After the initial publication of the Resus Crisis Manual, a thread started on twitter

The Tweets that Inspired the Debate

Sorry, but if you need a "how to do it" bullet list to handle resus pts your no1 priority should be to call someone who does not need that list! #HQCC no excuses, no exceptions! https://t.co/05rj8wtdBk

— Joacim Linde (@HEMS_Doc) July 30, 2018

.The paradox is that a ”resuscitationist” (by def trained & prepped to handle resuspts?) does not need literature like the exmple StEp ch. & someone who needs such lists risks being lured into situations they shouldn’t handle alone (in places where these pts predictably appear!)

— Joacim Linde (@HEMS_Doc) August 1, 2018

Click here to see the whole thread

or don't b/c it is useless b/c twitter SUCKS…

Joacim Linde

Consultant Anesthesia. Critical Care/EMS/PHCC

Medical Director,  County Ambulance Consult Health & Social Care

Inspectorate Director Swedish P-EMS/PHCC course

My Response to the Tweets

Joacim

This debate seemed kind of muddled on twitter, which I imagine is due to space constraints.
As I understand things, a fellow flight doc make a positive comment about the book and your response was to state that anyone who needs the RCM is someone who should not be taking care of resus patients and they should promptly call someone who doesn’t need the book in order to take care of these patients.

Further, can we accept as a given that a book such as this (or an idealized version thereof if this one happens to stink) can be incredibly useful for trainees not actually engaged in a resuscitation (i.e. during their study time)

I assume we agree on that one, so the real crux of the question is does an idealized version of a book such as this, which i will refer to as a resus Quick Reference Handbook (rQRH) have value in the midst of an actual resus.

My argument is that is does and I will make my argument from 3 points in time:

You have advanced notification of a patient in a Resus Setting

Most of the protocols in this book are infrequently encountered emergencies. Every resus doctor should know the bold face actions by heart (the entire left side are only bold face actions–used the same way as in aviation) [edit.-if you want to understand the boldface, listen to Novak's lecture] and easily be able to accomplish excellent care if they had no such book to review ahead of the emergency. Reviewing the right hand side for drug doses, etc. for something a resus doc may see once every 2 years doesn’t deserve the opprobrium you seem to assign the action

You have stabilized the Resus patient

Reviewing both the boldface and non-boldface actions as a cross-check seems very reasonable for emergencies you trained on, but see infrequently. Again it would seem unfair to malign a doc who felt reassured by this. Further this is precisely what is supposed to occur for all boldface actions in aviation once the crisis has been stabilized.

During the Critical Portions of the Resus Itself

I agree with you that any resuscitationist should have no use for a rQRH during the resus.

But there are a host of other providers who might. The one that springs to mind immediately is the community ED doc that may see any of these emergencies once every ten years. You can make the argument all you want that someone that only sees these issues once a decade shouldn’t take care of them but that is a pipedream. These are usually the only docs in these hospitals for many hours of the day and they are definitely going to transfer these pts to a bigger hospital, but that doesn’t account for the hour to hours that they need to care for these patients. If you accept that this situation exists, would you rather they had a rQRH or not. I would rather it was available.

I can think of a bunch of other cases where it would be great to have a resus-only doctor caring for a patient, but that just is not possible for a set period of time in which the pt can get much worse without proper care.

But the argument you seem to be making in the thread that sparked this is that there is a group of doctors that would ordinarily get help, but now armed with the rQRH will suddenly feel emboldened to not call for help/not transfer a sick patient. This is what I referred to as a straw man. I don’t see how this is anything but a speculative hypothetical. Who is this group? I can’t picture them in the States–perhaps your practice pattern is different. Nobody I can imagine would be in a position to take care of these patients in a situation where a rQRH would change whether they called for help vs. not. The only one I can come close to imagining is the Aussie ED registrars where there is no consultant in-house night coverage. But in those cases, the rQRH can be incredibly helpful while they are waiting for their consultant to arrive.

But even in these cases, I can’t see anyone running an actual resus in real time with this book open in front of them, that seems similar to the apocryphal stories of operations being performed with a nurse reading out the steps of the operation. That may have occurred but probably not in our generation.

My entire job is resus–that is all I do every day of the year. I think you are in a similar gig. I also spent 4 years editing this book. If anyone has the training and experience not to need this book, I think it is me. And yet I will happily look it over pre or post uncommon emergencies b/c I am not perfect, my cognitive faculties are often stressed by the 12 other critically ill patients I am caring for and the chaos that is my unit. If you truly think that makes me someone who shouldn’t be practicing resus, by all means tell me that.

So do I need this book? It depends on what you mean by need. Can I resus any situation in the book without the book–yes. Can I do it as well EVERY TIME in every circumstance regardless of what else is going on, probably not. That is my definition of need.

Crisis has a couple of different definitions in English. You have taken umbrage at any emergency being described as a crisis by a resus professional–so it seems you are using the definition of a time of intense difficulty and perhaps this is the source of our disagreement. The crisis of the RCM is defined by a time of critical decisions.

Joacim Responds

Scott,

Your arguments are well phrased, and there are certainly many ways checklists are beneficial. Having said that – I still believe the type of manual (as opposed to short checklists) we are discussing can create a problem, and I wish to elaborate a bit on this.

I would state that – with or without a manual – true quality of care in resuscitation is impossible unless the provider has advanced training combined with continuous exposure to these patients.

In certain contexts, such as South Africa (or perhaps Baltimore?), continuous exposure is perhaps not an issue. Many other regions, such as Scandinavia, have the opposite “problem” – true traumatic (and medical) emergencies are scarce, and it´s actually difficult for providers to get training, and uphold experience.

Our medical tradition and way off solving this has been to limit the number of providers, thus increasing exposure for the individual. Generally this philosophy is not controversial – for instance “General Surgery” is a rare phenomenon. In all areas with adequate resources we concentrate patients into places like – Liver Transplant Centres, Paediatric Surgery Units, and Trauma Centres where we strive to concentrate cases, thus increasing exposure.
The demand for quality is non-negotiable in a modern world context. One would hardly be trusted to operate on a ruptured AAA or do the PCI of a STEMI alone without documented and upheld expertise in one´s specialty.
Of course, handling resus with maximum available proficiency is just as necessary!

In Scandinavia the Anaesthesia/ICU doctors are the “resuscitationists”, a mandate received by dedicated training and continuous exposure in the ICU and operating theatre, as well as traditionally for all resus cases – inhospital answering resus calls in the ED and in regular wards and prehospitally by responding by ambulance helicopters and rapid response cars to patients in need of prehospital intensive care. This is our version of “bringing upstairs care downstairs (and even out the doors)”. In this way, we guarantee that also the resus patient gets medical care of adequate quality wherever they may fall sick.

In extreme rural areas, or in third world contexts, it may not be realistic to have this type of team continuously available. There are situations where circumstances are such that an inexperienced doctor really NEEDS to immediately assess and treat truly failing vital signs. Different well known concept courses originally catered for these needs. It is my belief that a manual as the one discussed could help in these situations. However these types of aid often represent a minimum acceptable standard and a manual aimed at these situations will have to responsibly handle the level of care that the user of the manual safely can reach.

Our opinion is that this situation is very rare, and virtually NEVER the case in rural Scandinavia. And in our type of western context it is- in our opinion- always a better idea to call for help than to try to solve the problem oneself. Even with the best reference manual in the world.

Can the specialized resuscitationist be helped by, a quick reference manual? The easy and short answer is, of course he can.
Like yourself I will however answer also by asking myself that question, will I read it and would I really need it?
It will undoubtedly be a popular book and part of my responsibility is to be updated. Therefore, I have read it. (and naturally after 20+ years in hospital and prehospital CC I strongly disagree with lots of things in it 🙂 that however is not the point)

The problems with writing a book in a format where the reader expects ready to follow “recipes” is that as soon as you put down any advice in writing you lose the individual flexibility and the ability to, in your advice, cater for the inter-individual differences that make up for most of the challenges to reach high quality resuscitation.

Ultimately, the “tailored treatment” that is one of the reasons I'm there, risks being lost.
I would not bring the book to resus.
Most of all I would constantly be worried that my junior colleagues would bring the book instead of preparing in advance and most importantly, instead of calling me!

Why?

I'll let you in on a little secret Scott. All through my studies, both to a M.Sc. and civil engineer degree in computer science and later to an M.D. I wrote “cheat sheets” for the exams.. Luckily the sweaty small notes stayed in my pocket and I never had to use them. You see, by the time I meticulously had written, processed and condensed even the most difficult mathematical theorem on a small piece of paper I not only knew it by heart but actually understood it.
Don’t take me wrong, I’m not calling a manual “cheating” but I do think that if I would have bought these notes ready-made the risk of me having to use them would have increased tremendously. With such a strategy I also know I would have been a much worse doc.

Knowledge is a lot about the process where you acquire it and understanding something beats knowing it by heart every day of the week and even just knowing something by heart beats reading it from a list by a mile. Also in resus!
I want my junior colleagues to understand what they should do and also why.
Being by their side during resus gives me the opportunity to tutor and teach them as best I can.

But the real problem (at least in Scandinavia) is this:

Most patients are not “champagne and glamour”. They are Hip Fractures and Urinary Tract Infections, they are Psychiatric and Social Problems, Old Age and Loneliness. It is not always thrilling and exciting, it is frequently unrewarding. This is the reality for most doctors. Particularly the work of the ER doctors, who face the unfiltered problems of our society and the bulk of patients, is unappreciated. Few patients need resus, it´s very different from TV series like “ER” and “Grey´s Anatomy” that some of them watched before starting medical school. And – though clearly one of the prime medical advances of the last decades, spreading knowledge like never before – the FOAM community and the glamourous SMACC conference also focuses on Resus to a very high degree.

I believe you have described a bit of this in your SMACC talk “ER is a failed paradigm”. Though that of course was a deliberately provocative title, that neither you nor I believe in, there are aspects of truth to this. It is a real problem for many, particularly young, ER doctors in Sweden where the specialty is new, and in the process of “finding its place” in the existing health care structure. What new ER doctor doesn´t listen to Emcrit, and dream of doing just what Scott Weingart does?

I therefore understand, and truly sympathize with, doctors trying to do as much of the resus as possible themselves, and using a quick reference manual to solve the issues they are so rarely exposed to is a tempting quick fix. But I also truly feel it is not in the best interest of the patients in our context. I believe there is a real danger that young colleagues are being lured into situations they are not ready to handle by themselves.

Instead, the actual work in the ER must be more appreciated, such as it is. This is a responsibility for the society as a whole – news reporters, politicians and hospital management. It is also a responsibility for the FOAM community and even the SMACC conference.

At least in our part of the world high quality resuscitation ultimately and undisputedly depends on concentrating the patients on specifically dedicated “resuscitation specialists” (in Scandinavia presently Anesthesia and intensive care), defined by their competence rather than by their ambitions. To comply with health legislation here these must be able to uphold ICU quality to their resus and the training of these must include regular and frequent exposure to patients with failing vital signs, good environment specific training and theoretical studies that promote understanding of not only “how to” but just as importantly “why”.
Such a specialty will be able to uphold high quality of care in the resus situation wherever it may be – inhospital or out of hospital.
Finally, a manual like the one discussed would for these resuscitationists be one of many tools that, when used wisely, certainly could help promote quality of care.

/Joacim

My Thoughts after reading Joacim's Reply

Twitter is Crap!

The thought foremost in my mind is that twitter is perhaps the worst thing that has ever happened to discourse. I read the comments on twitter and think what is wrong with this person, they are obviously deluded or are they deliberately trolling. Then I read the actual thoughts behind the 280 characters and think that not only do I almost entirely agree with this person, but based on words alone there is a kindred soul out there. How can those two impressions be diametrically opposed–simple, twitter is garbage. Twitter breeds discontent and misunderstanding; I would go so far as to say it is built to do so.

Now, clearly I should have listened to the miniature Jenny Rudolph sitting on my shoulder. When I read Joacim's twitter comments and said to myself, “What the F&*k,” I should have immediately asked instead, “What's their Frame?” The problem is I would have had no idea what Joacim's frame was. Luckily he has enough intellectual fortitude to want to spend the time to actually craft his thoughts in longform–if this was a requirement for every snarky comment on twitter, how many tweets would remain?

Where Joacim Changed My Mind

Now that I have gotten to ruminate on Joacim's comments I can see how we can both be right and why I initially could not understand where he was coming from. In fact in many ways, he did my baseline ethos better than I did. If you look at books that serve the role of rQRH from a perspective of what they can do from a system perspective, they might be net negative because they inspire the very failed paradigm i have railed against in the past. While it was not my intent to create a roll of duct tape to fix a broken system of dedicating the right resources to ED resuscitation, the book may very well serve as just that. I edited the book from a place of optimism with the mindset of its use by true resuscitationists and perhaps to make situations better while waiting for help. But Joacim is correct, when looking at a book such as this from a more pessimistic perspective it may be a tiny little pontoon on a ship that should sink.

I still love the book and think it can help a ton of people and maybe that will trickle down to helping a few patients, but I see what Joacim is saying.

What do you think?

Let us know in the comments below. And if you think Joacim coming on the show to talk about creating systems of excellence, put that in the comments as well b/c he is on the fence.

Pertinent Literature Mentioned in the Comments Below

• An Excellent Review of Aviation Checklists Pertinent to Healthcare¹

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Scott Weingart

Editor-in-Chief, EMCrit.org at EDECMO LLC

An ED Intensivist from NY. No conflicts of interest (coi).

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