--- Craig Ellis <[log in to unmask]> wrote:
> 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)
>
But no actual clinical evaluation - simulated resus
etc. Talking a good resus is quite different from
actually doing it!
> 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.
>
That may be so. Not a problem in our hospital (on the
EM side anyway), but still no difference in survival
to discharge. Now I accept that this is a crude
measure of success, but would contend that it is the
bottom line.
>
> >
> > > 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.
>
But what evidence do you have that they perform any
better? In my experience the arrests that have gone
well are those in which the team work well together.
Having all our nurses ALS trained has improved the
smooth running of arrests markedly. Now having a well
trained consultant leading a good team is obviously
the optimum, but I would suggest the good team is the
more important of the 2.
> > > 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.
>
Such as?
> 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.
Again such as? If anything I think ALS has got over
complicated by adding things that shouldn't be in a
resus course. What bright spark thought up the AF
Algorithm?! The core message of ALS - the universal
algorithm is right IMHO, good BLS, good oxygenation,
early defib and a vasopressive agent to optimise
coronary and cerebral blood flow. I'm waiting to see
the results of the trials to see if vasopressin
improves survival to discharge over adrenaline.
> 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.
>
What problems in particular? I realise that no set of
guidelines will ever be complete, which is why ALS is
dotted with seek expert help, consider various
options, think about causes etc. We certainly
encourage our candidates to use their brains on the
course. I've never seen anyone fail for using their
brain. People fail for doing stupid things like going
to shock sinus tachy as I had last week!
> > >
> >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.
>
That is interesting. We have recently started using a
similar system for some of the teaching with video and
feedback. I think it is very valuable.
Fred.
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