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Another iteration of the Brindley Sessions:

The Article

Followership by Leung, Lucas, Brindley et al.

The Table

Figure 1: Robert Kelley’s Followership dimensions and styles, adapted from Kellerman (2008)1

in the podcast, the passive followers are described as yes-people

from: https://www.medicalprotection.org

More Sparks for Ideas

* Kelley's followership model with discussion

* A related discussion we published in BMJ

* A discussion on culture (including nations) by Geert Hofstede

* And a darn good book about cultivating "eulogy virtues" rather than "resume virtues"

* NOLS 4 leadership roles

Listen to the Rest of the Brindley Sessions

More from Peter

Now on to the Session...

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A video lecture from my friend and airway guru,  Prof. George Kovacs. He has been obsessed with airway for decades. This lecture discusses breaking down the steps of airway management into chunks.

George's Site

* AIME Airway

More from George on EMCrit

* The Psychologically Difficult Airway by George Kovacs

* Definitive Emergent Awake Intubation with George Kovacs

* Airway Things I Learned from George Kovacs at the NYC Airway Course

* Antifragile in EM by George Kovacs

Now on to the Vodcast...

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Today, I get to speak with my buddy Zack Shinar about soem cardiac arrest science.

Questions Discussed

Is there a no-flow time past which there is no hope for survival?

If there is, how do we know the pt was actually fully no-flow--are we are conflating no-cpr for no flow?

What is the survival limit on low flow time?

VF survival is not linear across time. What happens to that number if you strip out all the 1-2 shock v-fib (real comparator for ecmo right?

Who are the few (5%) of non-ecpr patients who survive after 30 minutes of CC?

Effect of Transient ROSC on outcome data

Current Cardiac Arrest Assumptions – mantras needs changing

* Cardiac arrest rhythms have overlap but are very different disease

* Termination of Resuscitation (TOR) is outdated

* Pre-hospital prognostication needs an increase in sophistication

Some Literature on the Stuff Spoken About

* Asystole in patients with wearable ICDs are much better than historical1

* Shockable rhythm patients can have neurologically intact survival with CPR out to 47 minutes (mRS 0-3)2

* When Should EMS Transfer-Transport for ECPR should be considered between 8 to 24 minutes of professional on-scene resuscitation, with 16 minutes balancing the risks and benefits of early and later transport. Earlier transport within this window may be preferred if high quality CPR can be maintained during transport and for those with initial non-shockable rhythms.3 50%of ROSC would be captured at 8 minutes and 90% by 16 minutes.

* Reynolds et al. found similar data with 21 minutes being the 90% capture mark.4

* PEA should prob. not be an exclusion for ECMO, they can have a 23% neuro intact survival in this paper.5

* Wake County Data Packet

* Rate of Brain Death and organ donation, possibly another reason field termination in the field is a bad strategy in viable cohorts

* Adnet et al. on No-Flow and Low-Flow Durations

Other EMCrit Links of Interest

* Cardiac Arrest Update

* EMS Field Decisions in Cardiac Arrest with Howie Mell

Sign up for REANIMATE6 before tickets sell out

REANIMATEconference.com

Now on to the Podcast...

References

1.

Liang J, Bianco N, Muser D, Enriquez A, Santangeli P, D’Souza B. Outcomes after asystole events occurring during wearable defibrillator-cardioverter use. World J Cardiol. 2018;10(4):21-25. [PubMed]

2.

Reynolds J, Grunau B, Rittenberger J, Sawyer K, Kurz M, Callaway C. Association Between Duration of Resuscitation and Favorable Outcome After Out-of-Hospital Cardiac Arrest: Implications for Prolonging or Terminating Resuscitation. Circulation. 2016;134(25):2084-2094. [PubMed]

3.

Grunau B, Reynolds J, Scheuermeyer F, et al. Relationship between Time-to-ROSC and Survival in Ou...

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* Jenny Rudolph on WTF

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* Pew Center Article

* Types of People to Hate on Facebook

Now on to the Podcast...

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Why First Pass Success?

Best review article - first-shot-is-the-best-shot

Each Attempt Makes Things Worse

Hasegawa et al. showed at 3 attempts, things got bad (Ann Emerg Med 2012;60:749)

Sackles JC et al. showed that >1 attempt radically increased complications (ACADEMIC EMERGENCY MEDICINE 2013; 20:71–78)

Mort demonstrated this in the ICU, after two attempts risk of crit desat (70%) is huge and assoc. with cardiopulm arrest (Anesth Analg 2004;99:607)

Mort has further elaboration re: the dangers of intubation in the critically ill (J Inten Care Med 2007;22(4):208)

Heffner et al. showed a 4% cardiac arrest rate in ED intubations (Incidence and factors associated with cardiac arrest complicating emergency airway management. Resus 2013)

Duggan showed >1 attempt = badness

Learning Curve for Laryngoscopy

* Best review of lit is at Openairway

* How many general ED docs do: Ann Emerg Med. 2019 Jun 24. doi: 10.1016/j.annemergmed.2019.04.025.

* How many they need to do: West J Emerg Med. 2019 Jul;20(4):601-609. doi: 10.5811/westjem.2019.6.42946.

VL Teaches DL

This letter has a discussion and pertinent references (BJA 2017;119(4):842–843)

EMCrit Failed Airway Algo V2.0

click for pdf

Bug the ResusTO Folks to Do the Course Again

ResusTO

Blade Views by Nick Chrimes

Now on to the Vodcast...

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A few tweets sparked a debate (big surprise there) and suddenly there was a storm of opinions on whether OOH cardiac arrests should be transported or terminated in the field. Well, since I do not debate on twitter anymore, I needed a person to speak with on the topic--and there is no better than Howie Mell.

Howie Mell, MD, MPH, FACEP

Chair - ACEP Subcommittee on EMS Education

Reservist Emergency Physician - Vituity

Host of the So What 2.0 podcast

SMACCforcer

(@DrHowieMell)

Steel-Man Rules for this Debate

* Any time you want to contradict the other discussant, you must first restate the views they have just stated and confirm with them that you are understanding correctly. If you can bolster their point even more strongly before contradicting, this is even better.

* No ad-hominem attacks (i.e. attacks on the person, not their views. Feel free to politely destroy the views)

* Logical fallacies should be pointed out

* Try to state whether a viewpoint is based on evidence, and what quality or based on your clinical practice

Accepted as Given?

* We are dealing with Adults

* Asytole without signs of life should be run and terminated in the field

* There are EMS services and EDs where EMS does a better job running the arrest than the ED, in those venues EMS should run almost all codes to field termination

* There are some venues where nothing (nothing!) additional gets done in the ED beyond what EMS can do, in those venues EMS should run almost all codes to field termination

The Questions

* What is a public health view of EMS vs. a medical view?

* What is the best approach to <75 y/o vfib/vtach/PEA patient without end-stage comorbidity?

* Can we safely get these patients to the ED?

Cardiocerebral Resuscitation (CCR)

* Watch Ben Bobrow's vid

* Search for Pit Crew CPR to see amazing coordination and perfect, continuous hand cpr

Beam Me Up Scotty?

if we had teleporters…

Can We Safely Transport?

Take Out 1-2 Shocks from the Field Success Rates

and everything changes!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

why is this cheaper?

Things I Can Do in the ED

* Ultrasound

* TEE

* Arterial Lines

* Esmolol

* DSD

* Multiple Antidysrhythmics for Electrical Storm

* Cath Lab

* ECMO

* Blood

* Pericardial Drainage

* Thrombolytics

 

3 Scenarios for when a Resus Center can make a difference

Vfib shocks to Sinus and then Regresses

these patients almost always have a coronary lesion and there is NOTHING the field management can offer these patients. Even if they don’t you don’t have the monitoring to keep these patients in sinus. multiple pressors/varied pressors

Electrical Storm

there is nothing the field is going to accomplish in these patients

PEA

* what you can fix—hypoxemia

* what you can’t accurately diagnose

* tension pneumo

* what you can’t

* bleeding

* pericardial tamponade

* PE

* SAH

* what you sort of can

* hyperk

* toxicology in most protocols

Please tell us what you think in the comments section below

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Call it cric, call it surgical airway, call it FONA. Whatever you call it, you need to have the skills and mindset to make it happen at the ready every time you intubate. Every month make an appointment for yourself to practice cric (just like my buddy Sara Gray does).

First, you Need the Model

Head over here and print out a 3D model to have for the rest of your career

Next, Buy Some Gaffer Tape

[easyazon_image align="none" height="160" identifier="B00GZE3UJ8" locale="US" src="http://emcrit.org/wp-content/uploads/2018/08/51ZG6tchJxL.SL160.jpg" tag="emcrit-20" width="160"]

[easyazon_link identifier="B00GZE3UJ8" locale="US" tag="emcrit-20"]Gaffer Tape By GafferPower [/easyazon_link]

One roll will last a LONG time. And trust me, buy the gaffer power brand, some of the knockoff brands really suck.

Then Acquire Some 4x4s and Plastic Bags

I think you know where to find some...

Then, Watch the Video

For More on All Things Cric

Come on over to the EMCrit Cric Page

They made a bleeding model using Laura's Model

 

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What we have here is a failure to Resus Communicate...

Inspired by Reid, Brindley, Hicks, & Novak

My Favorite Paper on Resus Communication

* by the Brindley

Lecture You Must Watch

* Novak on Combat Aviation Lessons

Resus By Voice

* from flying by voice

* Shared Mental Model

* Resuscitate - Differentiate - Communicate

Tactical Pause (Hick's term)

* Step-Back or SitRep

* aka The Cross-Check- Keep coming back to the global patient picture before diving into any minutiae

* "What am I missing" - team realignment

* Ten-for-Ten1

Close the Loop

from Hargestam et al.

* Set a notification -"Put in an art line and tell me when it is done"

Podium Nurse

* 360 awareness

* Assignment of Tasks (3 Cs: Clear Instructions, Cite Names, Close the Loop)

Sterile Cockpit

* 10,000 feet

* Train the team to acknowledge that phrase

* Central Line Kits / Shock Trauma Hallways

Resuscitese

* from Cliff

* Combat Mitigating Language-Efficient and Unambiguous Communication - Directive, Descriptive, Informative

* Belay that

* Acknowledge or Close-the-Loop

* Say Again

* Read Back

* Tally Ho

* Nato Phonetic and [easyazon_link identifier="076367852X" locale="US" tag="emcrit-20"]read this book[/easyazon_link]

Briefings

PreBrief

* Planning: Mission, Defined Roles, and Set the tone

* Zero Point Survey Self-Team-Environment

Debrief

* Learning happens in the debrief

* Hot Debrief - INFO Model

Additional Info

* Communication Under Pressure

* More Critical Strategies

* LitFL Article

Sai De Silva

What are your thoughts on resuscitation communication? Tell me in the comments section below.

Now on to the Podcast...

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In an amazing lecture; Joe Novak, ED doc and former combat aviator; spoke about the need for memorized boldface actions and then the availability of a quick reference handbook (QRH) for the next steps. But where are either of those things for resuscitation? That lack was the inspiration for the past 4 years of my life and the life of my guest this week, Dave Borshoff. Dave is an anesthesiologist in Perth, AU and a former pilot. He is author of the Anesthesia Crisis Manual and co-editor of the just-released Resus Crisis Manual.

A QRH from a Cockpit

The Bold Face for Emergency Ejection

The Rest of the QRH for Controlled Ejection

Combat Aviation with Joe Novak

EMcrit # 99

Ready to Check Out the RCM?

See the Resus Crisis Manual

Now on to the Podcast...

Music by Caged Dreams (CC)

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We recently put up an amazing mock trial of an anaphylaxis case put together by my friend Mike Weinstock. If you have not watched that, then this wee is pretty much useless to you. In this discussion, we reveal the verdict and talk a little bit of the philosophy of malpractice and how to stay safe in the ED. I think you'll like it!