Tag Archives: human factors


The non-intubation checklist

no-sm

Scenario:

A 79 year old previously well female presents with loss of consciousness, having been found unresponsive by her daughter who saw her well one hour previously.

Examination reveals a GCS of E1V2M3 = 6 and reactive pupils with no lateralising signs. She is hypertensive. A VBG reveals a normal glucose and sodium and a pCO2 of 60 mmHg (7.9 kPa).

The emergency physician’s plan is to intubate and get a CT scan of her brain. This is explained to the daughter.

A no-brainer? You’d think so.

A consistent issue that recurs during discussions with UK emergency medicine colleagues is that of having to rely on anaesthesia and/or ICU colleagues for intubation of their patients in the ED. The pain comes not from disagreeing about who does the procedure or what drugs to use, but rather on the decision to intubate.

The refusal to intubate can stall or halt a resuscitation plan, delay care, result in risky transfers to the imaging suite, and even deny potential outcome-improving therapy (for example post-ROSC cooling). It can undermine team leadership and disrupt the team dynamic.

There are often different ways to ‘skin a cat’ and it is frequently helpful to invite the opinion of other critical care specialists. However, it is clear from multiple discussions with frustrated EM colleagues that the decision not to intubate is often influenced by non-clinical factors, most often ICU bed availability. Other times, it appears to be that the ‘gatekeeper’ to airway care (and to ICU beds) does not share the same appreciation of the clinical issues at stake. Examples here include the self-fulfilling pessimism post-ROSC based on inappropriate assignment of predictive value to neurological signs, and the assumption of non-treatable pathology in elderly patients presenting with coma.

The obvious solution to this is that the responsibility for managing the ‘A’ of ABC should not be delegated to non-emergency medicine personnel. Sadly, this is not achievable 24/7 in all UK departments right now for a number of awkward reasons.

So what’s a team leader to do when faced with a colleague’s refusal to intubate? The best approach would be to gently and politely persuade them to change their mind by stating some clinical facts that enable a shared mental model and agreed management plan, and to ensure the most senior available physicians are participating in the discussion.

Sometimes that fails. What next? Here’s a suggestion. This is slightly tongue-in-cheek but take away from it what you will.

It is imperative that the individual declining intubation appreciates the gravity of his or her decision. They must not be under the impression that they’ve done you (and the patient) a favour by giving their opinion after an ‘airway consult’. They have declined a resuscitative intervention requested by the emergency medicine team leader and should appreciate the consequences of this decision and the need to document it as such.

Perhaps say something along the lines of:

I see we haven’t managed to agree on this. We’ll just need you to complete the non-intubation form please for our quality improvement process. This will also help prevent your point being forgotten or misunderstood if we’re unlucky enough to face any complaints or litigation. I can fill it in on your behalf but I suspect you’d want to represent yourself as accurately as possible when documenting such a bold decision

And here’s the form. It is provocative, cheeky, and in no way should really be used in its current form:

nonintubationchecklistsm

Beherrsche die Reanimation

TLsm-icon The whole purpose behind my career and this blog is to save life. Like most emergency physicians I don’t see a huge number of resuscitation patients myself in a given week, so my best hope in making a difference is to develop my teaching skills so that I can motivate and inspire others to improve their ability to manage resuscitation.

The highlight of my week therefore has been the receipt of some email feedback from a colleague in Germany. An intensivist, internist, and prehospital doctor (I like him already) who tells me he found my ‘Own the Resus‘ talk helpful:


Dear Dr. Reid,

Few days ago, too tired too sleep after a long shift on my ICU (18 beds internal medicine ICU, I am specialist in internal medicine specialized in intensive care and prehospital emergency medicine in a major German city) I watched your talk via emcrit podcast. I was immediately caught, I soaked in every word, I was fascinated, watched it twice in the middle of the night and next afternoon I listened to it in my car driving to work.

At this very day I did some overdue crap beyond the end of my shift when I heard the ominous shuffling of feet and rolling of the emergency cart from the other end of the ward… “I think we need your help….”

There it was, difficult airway situation. Patient crashing.

Then what followed was a kind of “out of body experience”. I did what was necessary, made things happen like calling anesthesia difficult airway code, calling the surgeons, organizing fiber optics and meanwhile trying to secure that airway myself until i could dispatch anesthesia to the head and surgeons to the neck. Within few minutes there were 6 doctors and 5 nurses shuffling on 9 square meters…

I found myself 1 meter behind the foot end of the pts bed and with your talk in my head I found me consciously controlling the crowd. There was suddenly the messages of your talk and there was me. I don’t know how to put it into words, I wouldn’t have done something else in medical terms but thanks to your talk I had the vocabulary, the tools to reflect myself as the leader to be in charge of the situation somehow with more distance, and after a successful resus the 10 people involved in this code went off with a good feeling that everybody contributed in what they could and all for the pts benefit.

Your talk was a kind of transition to the next level for me: from the colleague who asks how to get out of trouble in many situations because he was often deeply in trouble, to the one who leads out of trouble.

With your talk many things suddenly became clear and I am looking forward to be able to work harder on this role of leading.

Thank you very much.

D

Save a life by watching telly?

BB2.055If you’re in the United Kingdom on Thursday 21st March please consider watching BBC’s Horizon program at 9pm on BBC2.

I’m in Australia so I’ll miss it, but I’m moved by the whole background to this endeavour and really want you to help me spread the word.

Many of you will be familiar with the tragic case of Mrs Elaine Bromiley, who died from hypoxic brain injury after clinicians lost control of her airway during an anaesthetic for elective surgery. Her husband Martin has heroically campaigned for a greater awareness of the need to understand human factors in healthcare so such disasters can be prevented in the future.

Mr Bromiley describes the program, which is hosted by intensivist and space medicine expert Dr Kevin Fong:


Kevin and the Horizon team have produced something inspirational yet scientific, and – just as importantly – it’s by a clinician, for clinicians. It’s written in a way that will appeal to both those in healthcare and the public. It uses a tragic death to highlight human factors that all of us are prone to, and looks at how we can learn from others both in and outside healthcare to make a real difference in the future.

The lessons of this programme are for everyone in healthcare.

It would be wonderful if you could pass on details of the programme to anyone you know who works in healthcare. My goal is that by the end of this week, every one of the 1 million or so people who work in healthcare in the UK will be able to watch it (whether on Thursday or on iPlayer).


From the Health Foundation blog

Please help us reach this 1000 000 viewer target by watching on Thursday or later on iPlayer. Tweet about it or forward this message to as many healthcare providers you know. Help Martin help the rest of us avoid the kind of tragedy that he and his children have so bravely endured.

For more information on Mrs Bromiley’s case, watch ‘Just a Routine Operation’:

Cliff

Dogmalysis

dogmaticI made up a word a while ago: “dogmalysis”. It refers to the dissolution of authoritative tenets held as established opinion without adequate grounds.

DOGMA: something held as an established opinion; a point of view or tenet put forth as authoritative without adequate grounds

LYSIS: a process of disintegration or dissolution (as of cells)

It’s my favourite thing in medicine. I don’t know why – perhaps because of my admiration since childhood for irreverent scientists who questioned authority, like Feynman and Sagan. Or perhaps it is because I think at times we physicians need to experience the humility of having our ignorance exposed. This is necessary to keep medicine science-based.

My undergraduate and much of my postgraduate training consisted of being taught medical certainties that I was required to regurgitate under exam conditions. The reality of clinical practice then revealed the awesome irreducible complexity of biology in our patients who ‘don’t read the textbooks’. As we learn in emergency medicine to navigate the perilous Bayesian jungle to a ‘very unlikely’ or ‘very likely’ life-threatening diagnosis, and when we have to weigh up the benefit:harm equation of an intervention that could either kill or cure, we begin to appreciate that certainty without evidence – dogma, or faith – can be lethal.

The problem is, however, that our human brains seem to thrive on it. We have evolved a whole senate of cognitive biases, which enable us to function well in everyday social situations, but which prevent us from conducting an impartial analysis of objective clinical data. An enlightening example of the degree to which our interpretation of the same information can vary is illustrated by a handful of trials on fibrinolytic therapy for stroke, producing a spectrum of reactions from aggressive promotion to skeptical opposition.

Being human, I have no doubt that I am occasionally dogmatic about topics to which I erroneously believe I have applied skepticism. I appreciate the courage of trainees who have the guts to challenge my assertions and who demand the evidence to justify them. Keep doing it. Keep asking. Keep challenging.

Keep lysing the dogma.

No-one said it better than Carl:

Dogmalytic posts

 

 

On chicken bombs and muppets

I want to clarify some terminology I use on a day-to-day basis, which is now so ingrained in my vocabulary that I forget that its meaning may not be obvious to all.

“You go in there and it looks like a chicken bomb has gone off…”

“..external muppet factors can delay preparation for transport”

Muppets

muppetJFThe first is ‘muppet’. This does not refer to the much loved and trademarked invention of Jim Henson, (and now property of Disney) – a word originally thought to be a synthesis of ‘marionette’ and ‘puppet’. If I were referring to these wonderful icons of children’s televisual theatre I would capitalise the ’m’. Nope. I refer to the British meaning, which the Oxford English Dictionary lists as: ‘an incompetent or foolish person’. However I apply it in the context of behaviour rather than character. A wealth of evidence has proven that good people can do bad things given the circumstances, and situational factors can lead us to behave in a way that we would not normally consider to be correct.

Certain situations can therefore lead our behaviour to at least appear to be incompetent or foolish. So perfectly good clinicians can appear to act like muppets during a resuscitation, given the circumstances. Various environmental and psychological factors contribute to this. Those factors generated within our own brains or bodies that influence our personal behaviour and performance have been called ‘internal muppet factors’. These include various cognitive errors such as inattention or fixation, or simple physiological stresses like fatigue or hunger. Those that relate to external forces such as environmental pressures or interaction with other team members are grouped under ‘external muppet factors’. These are most often a consequence of poor leadership and communication, and a lack of a shared mental model and agreed mission trajectory.

I had the privilege of working with Norwegian critical care doctor Per Bredmose, aka Viking One. He and I coined the terms internal and external muppet factors as a framework for debriefing resuscitation cases when attempting to understand the human factors involved. This was when we worked together in the UK in Basingstoke, where for the duration of my tenure we had a sign up on the wall in the resus room saying ‘No muppets’ (this now lives in my office in Sydney).

muppetpostercropped

Chicken Bombs

muppetCRWhen the external muppet factor is allowed to escalate unchecked, the end result is frenetic activity and noise from the staff without coordinated meaningful intervention for the patient. Comparisons with ‘headless chickens’ are often drawn. In particularly challenging scenarios, it can appear that the panic has swelled to such magnitude that it goes nova, as though the headless chickens have actually exploded, metaphorically filling the room with a gruesome blanket of giblets and a snowstorm of feathers, clouding ones ability to assess and manage the patient effectively. This high-point of group anxiety and ineffectiveness is what I mean by the term ’chicken bomb’, and I bet most readers of this blog will have witnessed the detonation of one.

I credit the invention of this term to emergency and prehospital physician James French, a master resuscitationist and human factors wizard who also introduced the idea of clinical logistics to us.

So, next time you encounter muppets and chicken bombs, feel free to use the terminology, although preferably not during an actual resus with those who might take it personally.

James French and Cliff Reid engaging in some muppetry, England, 2004

Speeding things up through equipment design

Ever been at a cardiac arrest resuscitation where someone’s opening and closing drawers at great speed but failing to retrieve the drugs or equipment you’ve asked for urgently?

What if your resus trolley were designed by team of clinicians, engineers, and designers? Such a project was achieved through a collaboration between Imperial College London and the Helen Hamlyn Centre for Design, and the award-winning result was called the ‘Resus:Station’.

The trolley separates into three trolleys for airway, drugs and defibrillation, and circulation. The contents are visible from the outside.

Image from Pubmed Free Full Text Article

As well as improving access to equipment, the trolley can log the team’s actions during each resuscitation attempt. It can also provide an instant display of its readiness for use by recording the removal and replacement of each item.

In a randomised comparison with a standard resus trolley, a number of measures of efficiency and team performance were significantly better using the Resus:Station during simulated cardiac arrest resuscitations.

It appears to be specifically designed for cardiac arrest situations rather than ‘resus’ in its wider context. The most recent article (cited below) reports that a newer prototype is being developed prior to the manufacture of the final product.

For an in depth discussion of how resus room layout can optimise efficiency, check out Minh Le Cong’s PHARM blog and podcast with James French and Scott Weingart on Clinical Logistics

The “Resus:Station”: the use of clinical simulations in a randomised crossover study to evaluate a novel resuscitation trolley.
Resuscitation. 2012 Nov;83(11):1374-80 Free full text

BACKGROUND AND AIM: Inadequately designed equipment has been implicated in poor efficiency and critical incidents associated with resuscitation. A novel resuscitation trolley (Resus:Station) was designed and evaluated for impact on team efficiency, user opinion, and teamwork, compared with the standard trolley, in simulated cardiac arrest scenarios.

METHODS: Fifteen experienced cardiac arrest teams were recruited (45 participants). Teams performed recorded resuscitation simulations using new and conventional trolleys, with order of use randomised. After each simulation, efficiency (“time to drugs”, un-locatable equipment, unnecessary drawer opening) and team performance (OSCAR) were assessed from the video recordings and participants were asked to complete questionnaires scoring various aspects of the trolley on a Likert scale.

RESULTS: Time to locate the drugs was significantly faster (p=0.001) when using the Resus:Station (mean 5.19s (SD 3.34)) than when using the standard trolley (26.81s (SD16.05)). There were no reports of missing equipment when using the Resus:Station. However, during four of the fifteen study sessions using the standard trolley participants were unable to find equipment, with an average of 6.75 unnecessary drawer openings per simulation. User feedback results clearly indicated a highly significant preference for the newly designed Resus:Station for all aspects. Teams performed equally well for all dimensions of team performance using both trolleys, despite it being their first exposure to the Resus:Station.

CONCLUSION: We conclude that in this simulated environment, the new design of trolley is safe to use, and has the potential to improve efficiency at a resuscitation attempt.

The Resus Room Life Guard

armstriconI was lucky to be accompanied through much of my emergency medicine training and specialist work in the UK by Bruce Armstrong. We shared many resuscitation cases together in hospitals and in prehospital care.

When preparing the team in resus, Armstrong used to appoint a ‘safety officer’. This could be a nurse or physician – it didn’t matter. Their role was to stay hands-off and be the eyes, ears, and mouth that would identify impending hazards and verbally intervene to thwart them.

This process seemed so natural that I rarely gave it a thought, but its glaring absence from every place I’ve worked since has only recently hit me.

Because my son goes swimming.

Photo on 29-12-12 at 10.31 AMMy three year old son attends a swimming class. There is usually one other child in the class. Recently a third child joined the class and I found myself getting uncomfortable. How could the instructor stay vigilant? What if while holding one child one of the others sank under water out of her field of view? My own obsessive reading about the limitations of human perception and cognition has convinced me that no-one can really focus on more than one thing at a time.

A friend of mine has coached kids at swimming so I asked him how they solve this. The answer was obvious – you rely on the life guards whose sole role is look out for everyone’s safety. Duh.

And then it came to me. Armstrong knew this all along. He got this idea from his prehospital experience working with fire & rescue crews and brought it into the ED. It didn’t occur to me that no-one else did this. It was just him.

Keen to explore whether anyone else had embraced this idea, I decided to go to the top when it comes to patient safety, and contacted Martin Bromiley. He told me he hadn’t come across the role in this specific setting, although did point out a great example from the BBC Documentary ‘Operation Iceberg’, in which ‘a group of scientists boarded an iceberg with someone watching over the big picture of polar bears and the berg cracking as well as fog etc’. Martin directed me to the Clinical Human Factors Group on LinkedIn, where interest was shown in the concept although it was apparent others haven’t come across it.

I went back to Armstrong to push him on further thoughts:


Yes a thought….in every other high risk environment they have a specific safety officer, whether it be nuclear industry, airline etc.

The role is specific not an add on to another role.

In healthcare we are seen as successful the more we do by one person. Think lean… think ‘efficiencies’ in the health service. Other industries focus on safety. Get safety right, your brand is safe and the public go with you. If you don’t put safety first it is only a matter of time before disaster strikes. In healthcare we have too many serious incidents. The time has come to believe in and practice safety in health care rather than ticking boxes and not applying CRM and human factors.


One such example from industry shows that safety officers may use checklists, such as this one from the Australian Maritime Safety Authority in response to an oil spill.

So here’s a proposed one for a Resuscitation Room Safety Officer. It’s a first draft to get the idea out there and start the conversation – just click the image below to enlarge. I’ve written (and used) checklists in resus before, but none specifically for a safety officer.

Safety Officer Checklistsm

I would like to hear if anyone’s already doing this anywhere, and how it’s been working.

Cliff

Perimortem Caesarean Delivery: Late is Better than Not


“To date, approximately one-third of the women who die during pregnancy remain undelivered at the time of death”

Guidelines recommend cardiac arrest in pregnant women beyond 20 weeks gestation should be treated with perimortem caesarean delivery (PMCD) commenced within 4 minutes of arrest and completed within 5. These time intervals come from two papers, neither of which is current or used robust review methodology.

To address this, an up-to-date fairly comprehensive review was undertaken of published cases of maternal cardiac arrests occurring prior to delivery. The primary outcome measures were maternal and neonatal survival to hospital discharge and the relationship between PMCD and this outcome.

The Arrests

94 cases were included in the final analysis.Most pregnancies were singleton (90.4%, n = 85) with an average gestational age at the time of the arrest of 33 ± 7 weeks (median 35, range 10–42).

The most common causes of arrest were trauma, maternal cardiac problems, severe pre-eclampsia and amniotic fluid embolism, together comprising about 70% of arrests; two thirds occurred in hospital.

The Outcomes

Overall, return of spontaneous circulation (ROSC) was achieved more often than not (60.6%) and overall survival to hospital discharge was 54.3%

Only 57 cases (75%) reported the time from arrest to delivery; the average time was 16.6 ± 12.5 min (median 10, range 1–60), with only 4 cases making it under the advocated 4-min time limit.

Timing of PMCD and Maternal Survival

In cases undergoing PMCD the average time elapsing from arrest to PMCD was significantly different between surviving (27/57) and non-surviving (30/57) mothers [10.0 ± 7.2 min (median 9, range 1–37) and 22.6 ± 13.3 min (median 20, range 4–60) respectively (p < 0.001, 95%CI 6.9–18.2)].

Timing of PMCD and Neonatal Survival

Mean times to PMCD were 14±11min (median=10, range=1–47) and 22 ± 13 min (median = 20, range = 4–60) in neonatal survivors and non-survivors respectively (p=0.016)

In cases with PMCD which reported outcome, the overall neonatal survival rate was 63.6% (42/66).


“The 4-min time frame advocated for PMCD usually remains unmet yet neonatal survival is still likely if delivery occurs within 10 or even 15 min of arrest”

Both maternal & neonatal mortality were higher with prehospital arrest location.

Summary

The study may be limited by recall bias, under-reporting and publication bias, but provides a more comprehensive evidence base on which to base resuscitation recommendations. The authors provide a useful warning against becoming fixated with the recommended four minute window, which may lead teams to fail to attempt a potentially life-saving intervention:


“Fixation on specific time frames for PMCD may not be ideal. It may be more important to focus on event recognition and good overall performance…. It may be wise to advocate a short time frame for performance of PMCD in order to achieve better outcomes; however, blanket endorsement of an unrealistic time frame may well create a defeatist attitude when that time frame cannot be met.”

Maternal cardiac arrest and perimortem caesarean delivery: Evidence or expert-based?
Resuscitation. 2012 Oct;83(10):1191-200


AIM: To examine the outcomes of maternal cardiac arrest and the evidence for the 4-min time frame from arrest to perimortem caesarean delivery (PMCD) recommended in current resuscitation and obstetric guidelines.

DATA SOURCES AND METHODS: Review and data extraction from all reported maternal cardiac arrests occurring prior to delivery (1980-2010). Cases were included if they provided details regarding both the event and outcomes. Outcomes of arrest were assessed using survival, Cerebral Performance Category (CPC) and maternal/neonatal harm/benefit from PMCD. Outcome measures were maternal and neonatal survival.

RESULTS: Of 1594 manuscripts screened, 156 underwent full review. Data extracted from 80 relevant papers yielded 94 included cases. Maternal outcome: 54.3% (51/94) of mothers survived to hospital discharge, 78.4% (40/51) with a CPC of 1/2. PMCD was determined to have been beneficial to the mother in 31.7% of cases and was not harmful in any case. In-hospital arrest and PMCD within 10 min of arrest were associated with better maternal outcomes (ORs 5.17 and 7.42 respectively, p<0.05 both). Neonatal outcome: mean times from arrest to delivery were 14±11 min and 22±13 min in survivors and non-survivors respectively (receiver operating area under the curve 0.729). Neonatal survival was only associated with in-hospital maternal arrest (OR 13.0, p<0.001).

CONCLUSIONS: Treatment recommendations should include a low admission threshold to a highly monitored area for pregnant women with cardiorespiratory decompensation, good overall performance of resuscitation and delivery within 10 min of arrest. Cognitive dissonance may delay both situation recognition and the response to maternal collapse.

Life, limb and sight-saving procedures

The challenge of competence in the face of rarity

by Dr Cliff Reid FCEM, and Dr Mike Clancy FCEM

This article is to be published in Emergency Medicine Journal (EMJ), and is reproduced here with permission of the BMJ Group.

Emergency physicians require competence in procedures which are required to preserve life, limb viability, or sight, and whose urgency cannot await referral to another specialist.

Some procedures that fit this description, such as tracheal intubation after neuromuscular blockade in a hypoxaemic patient with trismus, or placement of an intercostal catheter in a patient with a tension pneumothorax, are required sufficiently frequently in elective clinical practice that competence can be acquired simply by training in emergency department, intensive care, or operating room environments.

Other procedures, such as resuscitative thoracotomy, may be required so infrequently that the first time a clinician encounters a patient requiring such an intervention may be after the completion of specialist training, or in the absence of colleagues with prior experience in the technique.

Some techniques that might be considered limb or life saving may be too technically complex to acquire outside specialist surgical training programs. Examples are damage control laparotomy and limb fasciotomy. One could however argue that these are rarely too urgent to await arrival of the appropriate specialist.

The procedures which might fit the description of a time­‐critical life, limb, or sight saving procedure in which it is technically feasible to acquire competence within or alongside an emergency medicine residency, and that cannot await another specialist, include:

  • limb amputation for the entrapped casualty with life-­threatening injuries;
  • escharotomy for a burns patient with compromised ventilation or limb perfusion;

 

Defining competence for emergency physicians
A major challenge is the acquisition of competence in the face of such clinical rarity. One medical definition of competence is ‘the knowledge, skill, attitude or combination of these, that enables one to effectively perform the activities of a particular occupation or role to the standards expected’[1]; in essence the ability to perform to a standard, but where are these standards defined?

If we look to the curricula which are used to assess specialist emergency physicians in several English-­speaking nations, all the procedures in the short list above are included, although no one single nation’s curriculum includes the entire list (Table 1).

 

So an emergency physician is expected to be able to conduct these procedures, and a competent emergency physician effectively performs them to the ‘standards’ expected. It appears then that the question is not whether emergency physicians should perform them, but to what standard should they be trained? Only then can the optimal approach to training be decided.

There are convincing arguments that even after minimal training the performance of these procedures by emergency physicians is justifiable:

  • All the abovementioned interventions could be considered to carry 100% morbidity or mortality if not performed, with some chance of benefit whose magnitude depends on the timeliness of intervention. In some cases that risk is quantifiable: cardiac arrest due to penetrating thoracic trauma has 100% mortality if untreated, but an 18% survival to discharge rate, with a high rate of neurologically intact survivors, if performed by prehospital emergency medicine doctors in the field according to defined indications[2] and using a simple operative procedure[3]. In this extreme clinical example, no further harm to the patient can result from the procedure but a chance of supreme benefit exists. Thus, the ethical requirements of beneficence and non-­maleficence are both met even in the circumstance of very limited training for the procedure. It is hard to conceive of many other circumstances in medicine where the benefit:harm ratio approaches infinity.
  • The procedures in question are technically straightforward and can be executed without specialist equipment in non-­operating room environments. These factors appear to be underappreciated by non-­emergency specialist opponents of emergency physician-­provided thoracotomy whose practice and experience is likely to be predominantly operating room-­based[4].
  • Some of the procedures are recommended or mandated by official guidelines[5], raising the possibility of medicolegal consequences of failure to perform them.
  • The procedures are time-­critical and cannot await the arrival of an alternative specialist not already present. Simple pragmatism dictates that emergency physicians be trained to provide the necessary interventions.

 

The challenge of training
So how does one best train for these procedures? High volume trauma experience provided by a registrar term with the London Helicopter Emergency Medical Service or at a South African trauma centre will be an option for a very limited subset of trainees. Alternative training can be provided using simulation, animal labs, and cadaver labs, without risk to patients or requiring dedicated surgical specialty attachments.

Simulation manikins are not yet available for all the procedures mentioned, and lack realistic operable tissue. Human cadaver labs and live animal training bring administrative, legal, ethical and financial challenges that may be prohibitive to time and cash‐limited training schemes, or be less available to the ‘already trained’ providers in existing consultant posts. Even excellent focused cadaver-­based courses such as the Royal College of Surgeons’ Definitive Surgical Trauma Skills course[6] may not be appropriate for the emergency medicine environment: on such a course one of the authors (CR) was publicly castigated by a cardiothoracic surgeon instructor for inexpert suture technique during the resuscitative thoracotomy workshop, despite the former having successfully performed the procedure on several occasions ‘in the field’ without need of elaborate needlework.

An additional training challenge is that of metacompetence: the decision and ability to apply the competence at the right time. In the light of the relative technical simplicity of the practical procedures under discussion, this may indeed be the greatest challenge. Both authors can recount sad tales of colleagues failing to provide indicated life-­saving interventions despite being technically capable of intervening. Reasons for reticence include ‘I haven’t been properly trained’, and ‘I wouldn’t feel supported if it went wrong’.

 

Where do we go from here?
We have presented clinical, ethical, practical, and medicolegal arguments in favour of emergency physicians providing these procedures. Collectively, the emergency medicine curricula of English-­speaking nations mandate competence in them. The relative technical simplicity and overwhelming benefit:harm equation obviate the need to match the competence of a surgical subspecialist; these factors suggest training can be limited in time and cost as long as the metacompetences of ‘decision to act and knowing when to act’ are taught, simulated, and tested.

While we should capitalise on the technical expertise of surgical colleagues in the training situation, it is imperative that emergency physicians appreciative of the emergency department environment and equipment are directly involved in translating this training to emergency medicine practice. The rarity of the situations requiring these procedures requires that training should be revisited on a regular basis, preferably in the context of local departmental simulation in order to optimise equipment and teamwork preparation.

Finally, the College of Emergency Medicine needs to make it clear to its members and fellows that these procedures lie unquestionably within the domain of emergency medicine, and that emergency physicians are supported in performing them to the best of their abilities with limited training when circumstances dictate that this in the best interests of preserving a patient’s life, limb, or sight.

 

 

References
1. British Medical Association. Competency-­based assessment discussion paper for consultants, May 2008. http://www.bma.org.uk/employmentandcontracts/doctors_performance/1_app raisal/CompetencyBasedAssessment.jsp Accessed 22nd March 2012
2. Davies GE, Lockey DJ. Thirteen Survivors of Prehospital Thoracotomy for Penetrating Trauma: A Prehospital Physician‐Performed Resuscitation Procedure That Can Yield Good Results. J Trauma. 2011;70(5):E75-­8
3. Wise D, Davies G, Coats T, et al. Emergency thoracotomy: “how to do it”. Emerg Med J. 2005; 22(1):22–24 Free full text
4. Civil I. Emergency room thoracotomy: has availability triumphed over advisability in the care of trauma patients in Australasia? Emerg Med Australas. 2010;22(4):257­‐9
5. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation. 2010;81(10):1400-­33 Full text
6. Definitive Surgical Trauma Skills course. http://www.rcseng.ac.uk/courses/course-search/dsts.html Accessed 22nd March 2012
7. http://www.collemergencymed.ac.uk/Training-Exams/Curriculum/Curriculum%20from%20August%202010/ Accessed 22nd March 2012
8. http://www.eusem.org/cms/assets/1/pdf/european_curriculum_for_em-aug09-djw.pdf accessed 17 May 2012
9. The Model of the Clinical Practice of Emergency Medicine http://www.abem.org/PUBLIC/portal/alias__Rainbow/lang__en-%C2%AD%20US/tabID__4223/DesktopDefault.aspx Accessed 22nd March 2012
10. http://rcpsc.medical.org/residency/certification/objectives/emergmed_e.pdf Accessed 22nd March 2012
11. http://www.acem.org.au/media/publications/15_Fellowship_Curriculum.pdf accessed 17 May 2012
12. http://www.collegemedsa.ac.za/Documents/doc_173.pdf accessed 17 May 2012

Life, limb and sight-saving procedures-the challenge of competence in the face of rarity
Emerg Med J. 2012 Jul 16. [Epub ahead of print]