The ERC goes #FOAMed! I think it is great that they took the effort to record and publish all lectures of the European Resuscitation Council congress in Freiburg. For details on the lectures, check out the scientific program. You can go and check out the lectures on their YouTube channel. So if you are interested in CPR: grab a coffee, sit and learn! Thanks ERC!
As many of you know, providing adequate ventilations with a bag-valve-mask (BVM) during cardiopulmonary resuscitation (CPR) is challenging. It is difficult to create a good seal with the mask, the operator of the BVM often has other tasks at the same time like coordinating the scene during the first minutes of the arrest and the communication between the operator of the BVM and the person providing the chest compressions is often suboptimal due to the stressfull setting. As a result, it is difficult to provide high performance basic life support with adequate ventilations and optimal synchronization of compressions and ventilations, escpecially in the first minutes of the resuscitation attempt.
This is why I often teach resuscitation team members to apply the facemask with two hands and let the person who provides the chest compressions squeeze the BVM for two times. I call this the ‘four hands CPR technique’, although this is also referred to as the ‘modified 2-rescuers CPR technique’.
This has the following advantages:
√ Optimal seal of the facemask by using two hands
√ Optimal jaw thrust technique
√ You do not need an extra person to squeeze the bag for you
√ No simultaneous ventilation and compression, preventing gastric insufflation
√ Short pause in compressions (3 seconds in this video)
√ No need to communicate on the timing of the pause in compressions, creating more calm in the room
√ The provider who is giving ventilations gets feedback on the insufflations because you can feel the chest rising with the hand which remains on the chest
√ The person applying the facemask, when an adequate seal is achieved, can maintain this and is better able to delegate tasks to bystanders or other team members. This is especially useful in the case of a paramedic who is first on the scene or a resident attending an in-hospital cardiac arrest during a nightshift who arrives first.
Does it have disadvantages? Yes, a few things to keep in mind are:
– Continue to evaluate the adequacy of the ventilations. If the provider who is providing the chest compressions notices that the ventilations are not correct, he/she needs to prompt the provider who is holding the facemask to recheck the seal and jaw thrust (or consider using a oropharyngeal airway).
– You can’t squeeze the bag yourself, so instruct the person squeezing the bag not to overinflate. A pratical way to achieve this is asking them to squeeze the bag with two fingers. An other alternative is to use a smaller bag, like a pediatric bag.
– If you are the code team leader as well, delegate these hands-on tasks as soon as you can when others arrive who can take over.
That said, I think it is a very useful trick to improve your resuscitation performance. Certainly in that very difficult phase of the first stressful minutes when you simply have to run the code and the only person competent to provide airway maneuvers and BVM ventilation. And, like with everything else, I would strongly encourage you to train with this technique. When all team members are familiar with this technique, and train accordingly, you will optimize your performance. And hopefully that will benefit your patients.
Update June 2020:
This technique has been studied in 2 simulation studies, both showing an improvement in ventilation performance while maintaining chest compression quality. Check out:
Root CW, Deutsch BC, Lakha S, Shah A, Lin HM, Hyman JB. Feasibility of a Modified Strategy for 2-Rescuer Cardiopulmonary Resuscitation. The Journal of emergency medicine. 2019;57:51-8.
Shim HW, Park SO, Lee YH, Yoo YB, Hong DY, Baek KJ, et al. Effectiveness of a modified 2-rescuer cardiopulmonary resuscitation technique using a bag-mask for less experienced health care providers: A randomised controlled simulation study. Hong Kong Journal of Emergency Medicine. 2015;22:23-30.
Furthermore, this technique is now recommended by the International Liaison Committee on Resuscitation (ILCOR), in their practical recommendations in response to the COVID-19 pandemic.
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!
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!
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!
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.
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
Abstract
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.
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.
DutchResus 