Logistic considerations

Neurologically intact recovery after out-of-hospital cardiac arrest remains dismal. In the United States, an 8% meaningful recovery rate is hopeful at best. The introduction of extracorporeal membrane oxygenation (ECMO) during cardiopulmonary resuscitation (CPR) is not new but has been shown to provide upwards of 27-30% meaningful recovery, when applied to the appropriate patient population. In 2011 we began extracorporeal CPR (ECPR) in our emergency department - a suburban non-academic center in San Diego, California, USA; the results have been very promising. As a result, we also began refining all aspects of resuscitation. What specific things did we change about the way we do resuscitation? Proper preparation of the resuscitation suite: If we assume the patient will end up on ECMO, then early femoral vessel access is the priority. Traditional paramedic offloading was problematic for many reasons. To address that we: attempt transfer of the patient from medic gurney to hospital gurney in the ambulance bay, where there is more room. When ‘CPR ala fresca’ isn’t possible, we bring the patient into the resuscitation room on the right side of the room, which allows the doctor accessing femoral vessels to be sterile-prepped with ultrasound in-hand. Early femoral arterial transduction to guide the resuscitation Hemodynamic-Directed Dosing of Epinephrine intra-arrest Nurse Code-Team Leader: assign the rote elements of the code, the ACLS protocols, to a trained nurse code team leader. This provides physician cognitive offload. Use a mechanical chest compression device Use an Impedence Threshold Device: increases venous return decreases intracranial pressure (ICP) increases coronary perfusion pressure (CPP) Does any of this make a difference? Well, review of CARES data (U.S.-based cardiac arrest registry) shows that the 2014 arrest recovery rate, with meaningful neurologic outcome, at our hospital was almost double that of the nationwide data. And of the 50 patients included in the CARES database for our hospital, only 4 of those were resuscitated with ECPR. Perhaps we are just paying better attention and providing better overall care throughout the resuscitation. Perhaps we can all improve our resuscitation outcomes.

Assessment of blood loss

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Cutting Edge Resuscitation in the Community ED by Bellezo

Resuscitation legend John Hinds talks about the consequences of our actions in resuscitation. He discusses resuscitative emergency thoracotomies and the philosophy and mindset required by the practitioner rather than the technicalities of how to perform it. As John says, trying to find the fault in a wiring loom of a ZX10 is difficult. Opening a chest is not. But it has been built up to be such a heroic procedure that we're stopping people doing it. John discusses a case and the way it was discussed in the ensuing mortality meeting. He breaks down the personalities you see in these meetings - the sycophants, supporters, the skeptics and coins the phrase #resuswankers. The hardest part of a resuscitative thoracotomy is not making the first cut - it's dealing with the #resuswankers. Using simulation, optimising logistics and training the team effectively John managed to change the culture in an institution. This translated into an incredible save. Take home points include: Prepare. Know the evidence. Make your intentions honourable. Do it. Seek out the skeptics. Never allow a wanker to bring you down. He does this with his usual dry wit, genuine passion and refreshing modesty that have made him so popular. To see how mating hippos and batman are of relevance, you'll have to watch the talk. John will be dearly missed by our community and this talk shows you why.

Hemorrhagic shock and resusitation

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Hinds - Crack the Chest, Get Crucified

The management of the transected airway is frightening because it is a rare airway emergency and one that does not fit the usual plan A,B,C airway management algorithms. An approach is presented which considers two principal anatomical distinctions for injuries both above and below the cricoid cartilage. Secondly, the mechanism of injury is classified according to whether it is either penetrating or blunt trauma. Finally the airway management urgency is described according to either an immediate or semi-urgent approach being required. These three approaches, the location of the injury relative to the cricoid, the mechanism of the injury and thirdly, the urgency of the airway intervention required are then applied together to provide a guide to management of the transected airway.

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Dr Victoria Brazil discusses the Dunning-Kruger Effect, Imposter Syndrome and quality improvement. Vic starts the podcast reminiscing about her initial days as a resuscitationist. She talks about the two psychological phenomena noticed in people working in pre-hospital care. The Dunning-Kruger effect, where people tend to think they are better at a job than they are, and imposter syndrome, where people tend to think they are worse than they are at doing a particular job. People's perception of their performance can impact their chances of improvement. She suggests scientific methods to reduce this gap in perception. Resuscitation quality improvement (RQI) is a machine-based assessment method to improve the quality of chest compressions that helps doctors and nurses assess and improve their chest compression skills. An example is a person trying to intubate a patient while wearing a camera. This highlights how different his perception is of what he is doing. According to Vic, an important tool to improvement and reduce the gap in perception is feedback between the person in the field and the consultant. This is because according to Dunning, though we do not assess ourselves correctly, we are good at assessing others. For the feedback loop to be effective it is essential to follow three basic rules. Firstly, be honest. Secondly, do it often and thirdly be good at extracting feedback. Vic suggests that everyone should start practising giving feedback by assessing speakers. She suggests that rather than giving vague comments like “Good talk mate”, people should make an effort to give speaker specific comments about the talk. This could include what they liked and what could be improved. Vic demonstrates live feedback of her 47-year-old self giving her younger self, Registrar Vic, some feedback with help from the audience. Through this act she shows how to give effective feedback and how to extract good feedback. For more like this, head to our podcast page. #CodaPodcast

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