patients care and decrease long term consequences?
What is the role of the post ICU clinic? There’s no data that improves outcome.
Monica’s take home message: survivors from sepsis may have severe disabilities and the impact in their lives is huge. We need to address this with specific programmes.


Jo Anna Leuck
Remembering Rory sepsis and learning from error.

Why can’t medicine seem to fix simple mistakes?
Rory’s case: he was sent to ED by the GP for pain, fever and feeling unwell. He was quickly seen by an ED physician. He was discharged after 2 hours because he improved. WBC14.7 bands 53%. He was tachycardic when discharged. He continued to vomit through the night. He arrived in ED in full septic shock.
Was it preventable?
A simulation experience was created in order to explore the preventable areas in this case.
Recognition:
Vital signs are age dependant so it is difficult to remember vital signs.
You can use the fever adjusted role. Then you want to look at the skin.
Rapid treatment: fluids and Abx! Moreover don’t rush the intubation. Resuscitate first.

Monica’s take home message: another excellent example on how looking at basic interventions could hugely improve patient care. How can we fix these simple, basic but recurrent mistakes?

Teamwork the strongest drug in the hospital
Peter Brindley

Why teamwork matters? We live in a complex world. The ICU is 180 steps per patient everyday. There is difference between semplicity, something which is complex and complexity.
We can recognise heart failure but what about team failure?
Human factors! What about team failure. What stops us from talking about team Failure is the fear of people talking about us in the tea room.
Job one for us is communication. RRU: relationship repair units as a redefinition of ICU.
Care gap, expectation gap, education gap are all present in our environment.

Nocebo is the drug which can have a negative placebo effects.
You cannot not communicate: we always communicate even if we don t talk. We use verbal, paraverbal, non verbal, communication.
Rudeness affects indivual performance, team performance and diagnoses and procedures!
Rudness as a toxic drug. Rudness is a powerful toxic drug.
DAS guidelines is still focus on the individual call and not the team call.
You need a team to balance situational, physiological and anatomical difficulties.
Measuring the colour of the team is essential : we need to know if the situation is white, yellow orange, red grey or black when we measure team’s performance.
Ectopia : land of danger.
"You suck. I m great" . Too early vs too late approach. All these attitudes are dangerous for the team and affect the outcomes.
Task vs power.
Passing the baton is a real issue. Handovers matters!
A team of experts is not an expert team: this is fundamental to understand.
Our team needs to be strong inside and outside.

Our team is so good that we simulate blindfolded and so big that we do telephone simulation.
Be prepared. Use the ABC approach Airway, Breathing and Culture change.
Monica’s take home message: the power of communication and the importance of training teams and not only individuals.

Gareth Davies

Suspended animation in traumatic arrest.

Origins back in 1994 when Peter Safar and Bellamy looked at deaths from Vietnam War.
Significant soldier died from surgical simple lesions.
And they embarked a research programme.
Case of a patient at Isle of man. Dean was sat on the edge a rider came round the cornerlost control of his bike and both the rider and the bike came to the ground. Dan was hit in the chest by the bike, he exanguinated from an aortic tear to death. The lesion was < 2 cm in length. It could have been fixed.
Suspended animation: treatment to preserve the viability of organs.....
Now we call it EPR- emergency preservation resuscitation.
Process: at CA rapid cooling of body at 10* followed by reconstructive surgery during metabolic arrest, then rewarm and circulation restarted by cardiopulmonary bypass.
EPR is one of several options: open chest and aortic occlusion. Ecpr/ ecls, automated CPR, even artesunate!
Relationship between temperature and physiological and metabolic problems. Metabolic problems need to be controlled as coagulation problems but not cardiovascular and respiratory problems as there’s no need at that extreme situations.
DHCA (deep hypothermic cardiac arrest) is already used in cardiothoracic and neurosurgery
2 research groups: Pittsburg and Bethesda, the first with a dog no flow model the second with pig low flow model.
ePR CAT study in penetrating injury in traumatic CA
Is it realistic?
First pre H thoracotomy in London 1993 (successful). In France they do preH ECMO. In London REBOA.
Monica’s take home message: thoracotomy seemed unrealistic 20 years ago and now it’s a reality even in DGH! We still need to balance costs and outcomes I believe.

The final challenge:
The SMACC grand final showed an exciting competition between the teams, and a smacc Rapper.

Thanks for following this blog. The blog reflects what I take home from this conference which doesn’t necessarily matche what the speakers wanted to say! So please, try to network as much as you can with other participants and other resources because the quality and quantity of information was exceptional.

My opinion is that the SMACCDUB was not a good conference: it was an experience we shared, I lived and sometimes even cry on. Yes. We need academic sources and talks. But we need to tell stories and to listen to stories because these stories will be staying in our lives more than scientific data. These stories of people we met thanks to our profession are often 'non narratable' to our friends or family because they are bloody and cruel stories. And so it’s important that we share these stories and experiences so we stand together. The inspiration for improvement and the infectious enthusiasm of the speakers and participants is the other aspect I take back from Dublin.
'I am a part of all that I have met' Ulysses, by Alfred, Lord Tennyson.