Podcast 118 – EMCrit Book Club – On Combat by Dave Grossman

Today I am joined by the master of all things Mind of the Resuscitationist, Cliff Reid of resus.me and the Rage Podcast. In the first ever EMCrit Book Club, we discuss a book I read years ago and recently reread:


On Combat by Dave Grossman has enormous relevance to resuscitationists. I feel the entire book is worth reading, but we zoned in on the really juicy bits.

Section I – Physiology of Combat

Chapter Two – Stress Responses to Combat

We briefly discuss bowel and bladder control as they relate to stress

Chapter Three – Sympathetic & Parasympathetic Responses

Parasympathetic backlash-a time of cognitive danger

“The moment of greatest vulnerability is the instant immediately after victory” –Napoleon

Adapt a 360 degree visual sweep for threats (keep looking at all of your patients vitals and remember to bag)

SWAT Team Acronym-L.A.C.E. liquids, ammunition, casualties, equipment; For us–check your team, immediate reset of resus bay, drink something, debrief

Burn off the adrenaline dump

Conflict with colleagues. Exercise, Punching Bags? If a horrible call is reported on the EMS phone, but never shows–run a sim to burn the epi.

Sleep Deprivation-Caffeine can be our friend, nicotine not so much. If you are too exhausted to perform, tell a colleague and take a nap.

Chapter Four – Colored Conditions

originally from Bruce Siddle, Sharpening the Warriors Edge

Heart rate and task performance: heart rates are a guide, getting there by exercise is not the same as by fear/stress, so HR is merely an associated marker
Yellow 90-120, Over 115 and fine motor skills performance degrades significantly
Red 120-150, a 145 HR seems to be the break-point for optimal performance of complex skills
Black >150 and badness ensues, (or >175 in the highly trained, they get a gray zone)

  • Fine motor skills-precision tasks
  • Gross Motor Skills-ape skills
  • Complex-a combination of maneuvers or use of multiple body parts

SWAT team breaking down door function in condition red (or gray), but they have trained until the necessary tasks that require fine motor have been practiced till automaticity

Unified Model of Stress and Performance

On Combat Unified Model

From Grossman On Combat

On Combat Heart Rate Diagram


We need to train how we fight
Stress Inoculation Training and (Academic Medicine 2009;84(10):S25)

We are currently wasting high fidelity simulation, it should purely be for stress training. Perhaps, we should create a hell week for our 2nd years.

Stay in yellow (alert, but with fine motor control) – yellow dot stickers to remind you

“I understand a fury in your words, but not the words” –Shakespeare from Othello

Tactical/combat breathing to stay in the color zone

Hicks’ Law – procedures should only be learned one way-preflush central lines, one way to RSI.

Section 2 – Perceptual Distortions

Chapter 1 – Auditory exclusion and tunnel vision

tunnel vision – the toilet paper tube

Chapter 2 – Auto-pilot

What is drilled in during training comes out the other end in combat, no more no less

Chapter 3 – Grab Bag

Time perception is sent awry

This is why you must not squeeze a BVM when stressed.

Chapter 4 – Memory

Memories under Stress are Suspect

Self Debriefing is flawed, debrief with your team.

Section 3 – The Call to Combat

Chapter 2 – Training warriors

Need to train the puppy brain, because the doggy will be in control

Triune Model of the Brain

  • Forebrain-Human
  • Midbrain-Puppy
  • Hindbrain-Lizard

Cleanse denial: not if, only when. Do not train to “If I get into a CICO situation,” instead, “When I get into a CICO situation.”

“In combat you do not rise to the occasion, you sink to the level of your training.” –Grossman

Principles of Training

  1. Never Kill a Warrior in Training-this only trains them to die. Every engagement should end in the proper behavior
  2. Try to never send a loser off your training site
  3. Never talk trash about your students-Punish in private, Praise in public

This is a great chapter for folks running courses/simulations

Section 4 – The Price of Combat

Chapter 5 – Tactical Breathing

Autogenic / Tactical / Combat Breathing


  • Breath in through your nose filling up your belly for 4 seconds
  • Hold for 4 seconds
  • Exhale through your mouth for 4 seconds
  • Hold for 4 seconds
  • Repeat x 4

If you read the book and have thoughts, please leave them in the comments below

Now on to the Podcast…


Podcast 108 – How to Be a Hero with Cliff Reid


This was my favorite lecture from SMACC 2013. If you are not moved and inspired then your heart is made of stone.

This is a Cliff Reid lecture; if you want more Cliff, see these incredible lectures and podcasts:

I’ll post my own final SMACC lecture in 1 week and then we are done with SMACC 2013.

Want the Slides and a Beautiful Blogpost on the Lecture?

Head on over to the post on the Resus.me Site

Need an Audio-Only Version?

Right-Click Here and Choose Save-as

Now on to the Vodcast…

Podcast 106 – Making Things Happen with Cliff Reid


Mind of the Resuscitationist

This was Cliff Reid’s opening lecture from SMACC 2013. Cliff Reid runs the amazing Resus.me site and any listener of EMCrit knows that I have an enduring (and purely platonic) love for Cliff and all of his teachings.This lecture was on Making Things Happen and it is my #2 favorite lecture from the conference. My number one favorite was also by Cliff, but you’ll have to wait a bit for that one.

Want More Reid?

Want the Slides?

Need an Audio-Only Version?

Right-Click Here and Choose Save-as

Now on to the Vodcast…

Mind of the Resuscitationist – Chicken Bombs and Muppet Factors

Cliff Reid adds to the MotR lexicon with Chicken Bombs and Muppet Factors

Podcast 90 – Mind of the Resuscitationist Series: Cliff Reid’s Own the Resus Room

Cliff Reid is the prototypical resuscitationist; he rocks! He has discussed his philosophies on previous episodes:

And of course, Cliff’s blog, resus.me, is some of the best retrieval and resuscitation information around.

I brought Cliff up to speak in my Critical Care Track at the 2012 Essentials of Emergency Medicine. Mel Herbert was kind enough to give me permission to post the lecture here. I think you’ll love it as much as I do.

Need the audio-only version of Cliff’s talk? Right click the link and choose save-as.

Now, on to the podcast…

Podcast 82 – Mind of the Resuscitationist with Cliff Reid

Today, I put on my head-shrinker cap (it is a fez) and get Cliff Reid on the coach. You know Cliff from his previous podcasts:

and his insanely good blog:

Cliff discusses a case of an out-of-hospital cardiac arrest that he has been ruminating about for the past few days. Here are the teaching points that came out of the case:

Can we lyse intra-arrest?

We will discuss this question in a future show. For now, I would say if you strongly suspect PE or MI and you have exhausted other options, intra-arrest lysis is still an option.

The pulse you feel in the groin may be the vein

During the discussion Cliff mentions that he demonstrated to his whole team that the pulse they felt in the groin was the femoral vein. Use ultrasound for all intra-arrest groin catheter placements.

Securing lines during a code

I use 2″ tape. Cliff mentions during the discussion and on his blog, using tissue glue instead.

Continue CPR if there is an a-line pulse, but the pressure is low

Otherwise these patients will just re-arrest. Here is an article on thoracic pump vs. cardiac pump.

Percussion Pacing

Never heard of this? Read this manuscript on percussion pacing.

The Ethics of Different Capabilities at Geographically Close Hospitals

I want to hear what you folks think about this. Should all sick patients be taken to the closest hospital that has the most potential life-saving capabilities? Is there ny reason to bring really sick patients to tiny hospitals if the trip to a more advanced hospital only adds a few minutes? Let me know in the comments what you think.

The Mind of a Resuscitationist – A Resuscitationist Agonizes

This is why I really wanted to post this podcast. I run a series called the Mind of a Resuscitationist. For instance, the episode on

Today’s episode hits another key point to a resuscitationist’s mind: we agonize. We dissect every case that did not go perfectly to figure out if there was ANYTHING that could have gone better, been done smoother. This obsession leads to ulcers and interrupted sleep patterns AND better outcomes in the future.

Please share your thoughts below. Now, on to the podcast…


Podcast 058 – Interview with Cliff Reid – Part II

This Part II of an interview with Cliff Reid of the amazing blog, resus.me. Cliff is truly a doc after my own heart as you will hear from the cast.

If you haven’t already, please listen to Part I of Cliff’s interview as well.

He is currently an EMS physician and Director of Training at the New South Wales Ambulance Service.

Cliff’s blog, resus.me is an incredible collection of timely articles on emergency medicine, ems, critical care and resuscitation.

Here are some details on what Cliff carries on a mission.

Prehospital Amputation

One of the topics we discuss is prehospital amputation. For more information on this topic, check out the deep-dive page on prehospital amputation.

Come visit me at ACEP and AOCEP Scientific Assemblies.

Now to the Podcast…


EMCrit Podcast 47 – Failure to Plan for Failure: A Discussion of Airway Disasters

Cliff Reid of Resus.Me fame put out an incredible post on NAP4, the audit done on all of the airway complications in Great Britain. It was such a phenomenal post that I got in touch with Cliff and asked if he wanted to come on the podcast to speak about it. He did me one better and got an interview with one of the authors of the Emergency and Critical Care Section.

So in this podcast, we interview Dr. Jonathan Benger, professor of Emergency Medicine with a particular interest in the management of the airway.

Points that came out of the show

  • Mortality is higher in the ED and ICU compared to the operating room. Our patients are sicker, so we must be more diligent in planning
  • Quantitative wave-form ETCO2 should be the standard of care for EVERY ED and ICU intubation
  • Needle cricothyrotomy seems to fail more often than surgical cricothyrotomy
  • Awake intubation was not used when it was indicated
  • Junior resident anesthesiologists were often responding to the ED and ICU
  • There was a failure to plan for failure
  • Obesity figured into a large percentage of the airway disasters
  • Airway operators were not prepared or just did not properly progress to surgical airway

For more from the NAP4

Executive Summary

Full Report (Skip to the EM/ICU Chapter)

How to subscribe to Cliff Reid’s Brand New Podcast

Great Conferences Coming Up


EMCrit Podcast 41 – Interview with Cliff Reid of RESUS.me

I was able to cajole Cliff Reid of the amazing blog, resus.me on to the EMCrit program. Cliff is truly a doc after my own heart as you will hear from the cast.

He is currently an EMS physician and Director of Training at the New South Wales Ambulance Service.

Cliff’s blog, resus.me is an incredible collection of timely articles on emergency medicine, ems, critical care and resuscitation.

Cliff mentions the HEMS service in London. This amazing service sends a physician/paramedic team to the scenes of bad traumas by helicopter and response cars. A well done video is available on youtube:

The winner of the Toxicology Handbook is Jenny Mendelson. Yeah!!!

photo by Mad Scientist

Click Here to Play the Podcast