Tag Archives: resuscitation


Analysing Difficult Resuscitation Cases – 2

Towards Excellence in Resuscitation – Analysing Difficult Resuscitation Cases #2

Occasionally we step out of the resuscitation room feeling like a case should have gone better, but it can be hard to put our finger on just where it went wrong. In my last post I discussed the STEPS approach to analysing resuscitation cases: Self, Team, Environment, Patient and System.

Occasionally you can get a case where the STEPS seem to be aligned but things still feel bad. In which the outcome was unsatisfactory because the plan was wrong, or the team wasn’t able to execute the plan. Consider the following case.

1. A patient with a past history of DVT no longer on anticoagulants presents with chest pain and syncope. She is severely hypotensive with a raised jugular venous pressure and a clear chest x-ray. A working diagnosis of pulmomary embolism is made. Discussions ensue regarding empirical fibrinolysis and a respiratory physician is consulted, who over the phone cautions against treating without a CT pulmonary angiogram. The patient is given heparin and transferred to the CT scanner where she arrests. Intravenous rtPA is given during CPR but no return of spontaneous circulation is achieved and she is pronounced dead after 30 minutes of resuscitation.

 

On this occasion the team worked efficiently and communicated well under clear leadership. Everyone knew the plan and shared the mental model. The environment was well controlled and the patient had been swiftly moved to CT within 20 minutes of arrival. Thanks to simulation training the well rehearsed cardiac arrest resuscitation was conducted with precision and the team was able to rapidly access the thrombolytic and knew the correct dose.

By a quick STEPS analysis, this case appears to have gone as well as could be expected. Perhaps there is nothing to learn. Some you win, some you lose, no?

No. Autopsy revealed type A aortic dissection with pericardial tamponade.

The management may have been efficient but it failed to be effective. In other words, things were done right, but the wrong things were done.

This might be an example where STEPS is inadequate, and instead we should evaluate the clinical trajectory. The cognitive bias that led to a lack of consideration of alternative diagnoses might be classifiable under ‘self’ or ‘team’ but I find it more helpful to consider it under a failure of strategy. What is strategy? Strategy in my mind is another word for plan. The plan is based on a particular resuscitation goal, and will consist of the procedures & skills required to action the plan. We can thus break down an attempted clinical trajectory into:

Goal (what are we trying to achieve)
Strategy, or Plan (what’s our plan to get there?)
Tactics, or Actions (what procedures will be required to execute the plan)
And, at more granular level: If we’re failing at the procedural level, the components of procedures, namely Skills & Microskills.

So, as we zoom in from macro to micro in setting the clinical trajectory, we can look at Goals, Plan, Actions, and Skills:

In the above case it appears the following was applied, in terms of Goal-Plan-Actions-Skills:
G – resuscitate hypotensive patient
P – give fibrinolysis for likely PE
A – consult respiratory physician, get CTPA
S – request scan, give heparin, transport to CT

The goal was appropriate, but the plan was ineffective.

The following approach would have been more effective.

G – resuscitate hypotensive patient
P – identify cause of undifferentiated hypotension and initiate treatment in the resus room 
A – thorough bedside assessment in patient too sick to move: history, physical, CXR, ECG, labs, POCUS
S – Basic cardiac ultrasound

By planning to identify and treat the cause of hypotension in the resus room, the more appropriate investigation would have been selected (cardiac ultrasound) and the correct diagnosis is much more likely to have been made.

Let’s look at some other cases:

2. An 88-year-old male presents by ambulance to the ED with dizziness. He is hypotensive, pyrexial, hypoxic and confused. His chest x-ray shows likely bronchopneumonia. He has appropriate initial resuscitation and ICU is consulted. Soon he is intubated and on high dose vasoactive medication with escalating doses despite ongoing hypotension, anuria, and a lactate of 11 mmol/l, increased from 8 on arrival. As he is being wheeled off down the corridor towards ICU his distraught and frail wife arrives. She is taken to the quiet room where she explains that her husband would never want to be ‘on a life support machine’ and asks ‘can’t you just keep him comfortable’?

 

G – the goal – to provide maximally aggressive resuscitation – was not in keeping with the patient’s wishes. If the goal had been to provide care in accordance with his wishes, the plan could have included attempts to ascertain these sooner while providing initial treatment. Upon gaining sufficient information, a new goal can be established: maximising the patient’s comfort and dignity.

3. An obese 30-year-old female presents with syncope. At triage she is pale, tachycardic & hypotensive. Clinical and sonographic assessment, including free intraperitoneal fluid and a positive urine HCG, is suggestive of ruptured ectopic pregnancy. The gynaecologist and anaesthetist ask the ED team to bring the patient straight to the operating room. The ED team spends 20 minutes struggling to obtain intravenous access, eventually placing a 22G intravenous catheter in the patient’s hand and a humeral intraosseous needle. Her shock is considerably worse on arrival in theatre, despite attempts to transfuse O negative blood en route.

 

Goal – get her safely to the operating room
Plan – vascular access, cross match blood, start haemostatic resuscitation, go to OR as soon as possible
Actions – peripheral and/or intraosseous cannulation attempts
Skills – vascular access skills

Here the failure was at the actions and skills level. Better vascular access could have been attained using ultrasound guided peripheral cannulation, or central vascular access, or earlier intraosseous insertion.

4. A 120kg 32-year-old male with a history of deliberate self harm presents on the night shift with coma due to mixed benzodiazepine and venlafaxine overdose. The decision is made to intubate for airway protection. After rapid sequence induction direct laryngoscopy is attempted by the emergency registrar who obtains a grade 4 view. Cricoid pressure is removed resulting in a grade 3 view. The registrar asks for a bougie which she passes and then railroads the tracheal tube over it. The cuff is inflated, capnography is connected, and the self-inflating bag is connected and squeezed while the chest is auscultated. The abdomen distends, the capnograph remains flat, and gastric contents are seen to pass upward through the tube into the self-inflating bag. The tube is immediately removed and bag-mask ventilation is attempted. The oxygen saturation is now 78% and the airway is soiled. The airway is suctioned and repeat attempts to bag-mask ventilate fail. A successful cricothyroidotomy is performed and the patient subsequent has full neurological recovery.

 

Goal – Provide supportive care and minimise complications from overdose
Plan – Airway protection and admit to ICU for monitoring
Actions – Rapid sequence intubation, ICU referral
Skills – Pre-, peri- and post-intubation oxygenation techniques; patient positioning; rapid sequence induction of anaesthesia; direct laryngoscopy; bougie handling techniques; external laryngeal manipulation

In this case the patient was not placed in the ramped position and no nasal cannulae were applied for apnoeic oxygenation. A tube was railroaded over an oesophageal bougie, which arguably should not occur if ‘hold up’ is sought when the bougie is placed. Although the goal, plan and actions were appropriate, the team did not demonstrate adequate skill in this procedure. Likely due to a failure of training, standardised procedures, and checklists (or their application), this could also be identified as a ‘system’ problem in STEPS. It is also possible that the intubator forgot her training under stress – a problem classifiable under ‘self’. Alternatively other members of the team may have had knowledge but didn’t speak up or cross-check their colleague, which would be a ‘team’ issue.

Limitations of this approach

This sort of analysis is retrospective and subjective and at risk of hindsight bias (e.g. distortion due to projection, denial, or selective recall). However, these limitations do not negate the value of the learning exercise, particularly if we are aware of them and strive to minimise their impact (e.g. write down the details of a cases as soon as possible afterward). It at least provides a structure for individuals and teams to begin the conversation about where and how things may have been suboptimal.

Goals may be multiple and may change according to incoming information, and for each goal there may be several viable alternative plans. STEPS and GPAS may overlap, eg. team failures may result in inappropriate goals and strategies, or in failed procedures.

Summary

These models may prove helpful as a means of dissecting a case in a structured way. Put simply, STEPS offers a structure for identifying efficiency improvements (“doing things right”) and GPAS  can help us assess effectiveness (“doing the right things”).  Another way of looking at it is that STEPS provides the components of a resus at any point in time, and GPAS defines the trajectory: where the resus is going and how to get there.

I use this structure to analyse cases in my own clinical practice and in my teaching. I would be interested to hear from others’ experience. Do you find this approach useful in identifying areas for improvement in those cases that you feel should have gone better?

Thanks to Chris Nickson for his comments and improvements to this post

Analysing Difficult Resuscitation Cases

Towards Excellence in Resuscitation – Analysing Difficult Resuscitation Cases #1

A resuscitationist agonises. These words, expressed by Scott Weingart during a podcast we did together, ring true to all of us who strive to improve our practice. Driven by the passionate conviction that we should never lose a salvageable patient through imperfect care, we relive cases and re-run them through our mental simulators to identify areas for improvement.

In the search for actionable items though, we occasionally exit this process empty-handed. Something about a case felt wrong although ostensibly all the clinical interventions may have been appropriate. It is in these cases that it can be helpful to have a structure to aid analysis.

I, along with an international, interdisciplinary faculty of resuscitationists, have previously proposed an easily remembered system for optimising the clinical and non-technical components of resuscitation immediately before and during a patient encounter, dubbed the ‘Zero Point Survey’ (ZPS)(1), so called because first contact with a patient is rarely ‘Time Zero’ for a prehospital mission or hospital resuscitation case; there is invariably time for preparation of oneself, one’s team, and the environment (including equipment) prior to the primary survey and commencement of resuscitation. Following the assessment and management of STEP (self, team, environment & patient), the team should be regularly Updated on patient status and informed of the Priorities

.

But ‘self, team, environment and patient’ isn’t just a useful system for case preparation. It can also be used for case analysis. I have found by discussing many ‘unsatisfactory’ cases over the years with participants in human factors workshops that STEP can help us identify where the issues lie. Accompanying all these factors is another ’S’: the system in which they interplay – the organisational rules, processes, policies, resources and deficiencies that may facilitate or obstruct an effective resuscitation(2).

Using STEPS to analyse cases

The following (genuinely) hypothetical resus cases demonstrate how the application of this framework – Self, Team, Environment, Patient, System – might help identify correctible factors for future resuscitations:

1. Cardiac arrest in the bathroom on the orthopaedic ward – “it was chaos, there were too many people, and the resus trolley wasn’t properly stocked”.

STEPS analysis:
Team – Leader needed to assign roles and allocate tasks
Environment – Crowd control needed, lack of equipment
System – Adequate checks for resus trolley not in place

2. 19-year-old male stabbed in the chest and arrested on arrival in hospital. CPR provided but went from PEA to asystole. Team leader discontinued resus after 20 minutes. Resident: “I thought he needed a resuscitative thoracotomy but no-one was willing to do it. No-one even mentioned it”.

STEPS analysis:
Self – Lacked confidence to speak up, doubted own knowledge or influence
Team – Lack of team situational awareness or knowledge or skill regarding required intervention
System – Insufficient training and preparation for penetrating traumatic cardiac arrest scenario

3. 30-year-old mother with abdominal wound and her 2-year-old daughter with massive open head injury, both due to gunshot wounds, having been shot by husband/father who killed himself on scene. Child arrests in the ED, without ROSC, witnessed by mother before mother is taken to operating theatre.

STEPS analysis:
Patient(s) – tragic case with upsetting circumstances and compounded psychological distress for patient and staff. The best resuscitation team in the world is not going to feel good about this one.

4. 46-year-old previously healthy male with VF arrest achieved ROSC after prehospital defibrillation and brought to the ED of a non-cardiac centre comatose and intubated. Further refractory VF in ED. Received multiple shocks, antiarrhythmics, double sequential external defibrillation. No on-site access to mechanical CPR, cardiac catheterisation, or ECMO. Patient declared dead in ED.

STEPS analysis:
System – Prehospital team gave excellent care but brought the patient to a hospital ill-equipped to manage his ongoing needs, due to lack of ambulance service policy regarding appropriate destination hospital for cardiac arrest cases.

Summary

You can see from the above cases how STEPS may be applied to make some sense of where a resus has gone wrong. Note that I am not recommending this as a way of structuring a team debrief or formal incident investigation – many institutions already have processes for conducting these and various rules and sensitivities have to be accommodated. Rather, this is a format I’ve found helpful in applying during informal discussions that aim to get the nub of where things could or should have gone better.

Occasionally, you can get a case where the STEPS seem to be aligned but things still feel bad – in which the outcome was unsatisfactory because the plan was wrong, or the team wasn’t able to execute the plan. In my next post I’ll discuss another way of analysing cases that can accompany STEPS.

1. Reid C, Brindley P, Hicks CM, Carley S, Richmond C, Lauria MJ, Weingart S.  Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness. Clin Exp Emerg Med. 2018 – In Press

2. Hicks C, Petrosoniak A. The Human Factor. Emergency Medicine Clinics of North America. 2018 Feb;36(1):1–17. 

Convergent Evolution in the Jungles of Critical Care

boss-of-the-mob-1400090-1279x1923By Stuart Duffin
Expat Brit, intensive care physician and anaesthetist at Karolinska University Hospital in Stockholm, Sweden. Stuart trained in the UK, and spent some time working Australian emergency departments.

One of the most striking things for me about our new/old pan-specialty of critical care, brought into focus by the world-shrinking effects of FOAM and twitter, is just how differently it falls into the domains of the established specialities in different parts of the world. This leads inevitably to comments like, “emergency physicians shouldn’t intubate”, “anaesthetists cant do sick”, “nurses cant be doing such and such”, and so on. All of these statements are clearly equally rubbish because obviously, in certain parts of the world, they do. And they do it really well. Sure there are differences between countries and continents, populations and environments, but when it comes down to it, it doesn’t matter where you are, people still get sick, infected, pregnant, run over, stabbed or hit around the head with heavy things.

All over the world, in our previously quite isolated environments, these same ‘selection pressures’ have forced healthcare providers to evolve by the process of convergent evolution. Although obviously not strictly darwinian, the undeniable effects of simultaneous evolution by survival of the fittest-to-practice can be seen.

Convergent evolution is the process by which, in different parts of the world, completely different species have evolved in parallel to fill similar roles and have similar features. It didn’t matter whether it was a deer, a wildebeest or a kangaroo, there was a vacancy for a fairly big animal who liked eating grass and moved in big groups, and someone stepped up.

Unsurprisingly, critical care resuscitationists are also a little different from country to country and from continent to continent. They have different titles and work in slightly different ways. But when you really look at a critical care doc in action, or talk to one, or follow one on Twitter, we are all cut from the same cloth. I would argue that FOAM has created a critical care zoo in which the kangaroos and antelopes, lemurs and monkeys, aardvarks and echidnas and anaesthetists and emergency physicians are all chucked into the same cage. They’re all looking at each other thinking, “you look like me, but somehow not. We seem to do the same stuff, but we’re not identical – it cant be right!”.

In The United States, the idea of an anaesthetist doing a clamshell thoracotomy would be a little strange. In Scandinavia, an emergency physician doing central lines and fiberoptic intubation in resus would be just as eyebrow raising. A Swedish intensivist and anaesthetist spent some time working in Australia as an ICU senior reg. When attending a patient in resus the emergency physician there announced “we need an airway guy”. My colleague answered “I’m the airway guy”. “No an anaesthetist” replied the emergency physican. “I am an anaesthetist!” “No an….” and so it went on.

The effects of this process are of course by no means limited to doctors. Nurses, paramedics and physiotherapists are all part of this still changing ecosystem. A colleague of mine was showing a visiting Australian emergency physician our trauma bay and describing how major trauma is managed here without the involvement of emergency physicians at all. “When it’s really urgent, it’s anaesthesia and surgery” he explained. I wonder how that went down? There is an element of truth to the statement but the words are wrong. It should have been “When it’s really urgent, it’s airway, access, transfusion, invasive procedures and resuscitation thinking”.

The job title of the person who actually holds the knife/laryngoscope/needle and has what it takes to get it done isn’t important. When the push comes to shove and the bad stuff bounces off the fan, it’s more about skillset and mindset, and less about the collection of letters under your name on your badge, or after your name on your CV.

Resuscitationist lessons from a self-protection master

UCIt’s better to have it and not need it, than to need it and not have it

My great friend and fellow Brit Lee Morrison is in Sydney again, teaching people how to save lives. Like a resuscitationist. But Lee isn’t a health care worker. He is a professional self protection instructor and martial athlete. The lives he is teaching people to save are their own and those of their friends and families. Lee has travelled the world and taught a diverse range of professionals including law enforcement and military special forces personnel. His current world tour will include the Czech Republic, USA, France, Russia and Germany after Australia.

What does this have to do with resuscitation? In my experience, almost everything. Hitting someone in self defence is technically very easy. Doing a resuscitative hysterotomy is technically very easy. Being able to do either of those things under stress can be difficult or impossible for some people.

Those who strive to understand and cultivate the Mind of the Resuscitationist know the importance of preparation through simulation under stress; the need to acknowledge and control the physiological and emotional response to stress; the necessity to train outside ones comfort zone and minimise the gap between simulated and real situations by optimising the cognitive fidelity of training scenarios; and the requirement to access the right mental state in an instant in which failure is not considered to be an option.

People who do not wish to witness the discussion or demonstration of violence or who cannot stand swearing should stop now. Those of you who want to see mastery in action watch the video below of Lee teaching in Germany.

I want you to appreciate the following:

  • Presentation style – how to connect with an audience and fully engage them through humour, passion, emphasis, intelligent discourse, and detailed explanations that connect emotionally and physically as well as intellectually.
  • The loss of fine motor skill under stress (2 min 13 sec)
  • The mindset of determination (2 min 48 sec) – consider how this relates to the perspective of the resuscitationist prepared to do a resuscitative thoracotomy under stress
  • How to influence and win arguments in a conflict situation by being assertive but providing a face-saving get-out for the aggressor. I have applied this multiple times in the resus room and in retrieval situations. (4 min 11 sec)
  • Training honestly – maintaining safety but ‘doing it like you f—-ing mean it’. Get out of your comfort zone and make the discomfort as real as possible. (7 min 37 sec)
  • How to minimise the gap between your training and what you’re training for, when legal, moral, and safety restrictions prevent you from doing the actual task for real as a training exercise. Using fatigue, pain, and disorientation as perturbations so you learn to recognise and mitigate their effects. (9 min 19 sec)
  • Accessing a single mental state that provides focus and prevents distraction from discomfort (11 min 40 sec)

If the video made you feel uncomfortable ask yourself why. If it’s because you consider yourself to be above violence and find the subject matter, language, and humour to be distasteful, that’s your right to feel like that. But try to dig a little deeper and ask yourself whether there are potential situations in your life that could confront you with fear or pain that you could be better prepared for if you trained with a different mindset.

When the situation arises that demands life-saving action and you are tired, hungry, scared, and discouraged by opposing advice or opinion, do you have the self-knowledge and resilience to see it through? If you don’t know the answer to that, isn’t it time you found out?

You can find out more about Lee at Urban Combatives

Resus Team Size and Productivity

paedsimiconA paediatric trauma centre study showed that in their system, seven people at the bedside was the optimum number to get tasks done in a paediatric resuscitation. As numbers increased beyond this, there were ‘diminishing marginal returns’, ie. the output (tasks completed) generated from an additional unit of input (extra people) decreases as the quantity of the input rises.

The authors comment that after a saturation point is reached, “additional team members contribute negative returns, resulting in fewer tasks completed by teams with the most members. This pattern has been demonstrated in other medical groups, with larger surgical teams having prolonged operative times and larger paramedic crews delaying the performance of cardiopulmonary resuscitation.

There are several possible explanations:

  • crowding limits access to the patient or equipment;
  • “social loafing”- staff may feel less accountable for the overall group performance and less pressure to accomplish individual tasks;
  • seven is the number recommended in that institution’s trauma activation protocol, with optimal role allocation described for a team of that size;
  • teams with redundant personnel may experience role confusion and fragmentation, resulting in both repetition and omission of tasks.

In my view, excessive team size results in there being more individuals to supervise & monitor, and hence a greater cognitive load for the team leader (cue the resus safety officer). More crowding and obstruction threatens situational awareness. There is more difficulty in providing clear uninterrupted closed loop communication. And general resuscitation room entropy increases, requiring more energy to contain or reverse it.

However, for paediatric resuscitations requiring optimal concurrent activity to progress the resuscitation, I do struggle with less than five. Unless of course I’m in my HEMS role, when the paramedic and I just crack on.

More on Making Things Happen in resus.

Own The Resus talk

Resus Room Management site

Factors Affecting Team Size and Task Performance in Pediatric Trauma Resuscitation.
Pediatr Emerg Care. 2014 Mar 19. [Epub ahead of print]


OBJECTIVES: Varying team size based on anticipated injury acuity is a common method for limiting personnel during trauma resuscitation. While missing personnel may delay treatment, large teams may worsen care through role confusion and interference. This study investigates factors associated with varying team size and task completion during trauma resuscitation.

METHODS: Video-recorded resuscitations of pediatric trauma patients (n = 201) were reviewed for team size (bedside and total) and completion of 24 resuscitation tasks. Additional patient characteristics were abstracted from our trauma registry. Linear regression was used to assess which characteristics were associated with varying team size and task completion. Task completion was then analyzed in relation to team size using best-fit curves.

RESULTS: The average bedside team ranged from 2.7 to 10.0 members (mean, 6.5 [SD, 1.7]), with 4.3 to 17.7 (mean, 11.0 [SD, 2.8]) people total. More people were present during high-acuity activations (+4.9, P < 0.001) and for patients with a penetrating injury (+2.3, P = 0.002). Fewer people were present during activations without prearrival notification (-4.77, P < 0.001) and at night (-1.25, P = 0.002). Task completion in the first 2 minutes ranged from 4 to 19 (mean, 11.7 [SD, 3.8]). The maximum number of tasks was performed at our hospital by teams with 7 people at the bedside (13 total).

CONCLUSIONS: Resuscitation task completion varies by team size, with a nonlinear association between number of team members and completed tasks. Management of team size during high-acuity activations, those without prior notification, and those in which the patient has a penetrating injury may help optimize performance.

Family presence during resuscitation

CPR-iconFamilies allowed to be present during attempted cardiopulmonary resuscitation had improved psychological outcomes at ninety days.

Adult family members of adult patients were studied in this randomized study from France.

Resuscitation team member stress levels and effectiveness of resuscitation did not appear to be affected by family presence.

Family Presence during Cardiopulmonary Resuscitation
N Engl J Med. 2013 Mar 14;368(11):1008-18


BACKGROUND: The effect of family presence during cardiopulmonary resuscitation (CPR) on the family members themselves and the medical team remains controversial.

METHODS: We enrolled 570 relatives of patients who were in cardiac arrest and were given CPR by 15 prehospital emergency medical service units. The units were randomly assigned either to systematically offer the family member the opportunity to observe CPR (intervention group) or to follow standard practice regarding family presence (control group). The primary end point was the proportion of relatives with post-traumatic stress disorder (PTSD)-related symptoms on day 90. Secondary end points included the presence of anxiety and depression symptoms and the effect of family presence on medical efforts at resuscitation, the well-being of the health care team, and the occurrence of medicolegal claims.

RESULTS: In the intervention group, 211 of 266 relatives (79%) witnessed CPR, as compared with 131 of 304 relatives (43%) in the control group. In the intention-to-treat analysis, the frequency of PTSD-related symptoms was significantly higher in the control group than in the intervention group (adjusted odds ratio, 1.7; 95% confidence interval [CI], 1.2 to 2.5; P=0.004) and among family members who did not witness CPR than among those who did (adjusted odds ratio, 1.6; 95% CI, 1.1 to 2.5; P=0.02). Relatives who did not witness CPR had symptoms of anxiety and depression more frequently than those who did witness CPR. Family-witnessed CPR did not affect resuscitation characteristics, patient survival, or the level of emotional stress in the medical team and did not result in medicolegal claims.

CONCLUSIONS: Family presence during CPR was associated with positive results on psychological variables and did not interfere with medical efforts, increase stress in the health care team, or result in medicolegal conflicts.

Upstairs vs Downstairs: an EPIC Conundrum

A new breed, and new terminology

USAflagb&WResusScott Weingart MD and colleagues have published a discussion paper [1] outlining the role of emergency physicians who have completed additional critical care training – ED intensivists – and the potential benefits these individuals might bring to patients, emergency departments, and their emergency physician colleagues.

The paper also introduces a glossary of new terms which might help clarify future discussion of this practice area:

Emergency medicine critical care a subspecialty of emergency medicine dealing with the care of the critically ill both in the ED and in the rest of the hospital
EP intensivist a physician who has completed a residency in emergency medicine and a fellowship in critical care
ED critical care emergency medicine critical care practiced specifically in the ED
ED intensivist (EDI) EPIs who practice ED critical care as a portion of their clinical time
Resuscitationists EPs who have additional knowledge, training, and interest in the care of the critically ill patient
EDICU a unit within an ED with the same or similar staffing, monitoring, and capability for therapies as an ICU
RED-ICU a hybrid resuscitation area and EDICU allowing a department to adopt the ED intensive care model with minimal cost and no changes to the physical plant

Potential benefits of ED-intensivists – and associated adequately staffed areas within ED that facilitate ongoing critical care delivery – include:

Full intensive care provided to patients unable to be moved to ICU (usually due to bed unavailability)
Development of protocols and care pathways that allow other EPs to deliver enhanced critical care
Gaining of advanced skills for ED nurses
Removal of need for ICU bed for conditions that can be improved in a few hours (eg. some overdoses, DKA, acute pulmonary oedema)
Cost saving due to decreased ICU stay (if the above ‘short term critical care’ patients are admitted to ICU, ward bed unavailability can make it difficult to discharge them from ICU)
Additional airway skills in ED (and training around that)
Improved invasive and non-invasive ventilatory management (and training) in ED
Gaining of ED experience in ventilator weaning and extubation
Gaining of ED experience in haemodynamic monitoring, vasoactive support, and even mechanical circulatory support (balloon pumps and ECMO)
Improved sepsis care
Improved post-cardiac arrest care
Improved trauma management
Greater exposure to invasive procedures
Improved end of life care
Better critical care exposure for trainees

Improved ED-ICU communication and shared protocols

Scott’s whole mission is about bringing ‘upstairs care downstairs’, and educating others to do that, at which he is a true master. No doubt he will singlehandedly have inspired a large cohort of emergency physicians to train in critical care. Examples of ED intensivists and their roles are listed here on the EMCrit site.

Emergency physician intensivists in the Old Country

epic__logoUKflagAs an ‘ED-intensivist’ myself, I do believe many of those advantages can be realised. In the UK when I originally trained in both EM and ICM there was a small number of similarly trained individuals and we collectively called ourselves ‘EPIC’ – ‘Emergency Physicians in Intensive Care’.

Our shared energy and enthusiasm led to a dedicated conference in 2011 and it’s possible that our proselytizing combined with publications like Terry Brown’s ‘Emergency physicians in critical care: a consultant’s experience‘[2] may have made some small contribution to the subsequent explosion in interest in dual accreditation in EM & ICM in the UK.

Disappearing upstairs

AusflagWhen I moved to Australia in 2008 I was excited to hear that emergency docs now made up the largest proportion of dual trained new intensivists. When I asked a leading member of this group whether he saw any role for an ‘EPIC’ community in Australia I was surprised and disappointed with the response:

‘Nice idea but I don’t see the point. I can’t think of anyone who dual trained who’s still working in emergency medicine’

So it seems those who were in the best position to bring upstairs care downstairs had all disappeared upstairs. Many will admit it’s not just because they find critical care more interesting than emergency medicine; the combination of a significantly higher income (through private practice) with better working conditions plays a significant role.

There are other opportunities in Australia for emergency physicians to practice critical care. Prehospital & retrieval medicine services undertake interhospital critical care transport of patients from small and often remote facilities where all of the first few hours of intensive care must be delivered by retrieval teams in often challenging environments with limited personnel and equipment. In some cases it’s these retrieval physicians who are able to fulfil the role of ED-intensivist in their own EDs.

Integrated critical care models and SuperDoctors

ChrisTIconAnother Australian example is the ‘integrated critical care’ model pioneered in some regional centres in rural New South Wales where emergency physicians with critical care training aim to provide seamless care to patients in the prehospital, ED, ICU and ward environments. I was lucky enough to do some locum shifts in one of these centres – Tamworth – where the service is delivered by some of the most highly skilled and dedicated physicians I’ve ever met. Check out their registrar job ad for a flavour of their work. This model was described in a 2003 publication[3] by my Sydney HEMS colleague Craig Hore which lists its features as follows:

Features of integrated critical care
Multiskilled critical-care specialists trained and experienced in the various aspects of critical care in rural hospitals.

Multidisciplinary critical-care teams that provide:

A more seamless interface between the various phases of critical care and between its respective disciplines;

A rapid response to, and a continuum of care for, critically ill and injured patients;

Clinical leadership in evaluating and managing critically ill and injured patients, both in the hospital (including the emergency department, critical-care unit and hospital wards) and in the community (including retrievals, and support for ambulance crews, peripheral hospitals and general practitioners); and

Training of medical students, medical staff, nursing staff and allied health professionals to recognise and provide a systematic approach to critical illness and injury.

Team members who are empowered to work beyond perceived traditional boundaries, but within the realms of their clinical expertise and credentials, to enable the best use of available resources.

So it appears the benefits to patients, hospitals, and team skills of ED-intensivists have been espoused for some years in the Anglo-Australian setting, and different practice models evolve to best serve local need.

Resuscitating the resuscitationists

UKflagIs it time to revive EPIC? I chased up my UK buddies who co-founded it, and here are extracts from their replies (note ‘CCT’ refers to certificate of completion of training – the UK equivalent of specialist accreditation or board certification):

“Interesting to hear that most Aussies leave EM, my experience of [our regional] trainees is the opposite; of 4 EM / ITU dual CCT over last 5 years, I’m the only one still doing a little bit of CCM, the rest have all ended up in full time EM posts, despite all doing periods of locum consultant work in CCM. (Although, after last 4 winter months of UK EM, I’m beginning to appreciate that I backed the wrong horse! (In the wrong country!!))”
“Having recently dropped ICU/ED 40/60 mix for full time ED i think those gravitating to ICU have a point – an error on my part. The ED represents much more intense work with fewer staff and a work load that far far exceeds resources. As such time to deliver care falls and skills with it. I have just spend 5 weeks [overseas]. I spent time with several directors who pointed out they no longer look to the UK for high quality ED docs as they manage depts as opposed to caring for patients, lack critical care skills and lack the experience to review and manage patients as they improve or deteriorate – a sad state of affairs indeed.”
“I would like to see EPIC back in force and do see an increasing role. around 1 in 4 of our trainees here are looking to joint qualify and we have 3 in their last 2 years. two are currently looking for posts but struggling to find any with a 50-50 mix and are been told to choose one or the other both by prospective ED and ICU employers.”
“I am concerned that dual trained folk here will, like in Australia gravitate to ICU. Whether that is a reflection of where EM is currently in the UK or a personal reflection I’m not sure. Where as I still have days in the ED where I come home and think ‘best job in the world’ these are overshadowed by the stresses of trying to deliver quality care in a failing system. My impression is that urgent care in the UK may well implode soon as ever decreasing workforce meets an over increasing work load. Inevitable closures of units will speed up this process. I currently have a 50/50 ICM/ED job split but that might change to become more ICU.”
“The ED/ICU community in the UK is growing and it wlll be interesting to see the effect of the ICM CCT has on this. There is sadly still a paucity of ED/ICU jobs in the UK and we probably missed a trick with the trauma centres.”
“It would be great to re-create EPIC to make it a real player for the future.”

So it appears emergency physician intensivists are growing in number, but employment prospects in both specialties are not guaranteed. If we are to recruit them to work as ED intensivists (ie. providing critical care in the ED) we have a challenge in making such posts attractive and sustainable. Emergency medicine in the UK is suffering at the moment, and we’ll have to work hard to stop those who are dual trained from disappearing upstairs.

Your comments on this are invited. Should there be more critical care- trained EPs? Shouldn’t ALL EPs have the right critical care skills to manage the first few hours of critical care? Can you call yourself an emergency physician and not be a ‘resuscitationist’? Where do retrievalists fit into this spectrum? How do we help motivate those who are dual trained to stay in the ED for some of their time? Is there a need for a body like EPIC to guide those who are considering dual training, and to provide recommendations to employers and physicians on models of care and job planning? I would love to get more of an international perspective on this issue.

1. ED intensivists and ED intensive care units
Am J Emerg Med. 2013 Mar;31(3):617-20
Full text link available from here

2. Emergency physicians in critical care: a consultant’s experience
Emerg Med J. 2004 Mar;21(2):145-8
Full text link available from here


There is a growing interest in the interface between emergency medicine and critical care medicine. Previous articles in this journal have looked at the opportunities and advantages of training in critical care medicine for emergency medicine trainees. In the UK there are a small number of emergency physicians who also have a commitment to critical care medicine. This article describes a personal experience of such a job, looking at the advantages and disadvantages. Depending upon future developments in the role of emergency medicine in the UK, together with the proposed expansion in critical care medicine, such posts may become more common.

3. Integrated critical care: an approach to specialist cover for critical care in the rural setting
Med J Aust. 2003 Jul 21;179(2):95-7


Critical care encompasses elements of emergency medicine, anaesthesia, intensive care, acute internal medicine, postsurgical care, trauma management, and retrieval. In metropolitan teaching hospitals these elements are often distinct, with individual specialists providing discrete services. This may not be possible in rural centres, where specialist numbers are smaller and recruitment and retention more difficult. Multidisciplinary integrated critical care, using existing resources, has developed in some rural centres as a more relevant approach in this setting. The concept of developing a specialty of integrated critical-care medicine is worthy of further exploration.