As a UK trained EP I agree with Craig's comments about the unequal
distribution of resuscitation skills amongst existing consultants. The very
fact that we have an 'exit' exam like FFAEM at least means we are attempting
to address that, unlike for example new general (internal) medicine
specialists whose last formal assessment of their competence would have been
as SHOs doing the esoteric MRCP exam. We've still got a long way to go, and
the FFAEM exam needs to get a bit more clinical before it guarantees
competence in resus skills beyond for example APLS provider level. I feel
there's more to training than an exam though and it would be nice if such
skills were taught, tested, practised and refined over the five SpR years.

One more point - mortality's a pretty crude (if important!) endpoint. Surely
there are other advantages to having a trained emergency consultant leading
a trauma/critical illness resus, like earlier and wider differential
diagnosis, adequate analgesia, assertive leadership of the multispecialty
team, radiographic and ECG interpretation, prioritisation of interventions
('no, we'll intubate first and THEN do the chest drains and femoral splint
if you don't mind'), more experience at difficult vascular access, more
credibility with the gatekeepers to radiological tests and ICU beds, ability
to use the scenario to teach the juniors, and a whole bunch of other things
that rely on past experience and pattern recognition to avert potential
disasters.

You won't need that special underwear Craig - there're plenty of us who feel
the same way.

Cliff Reid
Australia


>
>>From: Fred Cartwright <[log in to unmask]>
>
>> > Yes, they will. The FACEM carries a significant
>> > Paediatric component in both the writtens and
>> > clinicals.
>> >
>>What format are the clinicals. Having seen too many
>>surgeons make it through to consultant level without
>>being very good at operating I am somewhat cynical
>>about the colleges assessment criteria. I accept that
>>it is changing, but it has been a long time coming.
>> >
>
>The clinical is 1 long case (usually adult), 4 short cases (one of which
>will be a paed) and 6 structured vivas (of which 1-2 will be paediatric)
>
>I accept entirely your comment about consultants - but I personally
>(putting
>on fire proof underware) believe (in EM anyway) it is more of a problem in
>the UK than Australasia. A number of consultants with no interest or
>experience in resuscitation have been grandfathered in to the UK Faculty -
>and as such all consultants are not equal. I certainly dont mean that in an
>insulting way - it just explains why there is such as spectrum.
>
>
>>
>> > But the difference at least at a superficial level
>> > is stark. Having worked in SHO driven units and
>> > Consultant driven units without a doubt Id rather be
>> > sick in a consultant driven one - now clearly your
>> > data does not support that - but would you rather
>> > have your resus run by a consultant (following
>> > guidelines and with knowledge to work around the
>> > edges of guidelines - and all their additional
>> > practical skills) or the ED/Medical SHO (following
>> > the guidelines). Especially if there is anything
>> > atypical about your arrest or trauma.
>> >
>>It depends if you mean sick or in need of resus. I
>>suspect our figures show no difference between grades
>>(consultants were no worse, but didn't seem to confer
>>any advantage) is that resus is a team sport. It is no
>>good having a star player if the rest of the team are
>>hopeless. As for the additional knowledge/skills of
>>consultants there are certain individuals of that
>>grade that I wouldn't let anywhere near me or mine!
>>Certainly if I was having my femur nailed in my
>>hospital then I know who I'd want to do it and it
>>wouldn't be any of the consultants - who haven't done
>>one in ages!
>
>But you can say that for any medical speciality or situation. I work in a
>hospital where the bulk of the resus's are consultant led - and Id prefer
>them over the ED SHO or medical registrar. Again if your in a one
>consultant
>unit and they never venture into resus, then obviously I wouldnt let them
>near me.
>
>> > Guidelines are a thorny issue too. Having observed
>> > the development of some national guidelines, I have
>> > lost a lot of faith in the concept of them
>> > reflecting best practice - safe practice perhaps,
>> > but certainly not best practice. A combination of
>> > "experts" from a number of specialities offering
>> > their interpretation of the available evidence and
>> > reaching a consensus that they (or a more accurately
>> > a majority) believe reflect best practice in
>> > accordance with the evidence. I think the uncritical
>> > acceptance of EBM guidelines is becoming more of a
>> > problem. You only need to look as far as the
>> > AHA/ILCOR antiarrythmic and medical management of
>> > USA guidelines to see the face of these problems IMO
>> >
>>I wouldn't agree with respect to ALS & ATLS
>>guidelines. They are certainly not just what the
>>experts think is best. Issues such as high dose
>>adrenaline, amiodarone, effectiveness of atropine etc.
>>have been subjected to clinical evaluation. The
>>results of the research are fed back into the
>>guidelines and then re-evaluated. A good example of
>>the audit cycle IMHO. The ATLS guidelines were even
>>changed to say not everyone needs their c-spine
>>x-rayed. Surely a major step for a US lead course. :-)
>>
>
>Again I would disagree on this one. Id didnt say it was just expert
>consensus, its an expert consensus interpretation of the literature - and
>compromises are made to keep everyone happy.
>
>The new ATLS guidelines 2001/02 certainly look like an improvement, from
>what Ive seen of them, but the 1997 guidelines are riddled with
>inconsistencies and sub-optimal practice. Equally there are a number of
>problems with ALS - or simplifications. Im not saying they are not useful -
>obviously they are immensely valuable. But I have to say the more Ive
>learnt
>and the more experience Ive got, the more frustrated I get with resus
>guidelines - and there often somewhat superfical dealing with a very
>complex
>area of medical research.
>
>> > The skill retention issue is also very complicated.
>> > We have done a number of studies using simulation
>> > looking at this. The main recurring theme is not the
>> > frequency of exposure, or time since initial
>> > teaching ( which are still important), the main
>> > issue is quality of initial teaching. This has
>> > become a recurring theme - we have tried a number of
>> > different teaching formats, and certain teaching
>> > formats had the highest correlation with 6 month
>> > performance. Very interesting stuff.
>> >
>>What teaching format came out top?
>
>Seperate medical and nursing teaching of the same material, with subsequent
>joint filmed and debriefed scenarios - the video feedback certainly seems
>to
>be very important.
>
>cheers
>
>Craig
>
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