Recommended: RAGE podcast

The RAGE podcast is the Resuscitationist’s Awesome Guide to Everything. It is an amazing FOAMed resource, for multiple reasons. First of all, it is produced by a great team of very experienced resuscitationists, so the content is great. Second, it really covers everything: technical and non-technical aspects, clinical stuff and education, research and innovation, work and private life, etc. The team does not limit itself in the subjects they focus on. All relevant aspects of the life of a resuscitationist are covered. And third, the podcast helps people all over the world to become a good resuscitationist, making a difference to critical patients.

So what is a resuscitationist? A resuscitationist is someone who…

… is passionate about resuscitating critical patients. (note: not bound to profession, specialty or level of training)
… always goes for what is best for the patient.
… is humble because he/she knows his/her limitations.
… is a life-long learner. Trains to 130%.
… loves to teach others, no matter who.
… also sees a person instead of a patient.
… knows that some patients cannot be saved, but will never accept it.
… will always try to improve their performance.
… is honest and reliable.
… respects the efforts of other health care providers in treating the patient. Like paramedics.
… says ‘good morning!’ when appearing at the department, brings cookies and is not afraid to help cleaning.
… is interested innovating critical care, but is not embracing every new gadget without critical appraisal.
… does not have to be the team leader, but can also be a team member. The resuscitationist is not the most important person in the room, the patient is.
… knows that home is more important than work.
… is not afraid to get outside of their comfort zone. Or is afraid to do so, but still does it.
… learns from other high-performing professions.
… values the work of the non-medical staff, like logistics and cleaning.
… uses his/her mind to achieve optimal performance.
… improves not only himself/herself, but also the system.
… knows when to switch from standard to individualised treatment and can keep the team on board when doing so.

And of course…
… listens to the RAGE podcast.

This list is based on what I have read/heard on resuscitationists (for example from EMCrit), summarized in my own words with some additions. And it is of course not complete. @RAGE: correct me if I’m wrong on any of these items. Want more? Check out more FOAMed on being a resuscitationist.

With this blog I would like to recommend everyone to go and check out the RAGE podcast. In particular the episode ‘Three men and a microphone’. In this episode, Cliff Reid, Brian Burns and Geoff Healy discuss a variety of topics, including the training they went through, the way they teach trainees, how to become a good resuscitationist and the struggles they face in their careers. This podcast is longer than most podcasts, but personally I think it is still too short. There are so many interesting topics in this podcast and still so many subjects left to talk about. It is very inspiring to hear these experienced resuscitationists talk to each other, also about the challenges and struggles they are faced with. Thanks Cliff, Brian and Geoff for the best podcast I have ever heard. Keep up the good work RAGE team!



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Recommended: Free online booklet ‘Prehospital Research’

The Falck Foundation is an organization which promotes research in prehospital care. They organize courses, give abstract awards and research grants. I had the privilege to follow one of their courses on prehospital research and found it very helpful. Fortunately, they have summarized the main points in a free digital booklet, which you can download from their website. So, if you are involved in prehospital research like me, click on the image to download it and check it out! Recommended!



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10 ways to improve collaboration between your hospital and ambulance service


When resuscitating critical patients, we sometimes take patients from their homes, through the Emergency Department, CT scan, cath lab and ICU within a few hours. Therefore you can imagine that critical patients do not care about domains of different departments, but should rely on a seamlessly connected process of the prehospital and inhospital phase. The chain of survival in cardiac arrest is a good example of this process. In order to improve emergency care within this chain, it is essential for hospitals to work together with the ambulance services (emergency medical services, EMS). Here are 10 ways to improve collaboration between hospitals and EMS;

1. Share education

Learning from each other is a great way to improve quality of care. My experience is that EMS personnel is eager to learn what the diagnostic and therapeutic processes the patients they present will be going through. Likewise, hospital staff will understand their patients better when they know what happened in the prehospital phase. There are different education activities in which these goals can be met. At the Academic Medical Center (AMC) in Amsterdam where I work, the regional trauma network (SpoedZorgNet AMC) organizes a theme-evening twice a year, which is an evening filling symposium with a central theme. Speakers will present different viewpoints on that theme, in which all phases of emergency care are discussed. Most of the time around 250-300 people attend these evenings, many of these from ambulance services

2. Case discussions

Next to education on a broader theme, case discussions can give great insight in the chain of acute care of a specific case. This gives the opportunity to discuss the specific elements, like the decisions that were made. Often, these decisions are made in a time-critical setting and it is good to reflect on the arguments at that time. Sometimes, an other decision would possibly be better for the patient, but often the decisions were right and that also can be very learnfull for people who attend the case discussion. For example, we have multitrauma case discussions in which 2 multi-trauma cases are discussed. Everyone is invited: dispatch center, ambulance service, ED, anesthesia, ICU, surgery, etc. Most of the time, the people who treated that patient are all there, including the ambulance crew. We try to start from the beginning, with the voice recording of the call to the dispatch center, prehospital phase, to the ED and subsequent period of hospital stay. Sometimes we even get to see pictures of the patient in the current phase of the out-patient follow-up. Patients almost always give consent for these meetings and pictures because they realize how important it is that we learn from their case.

3. Research

In both pre- and inhospital emergency care, much is still unknown. We need good quality research to increase our knowledge on how to improve the care for our patients. Most of the times, there is more research activity in hospitals compared to ambulance services. But the challenges faced in the prehospital setting have to be studied too, and this can help to improve treatment in the hospital as well. Enough arguments to get together and exchange thoughts on research questions and start collaborating. In my experience, ambulance crews are highly motivated to cooperate when they know the results have possible advantage for the care they give. As a consequence, it can be very rewarding for researchers to conduct a study when people are really willing to participate and implement improvements based on the results, to give better care of patients in an emergency.

4. Innovation

If you want to improve the care for patients in the emergency setting, you need to realize this probably has consequences for the rest of the chain. Collaborating in innovation can strongly amplify the impact on emergency care. For example, a digital system in which hospitals can show how busy their emergency department is, can help ambulances make the decision to which hospital they should go to. And also: having a virtual prehospital waiting room, through which you have insight on how many patients you will receive will help emergency departments arrange all what is needed to receive these patients. This is just one example, there is so much more to think of in regard to innovation. But do it together.

5. Contact persons

Knowing each other helps cooperation. Having a contact person with regular meetings can facilitate constructive dialogues on how to improve the care of our patients. And I don’t mean persons on a management level only, but also on the operational level for the practical stuff. Furthermore, it can be helpful for an EMS medical director to have a contact person (consultant) in the various departments to arrange specific questions regarding certain groups of patients (for example STEMI or stroke patients).

6. Invite the EMS Medical Director

There are frequent meetings in the hospital which are interesting for the EMS Medical Director. Both from a medical and organizational point of view. You can think of a symposium, case discussion or clinical governance day. Involving the Medical Director, or other senior medical staff in EMS, will broaden the discussion and increase mutual understanding. Or even better: invite him/her as speaker!

7. Audits

If you want to improve something, you have to measure it first. Only than you can determine if certain improvement projects are successful. So think of a few important aspects of emergency care which you can measure. Make sure that these quality indicators are clinically significant. Then arrange an audit to see where you stand and what possible improvements can be made. I think these audits are most likely to be successful when health care providers themselves are in the lead: both in the design of the audit and the audit itself. This will also increase the chance that the recommendations following the audit are implemented and create a culture of excellence. There are different audit toolkits available, like the Urgent and emergency care clinical audit toolkit.

8. Exchange personnel

What could be more effective for collaboration than actually working in both organizations? I don’t know all the stuff that has to do with contracts and human resources, and there are some disadvantages as well, but regarding the subject of this blog: improving collaboration between EMS and hospital, it is worth considering. You may already know some examples of people who both work in the prehospital setting and in the hospital. It is often these people who see opportunities to optimize the process from pre- to inhospital. And these people know who to talk to get things done. Above all, knowledge on the prehospital phase can be spread during grand rounds and skills which are needed frequently inhospital but infrequent in the prehospital setting (like airway management) can help EMS personnel who also work inhospital stay competent in these skills.

9. Rotations

If exchanging personnel is not possible, it is easier to organize some observer shifts. Have paramedics over to join you for some observer shifts in the emergency department. And have the trauma surgeon tag along on ‘the bus’ for an evening shift with the paramedics. It will increase understanding in the others expertise and setting and prevent unfriendly remarks at the hand-over. At the AMC, we have student ambulance nurses over for a three-day rotation with us as emergency anesthesiologists, on call for trauma and resus. In the meanwhile, we practice airway management in the sim lab and we spend time in the OR for both airway management and all kinds of other interesting stuff (physiology, sedation, IV access, shock, etc.).

10. Equipment

Not all, but some equipment can be the same in the hospital and the ambulance service. For example: using the same supraglottic airway device in prehospital care and in the hospital, will lead to familiarity with the device when the patients arrives in the emergency department. Or regarding mechanical chest compression devices, it is practical to have one in the ED to rotate with the ambulance who is bringing in an OHCA patient on a mechanical compression device. But this spare device in the ED can of course also be used for an arrest in the ED. So when deciding which equipment to buy, it can be smart to ask the other what opinion they have and be on the same page.

As you can see, there are many ways to improve collaboration between your ambulance service and hospital. See for yourself which of these ways can help in your local setting. And realize it is all about the patient. This should be our motivation to work together as a team. And perhaps this is tip 11: Don’t curse on each other. It is easy for everyone to make unfriendly remarks when having coffee and the other party not present. But this does not add to the culture of collaboration and excellent preforming systems. Same counts for the situation when EMS and hospital people meet or work together: be professional. We all work hard to get the job done. And when you feel there is room for improvement, discuss that later, with respect for each other. I strongly believe, when you invest in the first 10 ways on improving collaboration, there will be no need for tip 11.

On the picture, you see me with Micha Smit. An ambulance driver who now studies medicine and helped me a lot with my PhD research on ventilation during advanced life support for out-of-hospital cardiac arrest. It is great to work together, because we both have experience in prehospital and inhospital emergency care. The research we are doing now, increases the collaboration of our ambulance service and hospital. I am convinced that this will have a positive impact on patient outcomes in the near future.

Our patients need us to collaborate. So be a team!

Foto 24-03-17 12 15 47

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What I have learned at #dasSMACC in 35 quotes, keypoints and many tweets

As you will probably know, the Social Media And Critical Care (SMACC) congress took place last week in Berlin: Das SMACC! This was, again, an awesome congress with many inspiring lectures and workshops. And this year I was honored to be part of the faculty of the airway workshop. It is almost impossible to summarize all the things I have learned and appreciated in these days. But to give you an impression, I decided to list some key points and quotes of the things I heard. This can either be a summarizing sentence, based on the talk, or a quote in quotation marks. Credits are given to the speaker. I recommend you watching the lectures yourself when they become available online.

Foto 27-06-17 07 49 42

  1. “SMACC is like a reunion of friends who have never met before.” – Chris Nickson
  2. We have to start using technology more to save lives. The future is now. – Brian Burns
  3. “I got the diagnosis, but missed the point.” – Jessica Mason
  4. Be kind to yourself when you talk to yourself in your thoughts. Negative self-talk has a negative impact, positive self-talk has a positive impact. – Sara Gray
  5. Have a friend to talk to about your failures in clinical practice. – Sara Gray
  6. You can be sure of the fact that we all will die someday. This also counts for your patient. Learn to accept this and consider withholding treatment when this will not lead to recovery. – Alex Psirides
  7. “We train to perform CPR, but we do not train to not perform CPR.” – Alex Psirides
  8. Don’t rely on physiologic reasoning. Many treatments based on physiology were bad for the outcome of our patients. Look at the evidence. – Rinaldo Bellomo
  9. When setting up a program, look at all aspects: clinical practice, education, research and administration. – Resa Lewiss
  10. Think of endocarditis in patients with the combination of fever + one of these four: stroke, back pain, heart failure, 1° AV block – David Carr
  11. Use actors in simulation, when teaching on interaction between health care providers and patients. – Learning from sim sessions
  12. Driving pressures matter – Marcelo Amato
  13. Humor can have in medicine – realized this after hearing Suman Biswas
  14. “How you arrive at work will set the tone for the day.” – Liz Crowe
  15. “The director does not set the culture, you do.” – Liz Crowe
  16. There are tribes in the hospital. But it is not about the tribe, it is about the patient. Make the team a tribe. – Panel discussion by Walter Eppich, Jesse Spurr, Liz Crowe, Carol Hodgson, Ashley Liebig and Sandra Viggers.
  17. Complex problem? Divide it into different elements and delegate it to subteams. – Chris Hicks
  18. Want to increase survival in out-of-hospital cardiac arrest? Do the basics well: BLS, AED and good emergency and critical care. – Maaret Castren
  19. Arrest after cardiac surgery? Perform resternotomy in an early stage. – Nikki Stamp
  20. Doctors do not rule the resus. But: ergonomics, nurse-led codes, assigned roles, communication and briefing rule the resus room. – Ashley Liebig
  21. Use ultrasound for the lungs. And don’t let anyone hold you back. – Daniel Lichtenstein
  22. Don’t forget cardiac disease as a possible cause in children with subtle symptoms or failure to thrive. – Michele Domico
  23. Medicine is too complex to be caught in numbers and protocols, just like life. When you have sufficient experience, you can use naturalistic decision making. – MJ Slabbert
  24. In anaphylaxis, give adrenaline. And don’t forget to educate the patient and send them home with an epi-pen. – Daniel Cabrera
  25. Use ultrasound during every resus, preferably transesophageal ultrasound (TEE). – Resuscitation panel
  26. When aiming for 36 degrees in post-resuscitation care: still focus on temperature management. You still need to cool the patient to prevent fever. – Resuscitation panel
  27. Having a drink together is a great way to exchange ideas, get new friends and expand your horizon – SMACC party.
  28. You will fail. Face it and learn from it. – Kevin Fong
  29. When you think: WTF? Stop that thought and ask: what made him/her do that? – Jenny Rudolph
  30. Care about refugees. – Vera Sistenich
  31. When you failed, make sure the system also learns. – Martin Bromiley
  32. SMACC is oxygen. – Peter Brindley
  33. After 10 days, the ICU patient goes into a chronic state and prognosis is not determined by the characteristics of the acute setting, but by the clinical status before admission. – Jack Iwashyna
  34. Ubuntu: the belief in a universal bond of sharing that connects all humanity. – Annet Alenyo Ngabirano
  35. “Thank you” – James Piercy

Furthermore, take a look at my tweets during #dasSMACC;

Also recommended: the Lessons Learned and Take Home Messages From dasSMACC – R.E.B.E.L. EM


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Recommended: Article ‘The past, present, and future of ventilation during cardiopulmonary resuscitation’


Purpose of review: To evaluate the past and present literature on ventilation during out of hospital cardiac arrest, highlighting research that has informed current guidelines.

Recent findings: Previous studies have studied what are optimal compression-to-ventilation ratios, ventilation rates, and methods of ventilation. Continuous chest compression cardiopulmonary resuscitation (CPR) has not shown to provide a significant survival benefit over the traditional 30 : 2 CPR. The optimal ventilation rate is recommended at 8 to 10 breaths per minute. Methods such as capnography and thoracic impedance are being used to evaluate ventilation in research studies.

Summary: Future out of hospital cardiac arrest studies are still exploring how to optimize the delivery of ventilation during the initial stages of resuscitation. More prospective studies focusing on ventilation are needed to inform guidelines.

Go to article on website Current Opinion in Critical Care

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Recommended: Online lecture ‘When Should Resuscitation Stop’

Cliff Reid – When Should Resuscitation Stop from Social Media and Critical Care on Vimeo.

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Resuscitation after trauma: better survival chances thanks to goal-oriented treatment.

Ned Tijdschr Geneeskd. 2017;161(0):D1174.
Koers L, van Schuppen JL, Viersen VA, Kooij FO, Goslings JC, Hollmann MW.

Recent literature shows increased survival for patients with traumatic cardiac arrest. An early and aggressive approach to underlying causes and good integrated trauma care are probably responsible for this. The new resuscitation guideline of the European Resuscitation Council emphasises that treatment of the underlying cause deserves more priority than performing chest compressions. In addition to a structured approach with interventions focused on the causes of the arrest, standard operating procedures and protocols, regular scenario training and clinical governance are vital to improve survival chances for these patients.

[Article in Dutch]

For article: see pubmed or NTvG.


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Recommended: Online lecture ‘Science of CPR’

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The AED: carrier of vital information

AED banner

Over the last years, Automatic External Defibrillators (AED) are increasingly used in the case of an out-of-hospital cardiac arrest (OHCA). In the Netherlands, an AED is placed before arrival of an ambulance in 60% of the OHCA’s. This means that the true initial rhythm is recorded by the AED in the majority of the cardiac arrest patients. And this initial rhythm can stay unknown for the receiving hospital. This can prevent the admitting hospital to give the right treatment to the patient.

When admitting an OHCA patient, we are used to ask what the initial heart rhythm was of the patient when the ambulance arrived at the scene. The initial rhythm gives an indication on the prognosis, but more importantly, will have significant impact on the evaluation and treatment of that patient. For example, a patient with a shockable rhythm will more likely to be taken for an emergency percutaneous coronary intervention (PCI) and implantable cardioverter defibrillator (ICD). But when an AED is used, the initial rhythm observed by the ambulance personnel could have been changed by the defibrillation(s) by the AED. In this way, it can be uncertain what the true initial rhythm was.

It is not always clear whether or not the AED gave a defibrillation. When people are suddenly confronted with a cardiac arrest, stress will have significant impact on their senses, judgement, memory and performance. It is possible that a bystander didn’t see the AED provider giving a shock to the patient and gives the ambulance crew a handover that the AED did not give a shock. Laypersons could have forgotten that they pushed the shock button. Or the ambulance crew did not speak to the person who used the AED. Some AED manufacturers have a screen with information on the defibrillations given by the AED. This information is however lost when the AED is switched off, which can happen when the AED is removed to connect the patient to the monitor of the ambulance service.

Although it can be difficult for ambulance crew to get to know whether or not the AED gave one or more defibrillations, it is important to try. When the AED has a screen with info on the defibrillations, keep it turned on and check whether or not the AED gave a shock. When the AED does not provide you with this information, ask the person who connected the AED to the patient. Try to verify the answers with other persons who were present at the resuscitation.

As professionals who receive cardiac arrest patients, we are faced with this organizational challenge. We have to think of a system in which we can retrieve the essential information from the AED. There are different options to achieve this; The AED can be transported to the hospital along with the patient. In that case, the there has to be hard- and software available in the hospital to get the info from the AED. And efforts should be made to get the AED back to the owner. An alternative is to send someone to the location of the AED after the resuscitation. Possibly, the ambulance service could take on this role.

There are recent developments that AED’s can send data to a server through wireless (3G or WiFi) network. We should make efforts to retrieve this information to get it to the treating physician. That will sure help to solve this problem. Until then, we should do our best to retrieve the essential information on the rhythm and defibrillations from the AED. Make sure to organize this process with everyone involved in prehospital resuscitation. It can make a difference to your patient.

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Recommended: Video of CPR by Dutch police (with happy end)

A woman of 79 collapses and goes into cardiac arrest in the presence of Dutch police officers. They start CPR and the woman survives. Heartwarming to see them meet later when she recovered, having coffee together.

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