It’s up to us

Cliff Reid, who you’ll know as the all action educational powerhouse behind Resus.ME, recently posted ‘It’s up to you…‘. I think everyone in the critical care specialties should read it — and to facilitate this goal I’m republishing it right here, right now. This is what Cliff has to say:

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?


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!

I’m a big fan of visualisation as a training tool, and the broader concept of using our brains as the ultimate simulation devices. But its easy to talk about in theory. What about actually putting it into practice? Here’s Cliff’s advice:

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.

It is clear that media-rich learning resources, such as those found on many podcasts and blogs (even this one… Try Own the Airway! and Own the Chest Tube! for examples), are a real aid to this simulation-through-mentation learning technique. Even LITFL’s case-based Q&As facilitate this process when theyhelp isolate important decision nodes in the assessment and management of critical illness.

Cliff’s ideas dovetail nicely with Scott Weingart’s EMCrit Podcast 49 – The Mind of a Resus Doc: Logistics over Strategy. Scott emphasies the importance of visualising all the steps and potential complications as the key to ‘making things happen’ in the resus room. I can only agree with Scott and Cliff, making things happen truly is the essence of emergency medicine… Cliff even runs a course with that very name!

Thinking about all of this brings to mind Peter Safar’s 22nd Law for the Navigation of Life, which is the perfect note with which to finish:

22: It’s up to us to save the world.

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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