Breathing new life into resuscitation training

Recently, I spent a week playing with dolls and learning how to wash my hands. Am I regressing? Probably, but that is not the reason for the week's activities. No, I was attending a statutory training course where I learned (yet again) how to deal with cardiac arrest, the importance of hand washing, and the location of fire extinguishers.

I have been learning how to resuscitate patients for the last 40 or so years, so you would think that I might have cracked it by now. Evidence from Europe and North America suggests, however, that radiologists' knowledge in this area is somewhat lacking. In a U.K. study published in the October issue of the British Journal of Radiology (Tapping CR, Culverwell AD. Are radiologists able to manage serious anaphylactic reactions and cardiopulmonary arrest? 2009;82[982]:793- 799), only 13% of those responding to a questionnaire demonstrated full knowledge of guidelines produced by the national Resuscitation Council. When radiologists in Canada were questioned about the use of epinephrine (adrenaline) in an emergency situation, only 41% provided an acceptable route of administration, concentration, and dose. None produced an ideal answer. In fact, 17% prescribed an overdose and only 11% knew what was available on the crash cart (Lightfoot CB, et al. Survey of radiologists' knowledge regarding the management of severe contrast material-induced allergic reactions. Radiology 2009;251[3]:691-696).

Can we even guarantee to provide effective external cardiac massage? How many chest compressions should you do before you attempt rescue breathing (mouth-to-mouth resuscitation), and where in the world is the CPR mask kept?

These are chilling statistics. Imagine lying on the couch with a needle in your arm awaiting an injection of CT contrast. Would you really want to ask the doctor: “When was the last time you had to deal with a case of angioneurotic edema?” Or: “When was the last time you attended a resuscitation course?” Approximately 40% of radiologists in the U.K. would probably answer: “Over four years ago.” This despite the fact that annual training is mandatory here.

So why are we no good at playing with dolls? Resuscitation mannequins have become ever more sophisticated, allowing clinical scenarios of variable complexity to be replicated and offering both positive and negative feedback. Why are we reluctant to attend courses that are designed to revise and rehearse basic skills? If we attend those courses, why are we so poor at retaining knowledge?

We are often reminded that airline pilots must undergo extensive training in how to deal with a variety of adverse weather conditions, equipment failure possibilities, and other emergencies. They appear able to maintain their skills. I suppose it must feel more real to sit in a simulator that looks like a flight deck, where instruments are flashing warnings, than it is to be in a classroom with an inanimate mannequin. In an aircraft simulator, the altimeter spins terrifyingly if you are in a stall and the ground appears to rush towards you. Does our resuscitation doll go blue? Does she gasp, and do her relatives start screaming? No. Instead of actually demonstrating the features of respiratory or cardiac failure, we have a series of electronic warnings. This is not a real life (or death) situation.

It is difficult to take medical emergency training seriously when you don't feel under pressure. So how do we create an environment where radiologists and other healthcare professionals look forward to and even prepare for resuscitation training? In the U.K., this will become compulsory as part of a new process of professional revalidation. But will we actually have to pass or will it be enough to simply turn up?

An airline pilot would be grounded if he or she failed to pass the regular test of “skills under duress.” Should radiologists also be barred from practicing if they are unsuccessful during an assessment of their resuscitation skills? After all, 2% to 3% of hospital crash calls are made from the radiology department. We can all expect to deal with at least one emergency during our professional life.

Radiologists should be worried about more than the threat of losing their job. Fear of unemployment will undoubtedly concentrate the mind and possibly affect performance. But does this accurately reflect the stress you must confront when faced with a patient who is pale and sweating, hypotensive, and unresponsive, or who has progressive stridor as their laryngeal edema becomes more and more severe? Not really.

The compulsory resuscitation training in the U.K. is generic. I learn alongside hospital porters and secretaries, as well as nurses and other doctors of all grades. Some of the skills are indeed generic and all health workers should certainly learn external cardiac massage. The emergencies that occur in the radiology department are, however, reasonably predictable: cardiac arrest, adverse reaction to contrast, and postprocedural or postoperative bleeding leading to shock. On two occasions, because of the mixed group, I have had to resuscitate a woman with postpartum hemorrhage during training. I am now one of a few radiologists who perform antenatal ultrasound, but I have never had to deal with an acute postpartum hemorrhage in practice.

Resuscitation training should not only be compulsory, it should also be relevant to specialist groups. Radiologists should be trained and tested in emergencies that are likely to occur in the radiology department. In addition, a simulator model should be developed that better recreates the emergency environment. The “patient” needs to look like a real patient, the emergency call needs to be unexpected, an aura of anxiety needs to be fostered that can be calmed by effective actions of the radiology department team and made worse if the actions are not coordinated or effective. If we can respond effectively in such an environment, passing the test we will make us much more likely to cope effectively with genuine emergencies.

We have a responsibility to contribute to the development of training methods, methods of evaluation, and simulated environments that will ensure that our response to emergencies is second nature and our patients are better protected. I am not convinced that even those of us who undergo annual compulsory training are properly prepared at the moment.

On a lighter note, there is an alternative to increasing the sophistication of the simulation. Why not make the mannequins look like Keira Knightly or George Clooney? Then we might all become more enthusiastic about practicing chest compression and rescue breathing…