“Resuscitationist”?

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I saw this word on a Facebook page I was invited to this week. The idea is that it is an expert on resuscitation. (I did not come up with the term, I do not know who did.I would give them their due credit)

But what is an “expert at resuscitation?”

Early in my career I was taught “steps of resuscitation.” A list of things to do, in a particular order, that would permit you to drive a “live” patient to the hospital for another “initial step” which would be continued in the ICU, where “actual” resuscitation would take place.

                This was further taught and enforced when I was in paramedic school and early in my paramedic career, that “initial resuscitation,” was the defining skill set of a good or bad paramedic. Furthermore, it was emphasized we were doing everything that would be done in the Emergency Department. But we never directly admitted patients to the ICU, we always stopped in the ED.

                Survival rates were dismal.

                Recently there has been considerable press and focus on “pit crew” CPR, “quality” CPR, etc. Survival rates have gone up. Experienced experts and resuscitation scientists have been discovering and practicing resuscitation without “advanced procedures” which are recommended and advocated by guidelines from the AHA, ERC, ILCOR, and a few smaller ones.

                However, all providers are expected to know these guidelines, and people who do not spend their nights and weekends focusing on resuscitation science are still performing based on these guidelines. My colleagues and peers involved in resuscitation all sit around saying things like “no way would I follow that guideline because…”

                When I started pursuing my PhD, in my search for a mentor I was directed to a much respected clinician and scientist at my university. Because of my history and the fact I was not a physician specialist, it was suggested it would be more credible for me to do an academic PhD program in pathophysiology. Thus I started pursuing that route. When I got to the clinical research component, which was really basic science research in the clinical setting, it was discovered despite not being a physician, I really did have a lot of experience and knowledge and was very much an expert at resuscitation. So after just over a year of work, I went through a process to get permission to change to a clinical medicine PhD in intensive care. (It was not an easy process, but it worked out well for me) I was formally handed over to another mentor/promoter who is a neonatologist.

                Having taken and taught some Neonatal Resuscitation Provider courses as an “expert in resuscitation”, not particularly neonatal resuscitation, prior to medical school, I was fairly confident I had the topic in hand. I was very much mistaken. I read and learned things I had not even considered as part of resuscitation. Physiology, pathophysiology, homeostasis connections, basic science, I was initially overwhelmed and well and truly schooled.

                But when this influx of knowledge started to settle, I noticed some things that have made a considerable impact on my world of resuscitation. Not least of which is that neonatology is a fairly new specialty. Most practitioners admit not a lot of scientific knowledge exists for it, and as such, you can research things that would be absolutely forbidden to try in pediatric or adult resuscitation.

                When we are in basic biology in university, or even high school, we learn of life cycles. If you are reading this, you know the drill, larva stage, pupa stage, adult stage… Humans have a life cycle just like that! We give it different names, neonate, infant, toddler, adolescent, adult, but in one of nature’s conserved and enduring patterns, we are no different from other species. In anthropology, I was taught that there are certain characteristics unique to human birth and development because we evolved into a bipedal species, and certainly that information is relevant to both pediatric and neonatal resuscitation. (More to neonates actually)

                    But how this all ties together is: any research and consequent medical advances in resuscitation and breakthroughs can be expected  to come from neonatology. In fact, some advances currently introduced in both peds and adult resuscitation was transferred from neonatology. Limited use of oxygen therapy, the harm it causes, the mechanisms of those causes, and some potential treatments, mixed gas ventilation, and alveolar recruitment, were all neonatal discoveries.

                In any neonatology resuscitation class you take or book you read, you will see that medications are the last ditch effort at the smallest point of “the neonatal resuscitation triangle.” They have all but disappeared, being used only in very specific identified pathologies. Even predetermining futile resuscitation comes from neonatology. This too applies to peds. But not adults? I call malarkey!

                The inflammatory process, the focus of much research into shock and resuscitation, is being studied in neonates because of ethical restrictions in other populations.

                What have I learned? Too much to form a comprehensive list here. But advanced fluid balance, temperature regulation, subclinical detection of diseases, are a few that really stand out as being immediately applicable to other populations. Neonatology was also kind enough to confirm my hypothesis that in addition to the central circulatory organs of the brain, heart, and kidneys, other organ support such as the liver and gut are absolutely critical to resuscitation outcomes. Furthermore it has confirmed my other hypothesis that surgery and medicine must be combined, not separated by different specialties in resuscitation and severe disease processes. Moreover, I have confirmed there is no such thing as “initial resuscitation.” That is an idea for the convenience of providers, not best practice for patients. Any true hope of resuscitation will come from a continuum of resuscitative efforts, not independent skill sets. The ambulance and ED can no longer “do what they want” as biasedly confirmed by the clinical research which simply proves current practices should be paid for.

The only “initial resuscitation” is making sure there is an airway and CPR if needed and potentially beneficial. “The chain of survival” needs to be reworded from “early advanced care” to “early expert care.” Advanced or invasive skills are not enough. To adopt the term, resuscitationist.” Which is certainly a subset of intensive care, not emergency care based on the knowledge and principles.

                I think it is also time to start advocating more of a lifeline approach to resuscitation in the interim. Rather than answer questions on your own, perhaps phone an expert? Maybe even phone a friend? The ultimate goal would be to bring “initial resuscitation” providers up to the more advanced level with additional education and skills.(more on that later) Not just for cardiac arrest, but for all types of resuscitation. Also as I mentioned in another post, we must realign modern medical specialties to modern knowledge of disease and treatment. Antiquated specialty groups/training is not going to permit another recent buzzword I have learned, “science based medicine.”

 It might be time to write that book. The lecture circuit doesn’t seem to be working for me.

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2 thoughts on ““Resuscitationist”?

  1. Mike, I think you’re 100% right on this.

    Yesterday, I had a periarrest very late-stage Supercancer patient. He lacked a DNR, hysterical family, the works. Dying of cancer, respiratory arrest, a slow, slow onset of bradycardia and a slowly failing heart. I did what I could for him, but it wasn’t much, and the ED immediately Mongoed into Code Mode, which shattered his chest when he did code and ROSCd him just long enough to put him on a vent, rip him open, dump some more epi in and then have the thought “what do we do with him now?”

    Sad, and entirely preventable if patients were viewed more as people and less as skillsets.

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