A few weeks ago, I attended an ER-Critical care conference called The Big Sick.  They talked about resuscitation, whole blood transfusion, ECMO and there was even a NASA doctor discussing medical problems for a potential mission to Mars. Good stuff. And there was plenty of Swiss chocolate.

Above all, what stuck me the most was that there was a mock ECMO resuscitation from a bunch of guys from Australia. These guys worked like magic.  In this complex scenario, they had to deal with CPR, intubation, ventilation and installing  two large access in the groin area (femoral vein and artery).  All of this was done calmly, in a fast and efficient manner.  It was like watching a well-run orchestra.

And then I thought about how I, we run resuscitation cases.  It is usually a bit chaotic, there are too many people without clear roles, sometimes people take over even though there is an assigned leader. Compared to the Montreal Symphonic Orchestra, we are closer to a chaotic post-rock band, let’s say Godspeed You! Black Emperor.

Lately, in the air, there have been some talks about changing the ways we deal with resuscitation scenarios. This will be on paper soon hopefully. The roles will be similar and hopefully we will work better as a team. But to be written on paper will not be enough, we will also need to practice scenarios, just like orchestras practicing before the big night.

Competency rather than name badge.

The first step of the changes will be to redefine some roles and knowing well your tasks within this role. I think we should be moving from a « name badge » to a « competency badge ».  Basically, there are assigned roles with defined tasks, and only if you are competent to do it you can have it.  If not, we will find someone else.  

If you are willing to learn about that role, that will be great.  We will train you, show you how to do a FAST, install femoral accesses, put chest tube.  But I think the learning should be done prior big resuscitations, not always during when time and actions are critical. 

Medical voyeurism.

We need to cut down on the number of people present during a resuscitation.  Too many is like too few.  Often, people are present without a clear role, seeing or thinking about stuff but not saying it.  I call this medical voyeurism. People are just there. Standing. Watching.

I prefer a smaller group where everyone knows what to do and could work well in a team, rather than too many people, everyone just watching, or all-star doctors who cannot work efficiently together.  

As often having the role of the specialist during resuscitation, it is sometimes disturbing seeing that many, many people are there, occupying important space.

People are welcome to come and watch to learn.  But we have to seriously control the number of people present.

Silent resuscitation

One thing I will strongly emphasize in the future is the concept of silent resuscitation. Or almost-silent resuscitations.

Cut down on the number of people and if you are present, you have a role and do something.  Being proactive in that role.  Grabbing the ultrasound machine and scanning the patient.  Not necessarily waiting for instructions.  If you see people are struggling to put an IV, go for it, get the intra-osseous and be ready for it. I shouldn’t have to scream to you to give you instructions because it is too loud, I should be able to talk with a normal volume. 

Nobody should yell but we should give clear verbal instructions. There is usually enough stress during a resuscitation, we should try to minimize it and this start but controlling the noise.

All-in-all

At the end, the goal is that everyone should have a role and know what to do in that role.  We should also emphasize to limit the number of people present during a major resuscitation and make sure the noise is kept to a minimum. Be proactive, know your task definition and act on it.

But this will only come if we are disciplined and we practiced together. 

We are a nice group of people, and we can do amazing stuff together!

Do not forget to make ER great again. MEGA