So Dan – we want you to give this talk – about a job. A job that doesn’t exist. Or maybe it’s a thing – but we’re not sure what that is. Or maybe it’s a culture? Anyway, we don’t know, you get the idea, go on stage and get educating…. and that’s how I ended up giving the talk below. You can watch the video here or listen to the audio on iTunes, but I also thought it would be helpful to write down my thoughts on putting this talk together for #stemlynsLIVE.
That was essentially the brief for this talk, and one I will be getting revenge for at some point in the future. But I admit, it did get me thinking. About what a resuscitationist is, what one does, what one can do. Like all made up words, I suspect it means different things to different people. The sharp end of diagnosis? The early adopter? Someone who adds value to a complex action team?
As clinicians we seem to be reaching some form of consensus about it – there are even current job adverts out for resuscitationist (you are welcome East Kent) asking for someone to work across ED and critical care. Within this advert, there is mention of education, quality improvement, POCUS, research, hybrid ED-ICU’s.. Clearly lots of opportunity. But can you really become an expert at all this stuff as well as being able to resuscitate? Where is the ‘syllabus’ for a resuscitationist? What are the core skills? What must you absolutely nail.
Rather than ask ourselves what it means, we should probably ask our patients shouldn’t we? And maybe also their relatives. What do they think it means? What do they want from a resuscitationist?
This got me thinking about Al Pacino in Heat, which I decided to watch again (as homework) which was excellent use of study time. What has this got to do with resuscitation? Well, there is a scene in this film where he brings his stepdaughter to the ER after her attempted suicide. She arrives exsanguinated, unconscious, hypothermic, shocked. Al Pacino’s character has been around the block. He knows what she needs. After carrying her through the front doors he hands her over to a healthcare professional, and then he demands additional presence from other specialties. He wants expertise. He wants to try and gain some form of control. He wants to make things happen.
If he walked in to a hospital tomorrow, would he ask for a resuscitationist?
Would you? And if you did, what would you want from a resuscitationist? For yourself, your child, your parent. Anyone reading this is likely to know a lot about resuscitation – but are you the doctor you would want treating your family? Is your system the one you would want treating your family? If not, why not? If it’s someone else, why them?
Always very interesting to stop and reflect on your system as a potential user, rather than a provider. We’ll come back to the case, but this is probably the right point to think about 5 things that we might want from a resuscitationist, in order to maybe give us some idea about what the role can actually deliver. Here are my top 5.
- I want someone who extends the incision
Interestingly, we are going to start with a surgical analogy. Whenever I have seen a junior surgeon get into trouble in theatre and call the boss in – the first thing the boss has always seemed to do is calm down, slow down and extend the incision. Make life as easy for yourself as possible. This is a good maxim for resuscitation. There are lots of easy practical applications that we can all understand – struggling with a chest drain in an obese patient? Can’t get the trache in after dilating? Challenging front of neck access?Extend the incision.
But this also applies to diagnostics. Team management. Ongoing care of the critically ill. We all like to think we are master of the spot diagnosis – that we can stride into a room and confidently declare what is happening while others are floundering around. This rarely happens in real life. And, if you try this as a senior clinician enough times, you will be stung. I don’t want this from a resuscitationist. I want House, not the resident. I want a clinician who is thorough in evaluation, who uses system 2, who searches for corroborating evidence and is also cogniscent of potential for error and confirmation bias. The art of the differential diagnosis. A little less confidence and a little more action please.
A normal CT brain in a young trauma patient who is ‘not quite himself’ or GCS 13. Extend the incision. Is it toxin induced? A systemic response to bleeding elsewhere? Could it be early fat embolism syndrome? I want someone who keeps on thinking, who has enough experience to know when something is not quite right, and take that gut feeling seriously. Gestalt can give you a picture of diagnosis, or it can raise the concern that you are missing something. And the best always ask around – even if your own gestalt is not raising alarm bells, what about the other members of your team? “Can anyone think of anything we might be missing?” takes seconds to see, but can save you minutes to hours.
Advanced diagnostic imaging can also extend your initial incision. POCUS is the refuge of the good resuscitationist not because it replaces clinical judgement, but because it can add value. The Zanobetti paper in Chest last year highlighted that our clinical diagnosis often leaves room for improvement. This work showed just how sensitive we are at diagnosis in around 2 and a half thousand patients presenting to the ED with breathlessness, after history, exam, ECG and basic ancillary testing. POCUS can improve your sensitivity by 10% in heart failure and pleural effusion.
Even when you think you have the right diagnosis – the incision can still be extended. Serial assessment – time is an excellent test. Peer review – what do your colleagues think? What is the expected and actual response to treatment? Keep searching for evidence that your patient is moving in the right direction.
An arterial line can really help here, and sometimes I wonder why we don’t just put these in everyone in resus? The septic patient who ‘just needs a bit more fluid?’. The borderline asthma patient with a normal pCO2. The trauma patient with significant spinal injuries who ‘probably doesn’t have neurogenic shock’. Extend the incision. Give yourself more information and more time.
- I want someone who is sharp
Of course, we all want someone who has the technical skills to deliver resuscitation. But we also need someone who maintains situational awareness. And we know that one person can’t be there all the time. How do we want to balance this? First, I think we want a resuscitationist that understands this and has worked to develop a local model to address it. One that keeps people sharp. Sharp enough that you don’t need to let go of the command role. But sharp enough so that you can take over the technical aspects of any case if they become challenging.
There are competing priorities here, and balance is key. There are real challenges in providing bespoke critical care to a single patient, when you are working an ED shift for example. A service needs to be delivered, and we often need help and support to deliver this safely. This can reduce skill opportunities. I don’t think anyone would dispute the value of practical education in resuscitation and I would want clinicians in training to deliver my resuscitation. But I would want them supervised by an expert resuscitationist maintaining situational awareness. And I also want that person to be able to step in and be a skilled expert as required.
How does the individual resuscitationist therefore maintain their sharpness? With recognition, reflection and action. Making it clear to your colleagues what experience you want and need during a clinical shift. Cold theatre lists with anaesthetic support, in addition to the hot cases which may not come along as often as you need them to. Deliberate practice. Simulation. The pursuit of mastery. To strive for excellence.
All these things will actually come with tremendous fringe benefits – peer review, professional relationships, breaking down of silo’s, group think. We’ll come back to some of this later, but it goes without saying that this is a challenge. How you deliver it locally is up to you, but I would urge caution about the scope of your skill set. We all want the resuscitationist looking after us to be expert at the basics, good at the advanced and aware of the highly complex and specialist interventions. I don’t want someone resuscitating me who is fantastic at REBOA, unless they are excellent at everything else. Do you?
- I want someone who understands resuscitation science
There is sharpness regarding clinical skill, but also regarding evidence and practice. I think we would agree to need both from a resuscitationist. These clinicians need to keep up to date in their field, appraise new findings as they arrive and looks at these in context of their previous knowledge. Sometimes this gets mixed up with the idea of resuscitationists being innovators/early adopters. Personally, I am not sure that is necessarily true, or what we want here. I want someone looking after me who doesn’t just adopt a new practice because it sounds or looks cool. I want someone who strikes the right balance between appraisal, discussion, translation and adoption. Critically, I want someone who understands the totality of the evidence (or lack of it) and uses it to make an informed decision.
There is a great talk from Cliff Reid about propfol, I think from one of his original SMACC lectures, which asks you to decide whether propofol is the semen of the devil or the milk of lactating angels. Which do you beleive? If you’re reading this, I suspect you’re part of a biased audience.
This topic asks an interesting question about resuscitation science. I have not seen a single high quality study comparing propofol to any other induction agent, or highlighting a higher risk of complications in rapid sequence induction. And yet we all have anecdotes of spectacular cardiovascular collapse, when this drug is used without due thought process. As such it’s important for us to not just understand the evidence, but also the science here and verbalise it to inform discussion. This drug is a negative ionotrope. It is a profound vasodilator at high dose. Are you sure you want to use it for this patient? I’m worried about concealed haemorrhage. And onwards through graded assertiveness and the PACE acronym….
It follows on from this, that a good resuscitationist knows when to choose their battles and knows which are supported in evidence. We moan about tribalism a lot in EM, but sometimes we are equally guilty of creating silo working by trying to enforce change on others without discourse or supporting evidence base. Thiopentone, propofol, ketamine, midazolam and others all have pro’s and cons. I want a resuscitationist that understands the merits of each drug, knows when to use them and more importantly knows when to highlight this to the wider team.
And that involves reading, discussion and reflection. Don’t be Dr ‘Just the abstract’. A good resuscitationist needs to understand how the evidence affects the patient in front of you, today. Dr JTA will tell you that PEITHO clearly shows there is no role for thrombolysis in submassive PE. But what about younger patients with low bleeding risk, who are failing to improve with conservative management? Dr JTA will tell you that decompressive hemicraniectomy in TBI saves lives. Perhaps, but clearly at the expense of more severely disabled survivors. As such there is no black and white answer. Dr JTA is going to try and draw a definitive conclusion on 1:1:1 for trauma haemorrhage. There may be a signal here, but with overlapping confidence intervals and no statistically significant result are we sure we want to spend this time arguing? Or should we give 1:1 for now and then sit down and think about developing some local consensus protocols….
- I want someone who understands they are not the department
No matter how good you are, the likelihood is you will only be physically present in your department <20% of the time it is functional. That’s a 40 hour week, working entirely in a clinical capacity. For those of us with other stuff – more like 10% or less. So if you want to make a difference, a real difference, we need resuscitationists to invest most of their effort in making sure the department runs well in their absence.
How do you do this? How do you change things? How do you deliver care, when you are not there? Well, the first step is to prioritise this issue above your own personal development, even though it’s hard. And the second is to understand change management; a resuscitationist needs to blend evidence based medicine with charm and tenacity, in order to recognise what changes need to be made to facilitate consistent and effective care, and then deliver that change. There is some excellent work from John Kotter on change management which blossomed with a 2007 article in the Harvard business review on why change fails. This is worth reading for everyone who wants to work in an acute sector and has direct parallels to healthcare. His team go on to describe and refine an 8 step process for delivering sustainable complex change. As we said earlier; if we think that effective change is banning something from our resus room without discussion, interaction or debate, then we are as guilty of silo thinking as anyone else.
After change management there is still more we can learn from behavioural economics. The concept of the nudge is increasingly applicable to healthcare systems with electronic patient records, and choice architecture is a concept that spans disciplines and careers. How can you make the right choice, the easy, interesting, alluring, choice? How can you lead people to make the right decisions when you are not physically present? How can you facilitate excellence, in your absence?
Of course education and simulation have a huge role in this, but there are also subtle ways of influencing the department to function as you would like when you are on your jollys. People not using enough blood products in trauma resuscitation? Educate, sure, but also demystify your major haemorrhage protocol and make it easy to use. Problems with induction strategy or vasopressor use in your department? Develop pre-filled syringes that make it easy to use the safest choice. People consistently making specific drug errors? Develop an automated prescribing aid. How do you get 66% more Swedish people to walk up stairs instead of using an escalator? You get the idea. Not really sexy medicine, but likely to do more good, and more consistent good, than you being brilliant and doing a few extra shifts.
- The best ‘anything’ knows when not to do their thing.
The best goalscorers know when to pass, rather than go for goal. The best surgeons know when to conservatively manage, rather than operate.
You cannot avoid this issue if you want to work in resuscitation. Sometimes you will be thrust into a situation where there is a real question as to the appropriateness of active care. Scott Weingart talks about the resuscitationist in this vein as delivering maximally aggressive palliation; this description doesn’t really fit with my conservative british tendencies, although it’s very laudable. Alex Psirides also talks (at SMACC and many others) about the pressing need to make dying great again. The concept is clear throughout – in order to work in a functional system we need to be accountable for the decisions we make. We need a resuscitationist to be familiar and comfortable with the concepts of futility, opportunity cost and resource use.
This is interesting when the literature is telling us to be less nihilistic. We are encouraged to pursue care in Traumatic brain injury with blown pupils for example, or other unfortunate pathologies leading to devastating brain injury, or out of hospital cardiac arrest. But although there is sometimes merit in perseverance, we need to also understand that the 6 month favourable outcome rate for elderly patients with a significant brain injury is only 15%. That frail elderly patients admitted to ICU have a significantly and globally increased risk of death. That asystole on echo, in most situations, suggests a patient is unlikely to make a meaningful recovery. And that sometimes, a discussion about ceilings of care, and what our patients consider to be appropriate, is best done at the time of resuscitation.
Sometimes these decisions are really hard. Everyone needs friends – ask for a second opinion, bounce your thinking off a colleague. Take that peer discussion outside the hospital. Sometimes you will do more good by going for a drink with a consultant surgeon than you will by drinking from the literature firehose. Understanding when not to resuscitate should be a key part of any career in resuscitation, and we all need to demonstrate professionalism and accountability on this.
So let’s go back to the start now. How can we apply this learning to our case? What do we think a masterclass in resuscitation would look like here?
As a walk in case there is no role for a zero point survey here – but we are ready for that, because we know and understand and are confident in our environment.
Firstly – we are going to control this situation and portray confidence to the patient/relative – using touch, eye contact, clear and articulate voice.
We are going to get help. We do not work in isolation and we know that this patient would not thank us for doing so. We orchestrate and communicate a rapid CABC review through closed loop communication and then we are going to lead – we are not going to take the airway because we haven’t done one in a while, or we want the practice, or for any other reason. Our job is command and control. Others can fly the patient.
We are going to extend the incision. Has the patient taken an overdose, what are the gases like, do we need antidotes, are there other concealed wounds, what is the MHb? We are going to site an early arterial line because we know, from experience, that sometimes things go well initially but then they go badly – and the quicker we notice the better chance our patient has.
We are going for code red because we have previously arranged for it to happen in our hospital. And we are giving balanced resuscitation with blood products, because we have engineered that in pack one; we have had our arguments about what should go in this pack previously, in the cold light of day, and we have listened, and we have reached consensus.
We are going for vascular expertise but we are going to make it clear what we need and what we think is necessary. This will not be tribal, or disruptive, or compromise care. Because we have an ongoing relationship with our colleagues. Because we have put effort into this. Because we know them, and we know what they want and need during cases like this.
And there is lots more we can do – but even this first 5 minutes highlights what I think should be the main take home point from this talk. The system is the resuscitationist. We can all help this system in many different ways. And one person in isolation, no matter how good they are, will never be the resuscitationist I want working in my local hospital. I want the team, the infrastructure, the framework for care and the system.
Be the best you you can be, of course. But make sure you develop your system so it’s the best it can be. That, for me, along with the 5 points above, is what makes a resuscitationist.
If that is even a real job. I’m still not sure it is. But no doubt, the conversation alone is improving patient care. I will keep watching with interest, and the next time a job comes up I’ll be interested to see the ‘spec.