Welcome to DutchResus!DutchResus is a blog on resuscitation by Hans van Schuppen MD, an anesthesiologist from the Netherlands passionate about resuscitation. I hope to provide you with interesting info on resuscitation, emergency anesthesia, airway management, prehospital care, crisis resource management and all kinds of other interesting things I come across. For the past years, I have been learning through social media (#FOAMed) and with this blog I hope to give something in return, hoping that you will provide cutting edge critical care to patients in need. Cheers, Hans
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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]
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.
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.
This document aims to integrate current management recommendations and to describe the whole clinical pathway for patients with OHCA;
Everyone who is active in resuscitation teams will admit: treating a patient in cardiac arrest is a challenge and often things will not go as you would like them to. This can lead to negative feelings when the resuscitation attempt has ended, either because the patient did not regain return of spontaneous circulation (ROSC) or the patient is transported to the cath lab for example. Negative feelings can lead to a somewhat pessimistic attitude, especially when no progress is made to improve the quality of care. I think it is obvious we should avoid these things for many reasons. I am convinced that always debriefing you resus will make a positive impact on the quality of your resuscitations, the way your team members feel afterwards and the culture in your department. And it’s free. Dutch people love it when things are free.
Should we always debrief our cardiac arrests? I believe so. When you do not do it every time, you will miss opportunities to improve your system. But more importantly, when a case was really suboptimal, it is harder to get everyone together to debrief. I can remember working in an organization where debriefing was not standard. When after a case someone asked: “Shall we evaluate this case?” Team members were surprised, and perhaps also a little afraid. Someone reacted: “Why? Everything went all right don’t you agree?”. From that moment on I decided to make it standard. And not call it an ‘evaluation’ but debriefing.
I can also remember a prehospital case where the fire department was involved. From a medical point of view, it was a straightforward case (not a cardiac arrest). And it was not complex for the fire department either. Still, the fire chief came to us afterwards and asked us: was the information of the dispatch center clear? How were things on route to the incident? Were you satisfied cooperating with the fire department? And was communication optimal? We looked a little surprised when we heard all his questions but answered all of them. He could tell on the looks on our faces this we were not used to this so he explained: “If we are not able to manage these simple incidents perfectly, we will not be able to handle difficult incidents.” I knew he was right. It gave me the inspiration to debrief trauma cases even when there were no problems with the ABC’s. Debriefing should be standard. It allows you to get the basics right every time.
Getting all your team members together for a debriefing is one of the biggest challenges. Most of the time, people will come and go from the resuscitation room. After regaining ROSC, and being rushed to the ICU, CT, OR, and/or the cath lab, many of the team members from the initial resuscitation are not in the room. In this setting, I usually mention a certain time when we will try and be back at the Emergency Department to debrief the case. Most of the time, I get around 80% of the team members present. When the patient does not regain ROSC, the team is usually complete when the decision is made to stop CPR. I usually announce the standard debriefing shortly after stopping CPR. Sometimes even in the same room.
There are different ways to debrief a case. Most common ways are: having every one state one good thing and one way to improve, using a checklist or to reflect on the case in a chronological order. Having every one mention the two things has the advantage of relative short time needed and you getting to know the most important things to keep and to change. A checklist has the advantage of gaining information on specific elements which you might want to know on an organizational level but can sometimes limit a real dialogue between the team members. Going over a case in chronological order gives a structure and a complete overview but will not guarantee every one will say something. So every way has its advantages and disadvantages. I usually debrief according to the first method with a checklist afterwards to see if everything is covered.
One of the things I love about the debriefing is letting every one say something, including interns, guests and everyone else who was present at that case. It can give valuable insight into how things looked from a distance. This also can help break down hierarchy and create an atmosphere where everyone has the right to express his/her feelings. As a team leader, I think it is important to give compliments as well. Recently I had a case of cardiac arrest with severe hypothermia. During the code, one of the nurses reminded me of the implications for the resuscitation. Being busy getting the resus started, I did not think of this yet. During the debriefing, I gave a big compliment to her. She gave an example of high performance team membership.
During the debriefing things will be mentioned that need improvement. It is important to acknowledge these things and try to figure out ways to make that improvement. My mindset is: how can we prevent this from happening the next time, when other people form the resuscitation team? Make these improvements, if possible, as practical as can be. Usually I ask the person who mentioned the improvement to arrange it as well. And to let the team know if the improvement is made. In this way, you will experience a more constructive culture and, more importantly, the next patient will hopefully have a better chance of surviving their cardiac arrest.
Let’s debrief our resuscitations every single time. The best way is to agree on this on an organizational level but do not let this hold you back to start debriefing yourself. You can start with it today. I have experienced some great moments during debriefing and learned a lot. That is why I think we should debrief all our resuscitations. Missing a debriefing session is missing an opportunity to improve patient care. And it’s free!
Understanding the prehospital physician controversy. Step 2: analysis of on-scene treatment by ambulance nurses and helicopter emergency medical service physicians.
Eur J Emerg Med. 2015 Dec;22(6):384-90.
van Schuppen H, Bierens J.
In our previous study, we identified the similarities and differences in competencies of ambulance nurses and helicopter emergency medical service (HEMS) physicians in the Netherlands. This ensuing study aims to quantify the frequency with which the additional therapeutic competencies of the HEMS physician are utilized and to determine whether this is the main reason for usefulness as perceived by ambulance nurses and HEMS physicians.
MATERIALS AND METHODS:
A prospective observational study was carried out over a 2-month period, with one HEMS station covering six ambulance regions. Provider registration was recorded, supplemented by interviews of ambulance nurses and HEMS physicians. Competencies were categorized depending on whether the competency was specific for the nurse or physician, mutual or mutual with a qualitative difference.
A total of 225 HEMS dispatches resulted in 117 cases with HEMS on-scene in the study region and 78 patients were included. In 35 (45%) patients, the HEMS physician provided additional treatment: in 19 (24%) patients, a physician-specific therapeutic competency, in nine (12%) patients, a mutual competency with a qualitative difference and in seven (9%) patients, both categories. The presence of the HEMS physician was considered more useful by both ambulance nurses (89 vs. 60%) and HEMS physicians (97 vs. 81%) when additional treatment was provided by the HEMS physician.
HEMS physicians provide additional treatment in 45% of patients. The additional treatment increases the perceived usefulness of the HEMS physician. The presence of the HEMS physician was also considered useful when the physician did not provide any additional treatment, possibly because of diagnostic competence and clinical decision-making.
Understanding the prehospital physician controversy. Step 1: comparing competencies of ambulance nurses and prehospital physicians.
Eur J Emerg Med. 2011 Dec;18(6):322-7.
van Schuppen H, Bierens J.
In many European countries prehospital care by emergency medical services (EMS) is supplemented by physician-staffed services. There is ongoing controversy on the benefits of a prehospital physician. Possible advantages are additional competencies of the physician. Similarities and differences in competencies of EMS providers and physicians have however never been studied. This study aims to compare competencies of ambulance nurses and helicopter EMS physicians in the Netherlands to gain better insight into the controversy of the prehospital physician.
In this descriptive study, a quantitative inventory was made of the diagnostic, therapeutic, and clinical judgment competencies of the ambulance nurse and physician, based on analysis of protocols, registration, equipment, and personal interviews.
We identified 438 mutual competencies of the ambulance nurse and physician and 62 physician-specific competencies. The ambulance nurse masters 278 diagnostic, 131 therapeutic, and 29 clinical judgment competencies. The physician masters 285 diagnostic, 175 therapeutic, and 40 clinical judgment competencies. Seventy-one percent of the physician-specific competencies are therapeutic and related to advanced life support.
The ambulance nurse and physician have various mutual competencies. In addition, the physician can provide specific competencies on the scene. Knowing the exact overlap and differences in competencies is the first step to understand the prehospital physician controversy. Our results can be used as a tool for the next step in research on prehospital care by EMS providers and physicians and to improve prehospital care.