It's up to you….

Sometimes you have nothing to lose by doing a procedure that you may never have done before, if the patient is going to die or deteriorate without it.
In today’s competency-based-training-and-accreditation climate (a good thing), how does one achieve competence in a procedure that may be too rare to have even been seen, let alone practiced under supervision and formally assessed?
I spend a lot of time and energy trying to convince colleagues and trainees that there are situations where the benefit-harm equation is in favour of acting, despite reservations they may have about inadequate experience or training. These situations often require ‘surgical’ procedures. What they have in common is that they are all relatively simple to perform, but may save a life, a limb, or sight which otherwise may almost certainly be lost.
How best to train for these procedures, some of which may be too rare even for ‘see one, do one, teach one’ in an entire residency program? Simulators? Animal labs? Cadavers?

Slide from 'Making Things Happen' Course

In my view, the answer is to use the most high fidelity simulator in the universe – the human brain. It is those professionals who mentally rehearse the scenario and visualise the procedure over and over who are most likely to act when the patient needs it most. Several colleagues of mine over the years can recount incidents in which the indications for a thoracotomy or hysterotomy were present but they failed to act, talking themselves out of doing the procedure with a range of excuses from ‘I hadn’t had enough training’ to ‘No-one in the room wanted to do it’. Don’t be one of those! Get simulating now – you have all the equipment you need!

Ten steps to making it happen – be prepared
1. Pick a procedure (eg. thoracotomy)
2. Be ABSOLUTELY CLEAR on the indications – this helps remove any doubt when the time comes
3. Learn how to do it (talk to colleagues, read a book)
4. Know where the required equipment is kept
5. Start practicing in your mind – visualise seeing the patient, what you will say to your staff, where you will locate your equipment, what you will do procedurally step-by-step
6. Visualise possible outcomes and what your next steps would be (tamponade plus cardiac wound in a beating heart, tamponade plus wound plus VF, return of spontaneous circulation with bleeding from internal mammary arteries)
7. Read more and talk to more colleagues based on questions arising from your ‘simulations’
8. Travel, go on a course, get access to animal or cadaver labs if that’s an option in your setting
9. Speak to people who have done it in YOUR context (eg. for a resus room thoracotomy, talk to emergency physicians who have done it there, rather than a cardiothoracic surgeon who has only ever done them in the operating room)
10. Find an excuse on shift to talk about it to colleagues and rehearse the steps, locate the equipment, and so on. Remember: REPETITION IS THE MOTHER OF SKILL!

What’s on your list of life/limb/sight-saving procedures that can’t wait for someone else to do? Did I miss any? Should skull trephination be there? Comments welcome!

6 thoughts on “It's up to you….”

    1. The follow up this post is an article called ‘Life, limb and sight-saving procedures—the challenge of competence in the face of rarity’. I wrote this with UK College of EM president Mike Clancy as a kind of call to arms for those emergency physicians who feel they’re not sufficiently trained to do these procedures. The full article is here:

  1. Andrew, you are not a wuss. You are actually the norm. but it is due to hospital training pushing us to think in terms of silos of care. Anything surgical is left to the surgeons. You have to work hard to retrain that state of mind as Cliff writes.
    Cliff I totally agree with you on this topic. In fact I wrote a lecture a few years ago that look similar to that slide you have posted. Amazing we could have been thinking about the same thing at the same time!
    I’ll send it to you and perhaps you might consider posting it as a discussion point?
    keep up the great work and expect an invitation to Cairns ASAS 2012!

  2. Hi Chris
    In answer to your question, the simple answer is of course yes. Two examples that come to mind are emergency splenectomy and manual removal of placenta
    I know of actual cases in remote areas where these have needed to be done by non surgeons due to life threatening bleeding and each time with good outcomes.
    The International Red Cross War Surgery manual tells a great story of 2 African doctors who had to treat a road accident victim with a liver injury. They performed a laparotomy and identified the injury but did not know what to do as lacked experience. They ended up packing the injury and waking the patient up. The next day the patient was improving so they re-operated to remove the packs and clean the peritoneal cavity. He made a full recovery. Inadvertently they had stumbled across the future concept of damage control surgery.!
    Here at RFDS Cairns we even had one retrieval case of a bleeding ectopic pregnancy where the RFDS doctor flew in with a surgical assistant and did the surgery at the local hospital, with a local GP anaesthetist. Luckily in Australia you are not far from surgical help at a base hospital so as long as you get initial haemorrhage control a la Damage control surgery then you can always leave the wound open, pack the area and get them to the next level of care ASAP.

  3. Not life threatening, but sight threatening….lateral canthotomy for a retrobulbar haematoma.
    A fairly rare procedure, but sight saving.

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