by Darin Abbey

The Case
There you are working in the hospital when you and your team are called to attend an in hospital cardiac arrest [IHCA]. On your way to the patients room you think about the importance of getting in the right headspace to “run this code.” You scan your memory for lessons learned at your last ACLS course, and as you start to refresh the “H’s and the T’s” your recall is sideswiped by the uncomfortable memory of the chaos and confusion of that “other code.”

Upon entering the patients room there is a scrum of activity.

• Someone is performing chest compressions and asking for a step stool
• Someone is gathering IV access supplies while expressing the apparent difficulty of the access
• Someone has stationed themselves at the head of the bed and after placing an oral pharyngeal airway and is synchronizing bag valve mask ventilations with the chest compression provider
• Someone has turned on the defibrillator monitor and is placing the hands free defibrillator pads

Team first steps…
Slightly out of breath from the dash to the room, you inhale as you consider what choice leadership and followship strategies might be used to take this team of experts and quickly forge an expert team. What do you say to get this medical flash mob working in parallel to succeed in meeting the initial patient care priorities? What communication strategies will contribute to: a climate of safety, a shared understanding, and effectively obtaining the goals of resuscitation?

Medical first steps…
As the team works on the priorities of high quality CPR, questions begin to arise on the cause of the arrest and what interventions can be done to assure a positive outcome. Again the “H’s and the T’s” return to your mind. Here in the hospital bed, it is clear that the patient has not suffered the insults of a traumatic or hypothermic arrest, but what of the other causes? What is the frequency of the different causes of IHCA? How effective are clinicians at searching for and finding these various etiologies?

The Bottom Line…
During cardiac arrest, successful patient outcomes often hinge on teams abilities to negotiate the first steps of enacting high quality basic life support, and following this with the ongoing assessment and appropriate interventions of the secondary ACLS survey,  and the searching for and treating of reversible causes.

Suggested reading and to learn more:

West, M. and Lyubovnikova, J. (2013) Illusions of Team Working in Health Care. Journal of Health Organization and Management 27: 1, 134-142.

Bergum, D. et al. (2015) Causes of in hospital cardiac arrest – incidences and rate of recognition. Resuscitation 87, 63:68.

by Darin Abbey

Prior to flight, as the story goes the team in airplane cockpits employ the crew resource management strategy of “the sterile cockpit.” As I understand this practice, once established, the team in the cockpit can only talk about the task ahead which through the use of pre-flight checklists focuses the efforts, decreases distraction, and assures that key responsibilities are enacted. As a team, they may or may not have trained together, but as an industry the roles and the responsibilities are well understood. Informed through an ongoing series of case based iterations, flight crews have multiple checklists available to them. These checklists are finely honed and they assure that a commonality of practice is established. If things do not go well, the co-pilot may be asked to take control of the plane while the captain troubleshoots the situation.

Prior to your next code, can you imagine mirroring this arrangement with your Code Blue team? Can you imaging the team pre-briefing roles and responsibilities, honing in on lessons learned from recent events and reviewing checklists. Can you imagine “the sterile cockpit” being used to assure that only necessary conversation occurs? Can you imagine the code leader physician, turning to the code leader nurse and asking for the code to be run, while reversible causes are searched for?

As an industry might healthcare be able to prepare together and practice this way? What barriers can you imagine? How might they be overcome? What systems are in place to learn from recent events in the setting where you work? What role do checklists play in your resuscitations?

Suggested reading and to learn more:

Ornato, J. and Peberdy, M. (2014) Applying lessons from commercial aviation safety and operations to resuscitation. Resuscitation 85 173– 176

by Darin Abbey

THE CASE
There you are in your clinical arena when a patient presents with chest pain. Aspirin is administered, labs are drawn and an ECG is obtained which shows no time sensitive findings. Bedside monitoring is established, the patients vitals are all within normal ranges and after a targeted history and physical exam, the wait for the troponin begins.

THE CHALLENGE
A colleague notices that the patient is breathing room air and expresses concern that the patient is not receiving oxygen. As a savvy clinician you know that in the recent 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes it is suggested that “supplemental oxygen should be administered to patients with NSTE-ACS with arterial oxygen saturation less than 90%, respiratory distress, or other high-risk features of hypoxemia.” Following these guidelines, oxygen is not administered.

Further you know that if this patient encounter evolves into a STEMI the administration of oxygen may indeed cause harm.

LEARNING AND UNLEARNING
Like your colleague you too remember learning that oxygen met all comers with chest pain. Yet somehow along the way your practice changed. You learned, and you later unlearned. Perhaps this process was subtle and without angst or perhaps it was sudden and stressful. With the increasing pace of knowledge transfer within our industry, as quoted by Rushmore and Davies, Solovy notes that “… climbing the learning curve is only half the process… the other half is the unlearning curve.”

As a part of one’s commitment to being both an evidence-based clinician and a mind-full change agent, it is valuable to consider both of these processes. As we learn how to make the transition from old information to new, we may find both obstacles and opportunities for learning and practice change.

CONSIDERATIONS
How might you engage your colleague in a conversation about the changing role of oxygen in chest pain patients? Have you given much consideration to the dynamic process of learning and unlearning in healthcare? How might mastery of unlearning increase ones ability to learn?

Suggested reading and to learn more:

2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes

http://circ.ahajournals.org/content/130/25/e344

Avoid the oxygen reflex

http://www.scancrit.com/2014/11/26/avoid-oxygen/

The (Un)Learning Process

http://shortcoatsinem.blogspot.ca/2014/02/the-unlearning-process.html

Unlearning in Healthcare by Rushmore and Davies

http://qualitysafety.bmj.com/content/13/suppl_2/ii10.full.pdf+html

SGEM#49: Five Stages of Evidence Based Medicine Grief

http://thesgem.com/2013/10/sgem49-five-stages-of-ebm-grief/

by Darin Abbey

I remember when we used to talk about providing CPR to our cardiac arrest patients.

Then it became clear that we were not doing it well enough and so the industry started to refer to the need to provide High Quality CPR. Since then we are challenged both by the difficulty in defining exactly what the appropriate details of care are that comprise this intervention and likewise we remain challenged by ways to demonstrate ongoing clinical competence.

Recent years have provided continued research on what makes “best practice” chest compressions. Below are some facets of the 2010 Guidelines and possible changes that may be coming in the 2015 Guidelines:

In addition to continued enthusiasm for assuring “full chest recoil during chest compressions”, what is also likely not to change is the focus on systems of care and quality improvement. As Resuscitationists, both at the macro and micro levels we must continue to measure our performance and identify areas for improvement and strategies to do so.

And what about during CPR? Lately journals have discussed cases when CPR has been so strong that patients have regained consciousness. Resuscitation reports now exist of patients with purposeful movements, eye opening, localizing to painful stimuli, communicating with rescuers, and a few patients even understanding and adhering to voiced requests.

Such reports suggest that in a cartoon unreal world, that perhaps our goal during CPR should be to provide such great cerebral perfusion that our patients look to us and say, “You are doing a great job! Please keep it up!” Now that would be a measure of High Quality CPR to strive for.

However in our real world, the patient with apparent consciousness during high quality CPR presents an emotional and clinical challenge. In the absence of current guidelines recommendations teams may benefit from being informed of this possibility and considering potential clinical and emotional responses.

Suggested reading and to learn more:

Meaney P. et al. (2013) AHA Consensus statement on CPR Quality: Improving Cardiac Resuscitation Outcomes Both Inside and Outside the Hospital. Circulation.

http://circ.ahajournals.org/content/early/2013/06/25/CIR.0b013e31829d8654

Steill I. et al. What is the optimum chest compression depth during out of hospital cardiac arrest resuscitation of adult patients? Circulation 2014 Nov 25; 130 (22) : 1962-70

Olaussen A. et al. Return of consciousness during ongoing cardiopulmonary resuscitation: A systematic review. Resuscitation (2014), http://dx.doi.org/10.1016/j.resuscitation.2014.10.01