No matter what aspect of emergency medicine you work in (EMS, fast track, main ED, rural, remote, urban, suburban, or whatever else), you need to be a resuscitationist in my book. This is entirely my opinion, but I believe it is important one worth your time in both reading and listening.
Envision a busy night shift. It is three in the morning and somehow you still have a waiting room full of people waiting to be seen in your small ED that is hours away by ground to tertiary care. Scattered thunderstorms and overwhelmed emergency services have made it difficult to transfer out patients. You would swear it was a full moon, but when you were outside just to get a quick breath of fresh air from all the chaos you look up and it is not. Suddenly, you hear sirens in the distance and EMS reports are all coming in at once...
We have all been there and it is not easy. The night that will not end. This time though, you are about to get truly busy. The first call from EMS is an attempted suicide with an overdose of unknown substances that has been vomiting and no airway could be secured. EMS mentions the patient is also very bradycardic especially between episodes of vomiting. Medications and transcutaneous pacing have initially failed no their attempts. They have a two minute ETA and they require immediate assistance. Not a problem by itself until two more reports come in. A head-on MVC with two poly-trauma victims are also coming in with an approximately 10 minute ETA. One has obvious pelvic and open lower extremity fractures. He is coming in and out of consciousness but has obvious blood loss. The other person was ejected from the vehicle and has significant head and facial fractures. Trauma to the face is so significant and the patient so critical that there has not been an attempt at an airway. EMS advises this may become a surgical airway.
You immediately start to align your staff to address the issues. Of course this happens on a night with low staffing. Just as the first ambulance comes in, your triage nurse yells over the radio that she needs help up in the waiting room. A pregnant patient with abdominal pain who is 32 weeks pregnant just come in to register and suddenly collapsed. The triage nurse is checking for a pulse now, but says she cannot find one quickly. What do you do?
There is no easy way to put this and you may not agree, but everyone who works in emergency medicine must be a resuscitationist. I do not care whether you are a tech, nurse, paramedic, NP, PA, physician, or anyone else for that matter. If you say you work in emergency medicine, you need to be able to resuscitate someone. This may not be your everyday situation, but emergency medicine and resuscitative care should not matter based on your geography. You may not have all the tools and resources available in urban tertiary care centers, but there is a lot you can still do to help patients.
The above situation can be overwhelming no matter the department setup for almost any community ED, but it can be especially challenging for the solo provider. Even with a second provider on staff at the time this is a truly difficult situation. Up to four airways would need controlled and two have a higher risk of becoming surgical. Two or three may require even mass transfusion protocols. All of them could require pressure support. One may even need transvenous pacing and another a resuscitative hysterotomy! This may sound like a fairy tale to some visitors of this site, but similar situations occur across the country and this author has been a part of several such instances.
What can you do about such events? This is not the time to learn how to perform a surgical airway. You do not have time to look up dosings of all the medications that could be used. This is a time when the training has to be already in place. If you are not at that level, you need to get there quickly, especially if you provide solo coverage. Even if you work in shop where there can be backup available to you, do not rely on them. Some of your colleagues may have worked longer, but that does not mean they have more skills or knowledge in resuscitation.
If you are not at that level yet, how do you get there? This is a long process and there is no easy solution that can be done in a short time. However, some of the first steps are learning the basics and getting safe experience. The merit badge courses like PALS, ACLS, and ATLS are excellent jumping points which is why they are often required. They are just the basics though and will not suffice when it comes to situations like the one above. Taking advance courses like the Difficult Airway Course or various ultrasound courses will help provide more complete care. When it comes to experience, get time at departments that tend to have higher acuity where you can learn from other colleagues. If this is simply not possible, attend as many training events as possible where there is time to practice skills (though this can be done anyway just to get hands-on time). Make sure courses you attend provide ample time and do not leave the workshops early that day!
What about after those classes or experience? How do you keep up the skills? Your mind is the best simulator in the world. Run through cases and make them difficult. In the beginning, this may be one situation, but with time this can be more complex. Think of all the "what ifs" and the actual details. Do not act like this is your board exam where you can simply say, "I would secure an airway in this patient." What does that mean? How much of what medications do you use? What happens if the patient becomes hypotensive? How could you have prevented that from happening? All of these and more are questions to play out in your mind.
If you are lucky (and this varies in frequency by department), use the downtime you have available. Yes, it may not feel like it now but you probably had a time not that long ago where the shift was low census and people went home early. There may not be anyone on the tracker or just a couple of patients who are waiting for things that have yet to be completed. This is the perfect time to brush up on skills or learn new ones. Every piece of equipment should be looked through thoroughly. If there are any expired kits or ones opened that cannot be used due to sterility, keep them. Use it for training purposes. Most facilities would be happy for you to keep them just to go through. The situation above would need you to be at the top of your game and not wasting time trying to figure out where all the pieces for your chest tube kit are located. Is there something in your department you do not use regularly or not sure how it operates? This is an excellent time to learn! Down-time can be a great way to be taught how to use every piece of equipment in the department. For the resuscitationist or for a good provider in general, everything in the department should be available to us and we should know how to operate it. Ask yourself if you know how to operate your ventilator or the Level One infuser. Go through everything and make sure you know how to run it, troubleshoot it, and what backup options exist should they fail.
What happens when you hit the point where you may need to perform skills above what you usually do on a daily basis? Maybe you are lucky enough to have specialists available to help, but what if they are 30 or more minutes away? Most truly emergent procedures cannot wait that long. Although you should never perform outside your scope of practice, you need to be able to perform as many procedures as possible and do so safely. Maybe ECMO and REBOA are not possible at your facility because you lack those resources, but you still need to know at least the basics of how they are performed and where patients who need such measures should go. One quick point is to make sure your privileges are as broad as possible. Try to even have a stipulation that advanced procedures can be performed on an emergent basis depending on an appropriate situation (such as rarely performed events like a resuscitative thoracotomy or hysterorotomy). As a warning, when performing such interventions, there may be backlash later but this should never prevent appropriate care. The late and great John Hinds had an excellent talk on this issue that everyone in emergency medicine should listen to at least once.
Remember that simply knowing what to do is not enough. It also takes being able to make the decisions to provide such care and the leadership to accomplish what needs to be performed. Cliff Reid provides an inspiring talk with "Making Things Happen" that helps better teach how to guide a resuscitation well and his "How to Be a Hero" talk hits on similar points making both worth the time listening. One important pearl to keep in mind is that everyone needs to share a mental model of events and plan ahead as much as possible. This can be done again in down-time by going through scenarios with staff or even just minutes prior to a patient coming in.
Overall, becoming a resuscitationist is not easy. There are very few people who can be truly experts in resuscitation to the likes of Scott Weingart, Cliff Reid, or John Hinds. To learn more you can also check out the Mind of the Resuscitationist podcasts and similar posting on EmCrit. Keep in mind that the change takes years and in all reality for most of us a lifetime, but the process is worth it when you can better serve your patients and save lives.
Let us know what you think by giving us feedback here in the comments section or contacting us on Twitter or Facebook. Remember to look us up on Libsyn and on iTunes. If you have any questions you can also comment below, email at firstname.lastname@example.org, or send a message from the page. Please check our bandwidth sponsor, FunnyRx, too. We hope to talk to everyone again soon. Until then, continue to provide total care everywhere.
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