Cite this post as:
Scott Weingart, MD FCCM. EMCrit – A Debate on the Use of Cognitive Decision Aids for Resuscitation and why Twitter is absolute, utter Crap. EMCrit Blog. Published on August 10, 2018. Accessed on April 19th 2024. Available at [https://emcrit.org/emcrit/emcrit-a-debate-on-the-use-of-cognitive-decision-aids-for-resuscitation-and-why-twitter-is-absolute-utter-crap/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: August 10, 2018
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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I’m a paramedic so my frame is different. rQRH is a TOOL, nothing more & nothing less. No one knows everything at all times and under all conditions (e.g. times of cognitive overload). Having a checklist and/or reminder is not a bad idea. Forcing people to rely on memory, especially for rare incidents, is a recipe for stress & failure. [and we could start a whole thread on other problems like cognitive slip, etc.] Like all tools, it has the potential for good and for evil. Is it possiblethat some will use this in lieu of calling for assistance? Well,… Read more »
yes, rQRHs build the mental model that allows you to dispense with rQRH but even then you shouldn’t b/c it burns the mental model in even stronger each time you use it
It seems to me that Joacim problem is more about Emergency Medicine trained physicians managing critical patients than about the book itself. However there also seem to be the implication that doctors with adeguate exposure and training should never need a quick referenze tool. I think we have been shown time and again that this belief is dangerous and can lead to tragedy….
yes
I think the problem is there and there. Yes, cases do occur once in 10 years. And Yes, partial knowledge is a dangerous thing. But think saving a +1 life at 10 is really not enough? In addition, you need to understand that everything is interconnected – knowledge about one situation that happens every ten years – can help in 10 other situations. Of course, my words may sound stupid, I’m not a doctor, not a pilot, etc . But from the point of view of the human factor – so it is, the butterfly effect, one little thing can… Read more »
There will definitely be people who will cling to checklists as an excuse to be poorly versed in material, but I do not think those people should undermine the importance of checklists and cognitive aids. It seems to me the research is pretty clear checklists help even in medicine. Take the part-set cuing effect whereby recalling certain items items in a set can cause difficulty in recalling other items in that set. A checklist solves this problem by giving you all the items in the set ensuring you will not overlook any important task. That’s a cognitive bias that can… Read more »
fantastic comments
Very interesting debate ! It’s true that a big part of emergency medicine is not aim at resuscitation and i would have problem arguing that i am a better resuscitationist than a ICU guy managing exclusively sick patient at full time. I think that our main area of expertise is as chaos manager, we are the only area in medicine with absolutely no control on the type of patient that we need to care for. Doesn’t matter if you are working in a non trauma adult ED, you will have to manage the kid who get stabs on the street… Read more »
yes!
The point here that I think Joacim is fundamentally making is essentially that even good protocols are no substitute for training. This is such an important principle, and one that I think is often critically underappreciated in modern healthcare. The scenario we all want to avoid is an ED which neglects to put the effort and money into training its clinicians, opting instead to keep a dusty copy of the manual on every nurses station – on paper certainly a much more cost effective solution. In the right context, however, there are many advantages to such a manual (though full… Read more »
Love this post .kudos to you both to engage in a spirited yet classy exchange of ideas and opposing views. P.s I agree with your views on twitter.
Would view the RCM as fundamentally a set of checklists (augmented with additional details etc, but still fundamentally checklists). There are lots of folks out there who know far, far, far more about human factors research and checklists than I do, but that said here are a few thoughts: 1) Checklists for rarely encountered emergencies are unequivocally good. If we’re going to say that an intubation checklist is helpful (a situation which is commonly encountered), it is only logically coherent to say that a checklist for a rarely encountered emergency is vastly more important. This isn’t matter of training or… Read more »
After reading Joacim’s response, I was not going to be as generous as Scott (having been involved with cognitive aids for more than 20 years now) and was formulating my perspective on this before writing a response. However, I think your response, Josh, pretty well sums it up. When the Anaesthetic Crisis Manual was first published, there was a similar debate – particularly with the older, ego driven practitioners adopting the line of ‘not needing checklists’. However, simulation studies have since shown that many of us don’t perform as well as we imagine we would and that cognitive aids can… Read more »
agree with all but #5
Hi, Great debate.. I think that both are right, and both debattants are showing mature behaviour in this debate – great ! I truly believe that there is a room for aid memoares.. however, these CAN NOT substitue or compensate for SKILLS, CLINICAL EXPOSURE (and experience) and KNOWLEDGE! My fear can be, with the Scandinavian frame ind the mindset, that such a checklist / booklet becomes the truth and the bible (as some cultures se the ie ATLS manual as)… it is extremely important to look at “frames”. I have only had the chance to read some of it, and… Read more »
there are many ways of accomplishing resus tasks and they will vary system to system based on resources, training, etc. But I don’t really think frame is the right lens to view these differences. Just as many base trainings go into Australian crit care making that specialty richer and more robust. WHat you are suggesting is very similar to the utterly dysfunctional system of USA critical care in which each specialty has their own crit care training, i.e. their own frame. This is a failure. There should only be 1 frame of resus-optimal care for the sickest patients. This will… Read more »
there are many ways of accomplishing resus tasks and they will vary system to system based on resources, training, etc. But I don’t really think frame is the right lens to view these differences. Just as many base trainings go into Australian crit care making that specialty richer and more robust. WHat you are suggesting is very similar to the utterly dysfunctional system of USA critical care in which each specialty has their own crit care training, i.e. their own frame. This is a failure. There should only be 1 frame of resus-optimal care for the sickest patients. This will… Read more »
all very interesting, both the main discourse, as well as the comments. i think it may be a very valuable experience to be honored with Dr Joacim Linde’s appearance on the show. I have the sense from his response that he has a good many other ideas about resus, and a great a many other aspects of health care delivery, education, philosophy. he is like a Swedish Scott Weingart, in a way. it may be tremendously educational and stimulating to see what Dr Linde perceives healthcare to be in his neck of the woods. i work in a shop that… Read more »
all very interesting, both the main discourse, as well as the comments. i think it may be a very valuable experience to be honored with Dr Joacim Linde’s appearance on the show. I have the sense from his response that he has a good many other ideas about resus, and a great a many other aspects of health care delivery, education, philosophy. he is like a Swedish Scott Weingart, in a way. it may be tremendously educational and stimulating to see what Dr Linde perceives healthcare to be in his neck of the woods. i work in a shop that… Read more »
Hey folks, I donˋt know if it’s good to discuss with the yodas of EM, but maybe every opinion counts in such a controversial debate. I don’t want to mess with you by telling how many intubations I did, because 1. it’s far far less than you all did and 2. it’s not of interest because me being part of EM is not worth a debate. Want to know why? Because if I, as a junior doc (5+years of EM) don’t do the job, no one else will… In most hospitals in germany juniors docs like me are responsible in… Read more »
exactly the situation i mention above.
LOL….so many haters out here. As a young and upcoming CritCare fellow, it’s quite funny to see so many old grumpy egotistical docs who are apparently BEYOND being helped by a book. Stop hatin’ – it will lower your own morbidity & mortality!
As a former airline pilot that practices medicine, I have a unique perspective and mixed feelings on this topic. I do not pretend to be a human factors expert or have all of the answers. I recently listened to Jim Afremow”s book ‘The Champion’s Mind’. In it he mentions that Michael Jordan has the NBA record for making the most game winning shots and the record for missing the most game winning shots. His shooting percentage for making game winning shots is below his career shooting percentage. Pressure degrades performance and if the GOAT falls victim, what do you think… Read more »
thanks for this amazing comment!
What is being debated? This is a book. High quality and written by resus beasts. You can trust the information. If you know most of the content, you need it less; if you don’t, you should probably learn the material. The debate ongoing here is ostensibly not about the book, but about the system and how to optimize care. How to train people and how to place docs in the right places. In that respect the discourse is healthy and welcomed. BUT re: debate about books and twitter: 1. Books are good. Good books are sacred. 2. Dr Weingart as… Read more »
What is being debated? This is a book. High quality and written by resus beasts. You can trust the information. If you know most of the content, you need it less; if you don’t, you should probably learn the material. The debate ongoing here is ostensibly not about the book, but about the system and how to optimize care. How to train people and how to place docs in the right places. In that respect the discourse is healthy and welcomed. BUT re: debate about books and twitter: 1. Books are good. Good books are sacred. 2. Dr Weingart as… Read more »
I have enjoyed the discussions on EMCrit regarding checklist use. After being inspired by the podcast “Combat aviation paradigms for resuscitationists” two years ago and reading Atul Gawande’s The Checklist Manifesto: How to get things right, I wrote a paper for my master degree about why we should incorporate checklists into our care of patients in our department. I am trying to follow the link to buy the book, but I am unable to via https://resuscrisismanual.com. The “Buy now” just takes me to a basic html page on leeuwinpress.com. Is this book still available for print or in a digital… Read more »
think it’s working now, let me know if not
Great debate. Well handled and impressively candid, on both sides. As an off-the-cuff suggestion, maybe include this flowchart on page 1: Are you the first point of contact? -> Yes -> Get help | No | Is this the first time you have managed this resuscitation event? -> Yes -> Get help | No | Is this a resuscitation event that you have specifically spent time learning to manage? -> No -> Get help | Yes | Are you the trained resuscitationist who has been tasked to attend this resuscitation event for the purpose of assisting with the management and… Read more »
Do you think this specific RCM would be beneficial to (at least some) Paramedics on the streets? Better yet, if you were their medical director, would you see the benefit? Surely a bit more than what we do, but perhaps gives us pause to think of the end game?