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Our host Kevin Grange is joined by Mike Lauria. Mike is not just an emergency medicine physician, but also served in the US Air Force as a pararescueman. From ski patrolling to firefighting, to working with various special operations organisations, his career span is as diverse as it gets. Today, Mike will be sharing his insights on dealing with high-stress situations in medicine, rooted in his multi-faceted background. We'll be talking about his Btsf (Beat the Stress Fool) method and how it employs breathing, self-talk, seeing, and focusing to manage stress. Plus, we'll get a closer look at the use of Emergency Reflex Action Drills (erad) in high-pressure medical environments. So, whether you're an emergency medical professional, a firefighter on the front lines, or anyone interested in enhancing your focus and calm in high-stress situations, you're guaranteed to walk away with a handful of useful strategies. Mike Lauria was a Pararescueman (PJ) in the US Air Force and Critical Care/Flight Paramedic for the Dartmouth-Hitchcock Advanced Response Team (DHART) . Now, He's an Emergency Medicine Physician at the University of New Mexico Health Sciences Center, EMS/Critical Care Fellow, Flight Physician, and the Associate Medical Director for Lifeguard Air Emergency Services.
Calcium administration to trauma patients has become a hot topic with the rise of the “Lethal Diamond." While evidence exists regarding the association between hypocalcemia and mortality, it remains unclear whether hypocalcemia is the problem or simply a finding secondary to critical injury. In this podcast, Dr. Lauria reviews the evidence behind calcium administration in trauma and identifies which patients, given the available evidence, might benefit from calcium administration. Don't miss another FlightBridgeED Podcast feature episode of the MDCast! So much good stuff! Please like, subscribe, and leave any questions or comments. References for the use of Calcium in Severe Trauma Chanthima P, Yuwapattanawong K, Thamjamrassri T, et al. Association Between Ionized Calcium Concentrations During Hemostatic Transfusion and Calcium Treatment With Mortality in Major Trauma. Anesth Analg. Jun 1 2021;132(6):1684-1691. doi:10.1213/ANE.0000000000005431 D B. Prehospital administration of calcium in trauma J Paramed Prac. 2022; DeBot M, Sauaia A, Schaid T, Moore EE. Trauma-induced hypocalcemia. Transfusion. Aug 2022;62 Suppl 1:S274-S280. doi:10.1111/trf.16959 Ditzel RM, Jr., Anderson JL, Eisenhart WJ, et al. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg. Mar 2020;88(3):434-439. doi:10.1097/TA.0000000000002570 Giancarelli A, Birrer KL, Alban RF, Hobbs BP, Liu-DeRyke X. Hypocalcemia in trauma patients receiving massive transfusion. J Surg Res. May 1 2016;202(1):182-7. doi:10.1016/j.jss.2015.12.036 Kronstedt S, Roberts N, Ditzel R, et al. Hypocalcemia as a predictor of mortality and transfusion. A scoping review of hypocalcemia in trauma and hemostatic resuscitation. Transfusion. Aug 2022;62 Suppl 1(Suppl 1):S158-S166. doi:10.1111/trf.16965 Leech C, Clarke E. Pre-hospital blood products and calcium replacement protocols in UK critical care services: A survey of current practice. Resusc Plus. Sep 2022;11:100282. doi:10.1016/j.resplu.2022.100282 Messias Hirano Padrao E, Bustos B, Mahesh A, et al. Calcium use during cardiac arrest: A systematic review. Resusc Plus. Dec 2022;12:100315. doi:10.1016/j.resplu.2022.100315 Moore HB, Tessmer MT, Moore EE, et al. Forgot calcium? Admission ionized-calcium in two civilian randomized controlled trials of prehospital plasma for traumatic hemorrhagic shock. J Trauma Acute Care Surg. May 2020;88(5):588-596. doi:10.1097/TA.0000000000002614 Savioli G, Ceresa IF, Caneva L, Gerosa S, Ricevuti G. Trauma-Induced Coagulopathy: Overview of an Emerging Medical Problem from Pathophysiology to Outcomes. Medicines (Basel). Mar 24 2021;8(4)doi:10.3390/medicines8040016 Steele T, Kolamunnage-Dona R, Downey C, Toh CH, Welters I. Assessment and clinical course of hypocalcemia in critical illness. Crit Care. Jun 4 2013;17(3):R106. doi:10.1186/cc12756 Stueven H, Thompson BM, Aprahamian C, Darin JC. Use of calcium in prehospital cardiac arrest. Ann Emerg Med. Mar 1983;12(3):136-9. doi:10.1016/s0196-0644(83)80551-4 Vallentin MF, Granfeldt A, Meilandt C, et al. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. Dec 14 2021;326(22):2268-2276. doi:10.1001/jama.2021.20929 Vallentin MF, Povlsen AL, Granfeldt A, Terkelsen CJ, Andersen LW. Effect of calcium in patients with pulseless electrical activity and electrocardiographic characteristics potentially associated with hyperkalemia and ischemia-sub-study of the Calcium for Out-of-hospital Cardiac Arrest (COCA) trial. Resuscitation. Dec 2022;181:150-157. doi:10.1016/j.resuscitation.2022.11.006 Vasudeva M, Mathew JK, Groombridge C, et al. Hypocalcemia in trauma patients: A systematic review. J Trauma Acute Care Surg. Feb 1 2021;90(2):396-402. doi:10.1097/TA.0000000000003027 Vettorello M, Altomare M, Spota A, et al. Early Hypocalcemia in Severe Trauma: An Independent Risk Factor for Coagulopathy and Massive Transfusion. J Pers Med. Dec 28 2022;13(1)doi:10.3390/jpm13010063 Wray JP, Bridwell RE, Schauer SG, et al. The diamond of death: Hypocalcemia in trauma and resuscitation. Am J Emerg Med. Mar 2021;41:104-109. doi:10.1016/j.ajem.2020.12.065 Zhang Z, Xu X, Ni H, Deng H. Predictive value of ionized calcium in critically ill patients: an analysis of a large clinical database MIMIC II. PLoS One. 2014;9(4):e95204. doi:10.1371/journal.pone.0095204 See omnystudio.com/listener for privacy information.
Join FlightBridgeEDs new Chief Medical Director, Mike Lauria, as we launch the FlightBridgeED MDCast. Dr. Lauria will hijack these episodes for a new perspective on current topics in critical care medicine. In this episode, Dr. Lauria looks at Eric's previously published podcast [episode 224] on ASA Overdose and gives his insight, practical application, and overall thoughts on these difficult-to-manage patients. Don't miss this episode! So much good stuff! Please like, subscribe, and leave any questions or comments. References for Acute Salicylate Intoxication Anderson RJ, Potts DE, Gabow PA, Rumack BH, Schrier RW. Unrecognized adult salicylate intoxication. Ann Intern Med. Dec 1976;85(6):745-8. doi:10.7326/0003-4819-85-6-745 Chyka PA, Erdman AR, Christianson G, et al. Salicylate poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(2):95-131. doi:10.1080/15563650600907140 Dargan PI, Wallace CI, Jones AL. An evidence-based flowchart to guide the management of acute salicylate (aspirin) overdose. Emerg Med J. May 2002;19(3):206-9. doi:10.1136/emj.19.3.206 Delaney TM, Helvey JT, Shiffermiller JF. A Case of Salicylate Toxicity Presenting with Acute Focal Neurologic Deficit in a 61-Year-Old Woman with a History of Stroke. Am J Case Rep. Feb 15 2020;21:e920016. doi:10.12659/AJCR.920016 Espírito Santo R, Vaz S, Jalles F, Boto L, Abecasis F. Salicylate Intoxication in an Infant: A Case Report. Drug Saf Case Rep. Nov 27 2017;4(1):23. doi:10.1007/s40800-017-0065-9 Goldberg MA, Barlow CF, Roth LJ. The effects of carbon dioxide on the entry and accumulation of drugs in the central nervous system. J Pharmacol Exp Ther. Mar 1961;131:308-18. Juurlink DN, Gosselin S, Kielstein JT, et al. Extracorporeal Treatment for Salicylate Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup. Ann Emerg Med. Aug 2015;66(2):165-81. doi:10.1016/j.annemergmed.2015.03.031 Kuzak N, Brubacher JR, Kennedy JR. Reversal of salicylate-induced euglycemic delirium with dextrose. Clin Toxicol (Phila). Jun-Aug 2007;45(5):526-9. doi:10.1080/15563650701365800 McCabe DJ, Lu JJ. The association of hemodialysis and survival in intubated salicylate-poisoned patients. Am J Emerg Med. Jun 2017;35(6):899-903. doi:10.1016/j.ajem.2017.04.017 Miyahara JT, Karler R. Effect of salicylate on oxidative phosphorylation and respiration of mitochondrial fragments. Biochem J. Oct 1965;97(1):194-8. doi:10.1042/bj0970194 Oliver TK, Jr., Dyer ME. The prompt treatment of salicylism with sodium bicarbonate. AMA J Dis Child. May 1960;99:553-65. doi:10.1001/archpedi.1960.02070030555001 Oualha M, Dupic L, Bastian C, Bergounioux J, Bodemer C, Lesage F. [Local salicylate transcutaneous absorption: an unrecognized risk of severe intoxication: a case report]. Arch Pediatr. Oct 2012;19(10):1089-92. Application cutanée localisée d'acide salicylique : un risque méconnu d'intoxication : à propos d'un cas. doi:10.1016/j.arcped.2012.07.012 Palmer BF, Clegg DJ. Salicylate Toxicity. N Engl J Med. Jun 25 2020;382(26):2544-2555. doi:10.1056/NEJMra2010852 Penniall R. The effects of salicylic acid on the respiratory activity of mitochondria. Biochim Biophys Acta. Nov 1958;30(2):247-51. doi:10.1016/0006-3002(58)90047-7 Shively RM, Hoffman RS, Manini AF. Acute salicylate poisoning: risk factors for severe outcome. Clin Toxicol (Phila). Mar 2017;55(3):175-180. doi:10.1080/15563650.2016.1271127 Stolbach AI, Hoffman RS, Nelson LS. Mechanical ventilation was associated with acidemia in a case series of salicylate-poisoned patients. Acad Emerg Med. Sep 2008;15(9):866-9. doi:10.1111/j.1553-2712.2008.00205.x Thurston JH, Pollock PG, Warren SK, Jones EM. Reduced brain glucose with normal plasma glucose in salicylate poisoning. J Clin Invest. Nov 1970;49(11):2139-45. doi:10.1172/JCI106431 See omnystudio.com/listener for privacy information.
Dr. Mike Lauria is an emergency physician with a background as a paramedic, flight paramedic, and an elite special forces Pararescueman in the Air Force. In this amazing 7 Things, Dr. Lauria combines this experience into 7 Things that will help you be a better EMT or paramedic on the street. Don't miss it!Get CE for listening! 1 hour CAPCE-approved F3 CE (basic). Purchase here: https://www.lc-ready.com/store/details/88-7_things_street_medicine
Special forces pararescueman turned ER doctor and expert on human performance, Mike Lauria, MD, talks about evolving our ability to perform when it matters most.
This week on the EDjam we discuss resuscitation. Dr Aruna talks through her approach to running a successful resuscitation for her patients, herself and her team. We talk about categorising the resuscitation into themes, mental offloading to the wider team, being prepared for the worst and understanding your roles as team leader. Aruna gives some great medical and non medical advice that any emergency clinician could use in their practice. We also touch on being a female in emergency medicine and the challenges faced. Aruna will leave you feeling inspired and more connected to the emergency calling. Show Notes * John Hinds - Crack the Chest. Get Crucified- click here * Situation Awareness in Resuscitation by Mike Lauria click here * EMCRIT PODCAST Click here * Life in the Fast Lane - click this for link to website
March 2021 - Wilderness & Environmental Medicine Live Wilderness & Environmental Medicine journal online: www.wemjournal.org Questions/comments/feedback and/or interest in participating in WEM Live? Send an email to: wemlive@wms.org Part 1 (1:49) Journal Club Title: Utilizing Drones to Restore and Maintain Radio Communication During Search and Rescue Operations Author: Jake N. McRae DOI: https://doi.org/10.1016/j.wem.2020.11.002 CME Available: https://wms.org/members Presenter: Jake N. McRae Reviewer: Darryl Macias Part 2 (29:35) Darryl chats with Mike Lauria about working under stress, how to mitigate stress, and why it's important for wilderness medicine practitioners. Part 3 (1:13:50) Highlights from talks from the WMS 2021 winter conference.
In this episode, our guests discuss the holidays, family arrangements, a Tibetan story of Milarepa, and discuss an article by Terry Warn (CNN) titled: The Secrets of Couples Thriving Right Now in the Pandemic. Our conversation shows how different of a landscape this month is for many families and couples. We also want to wish you a very happy holiday season! Season Two of the Vir Vulnerabilis Vir Podcast is sponsored by our good friends at Standard & Strange - where the clothes and the people are anything but ordinary and the motto is own fewer better things! Be sure to follow us on Instragram @virvulnerabilisvir @denimmindset @upstateguystyle @standardandstrange @lizzyisart @nybeardedgent @whiskey_leatherworks
In this episode, Adam and Albert talk with Liz and Mike Lauria, the first couple on the show, about their relationship, COVID, working from home, and the importance of a unified front. What started as a thought to have some relationship fun, turned into a deep conversation about communication in modern relationships. Join us in our first of many talks with partners on the show. Season Two of the Vir Vulnerabilis Vir Podcast is sponsored by our good friends at Standard & Strange - where the clothes and the people are anything but ordinary and the motto is own fewer better things! Be sure to follow us on Instragram! @virvulnerabilisvir @denimmindset @upstateguystyle @standardandstrange @nybeardedgent @lizzyisart
In this episode, we're doing something a little different. Inspired by our listeners, we'll be discussing the first two episodes of Season 2 (Boo Ray & Bruce Feiler). Adam and Albert along with previous guests Neil, Mike, and Evan, give us their take on the episodes and what aspects reached them. Join in on the discussion this episode. Season Two of the Vir Vulnerabilis Vir Podcast is sponsored by our good friends at Standard & Strange - where the clothes and the people are anything but ordinary and the motto is own fewer better things! Be sure to follow us on Instragram @virvulnerabilisvir @denimmindset @upstateguystyle @standardandstrange @nybeardedgent @shadesonindig0
Celebrate our 25th episode with our special guests Tim Sorenson and Mike Lauria! Adam and Albert discuss how we've all adapted and grown since we last talked. We discuss changes within our relationships, home and work life inside quarantine. Thanks so much for listening as we hit our first milestone in our podcast! Follow us on Instagram @virvulnerabilisvir @denimmindset @upstateguystyle @tlsorenson & @nybeardededgent
In this episode, Adam and Albert interview Mike Lauria on his relationship with his wife. He talks about break ups, growth, love, and the 3 acts of his life. Dive into the love with this episode. Be sure to follow us on Instagram at @virvulnerabilisvir @denimmindset @upstateguystyle & @mikelauria !
Show Notes for Episode Twelve of seX & whY: Sex and Gender Differences in CPR Part 1 & 2 Host: Jeannette Wolfe Guest: Dr Justin Morgenstern Two big databases surrounding cardiac arrest Cares- Cardiac Arrest Registry to Enhance Survival which is based on information from national EMS data input via the NEMSIS national EMS information system ROC- Resuscitation Outcomes Consortium (ROC) 2011-2015. The ROC is a network of National Institutes of Health -funded clinical trial network evaluating out of hospital cardiac arrests that collects data from 11 different sites around the United States Here are two great articles that cover this material in depth AHA 2019 stats When the Female Heart Stops: Sex and Gender Differences in Out-of-Hospital Cardiac Arrest Epidemiology and Resuscitation What we know Over 350,000 people will have a cardiac arrest this year Men account for about 2/3 of OHCA average age for men 66 average age for women 72 About 20-25% will occur in public place Men are proportionately more likely to collapse in public place than women (19% versus 8.4% in one study) About half of cardiac arrests are witnessed (about 37% by layperson and 12% by EMS) compared to men, women have higher rate of unwitnessed arrest. (46% vs 52% in one study) Bystander CPR doubles to triples rates of survival Rates of bystander CPR are highly variable and depend heavily upon where you live and its demographics with CPR being less likely to be started in predominately minority and lower socioeconomic communities. Overall, it appears that about 35-40% or cardiac arrests will get bystander CPR Where you live is also dramatically associated with your rates of leaving the hospital neurologically intact. One study that examined 132 different counties showed, depending upon the county, functional recovery rates ranging from 0.8%-20% (which again, is likely heavily influenced by variations in CPR and AED use.) CARES data bank stats suggest that out of hospital cardiac arrest (OHCA) 28% live to hospital 8% leave neurologically intact Usually less than 20% of initial rhythms of OHCA are shockable though sex difference here also (one study 29% men vs women 16% with initial shockable rhythm) Per one survey about 2/3 of people has some type of CPR training with 20% being currently trained CPR training noted to be lower amongst Hispanics, elderly, lower income, less formally educated Of those trained in CPR only about 1/3 of people will actually step up and do it when indicated First study Gender disparities among adult recipients of bystander cardiopulmonary resuscitations in the Public from Audrey Blewer in Cir Cardiovasc Qual Outcomes 2018 Primary study question- is there an association between an individual's biological sex and the likelihood they will receive bystander CPR Resuscitation Outcomes Consortium (ROC) 2011-2015 This was a retrospective analysis of data collected in a prospectively for several clinical trials in out of hospital cardiac arrests from 7 of these sites. Exclusion: Traumatic arrest Occurs in a residential institution or hospital Less than 18 CPR initiated by someone who was not a layperson (police EMS doc) The variable they used in logistic regression modeling included whether event was witnessed, location, layperson CPR, time of event, and basic demographics including age, race, gender Nontraumatic out of hospital cardiac arrests 19331 events Mean age 64 63% male 17% public location (3297) 82% private (15788) Overall 37% received CPR (38% of men and 35% of women) If collapse occurred in public place 45% of men and 39% of women If collapse occurred in private place 36% of men and 35% of women received CPR Overall: Males had 29% increased odds of survival Bottom line: If you have a OHCA in public you are about 6% more likely to receive CPR if you are a man than a woman This is not the only study showing gender differences in CPR here is a Netherland study and an avatar study which also highlight these differences. There are also studies suggesting subtle gender differences in EMS treatment of chest pain/cardiac arrest: time to CPR, time to first rhythm strip, IV placement, medication administration likelihood of getting lights and sirens or aspirin Ok so why is that happening? So first let's talk about some general barriers to stepping up and doing CPR in public- A 2008 study by Swor in Annals of EM interviewed almost 700 bystanders to an OHCA. Although about ½ of the bystanders had previous CPR training only about 20% actually started doing CPR. Cited barriers to doing CPR included: - feeling of panic (reported by about 38% ) - concern of doing it incorrectly (9%) - concern they could cause harm (1%) - reluctance to do mouth to mouth (1%) In another study which surveyed community members from areas in which there were low rates of bystander CPR to understand why the rates were so low, answers included: - fear of getting sued - emotional overtones of the situation - lack of knowledge - situational concerns A different study suggested that disagreeable physical characteristics- read dentures and vomit- might hamper CPR initiation. Overall you are more likely to step up and do CPR if CPR training within last 5 years (OR 6.6) in public (OR 3.1) see them collapse (OR 2.3); bystander has greater than a high school education (OR 2.0) So the next question is, are these the reasons why there is a gender difference in who gets bystander CPR or are there additional factors to consider. Second study Public Perceptions on Why Women Receive Less Bystander Cardiopulmonary Resuscitation than Men in Out of Hospital Cardiac Arrest Perman Circulation 2019 Primary Question- what are the public perceptions as to why women are less likely to get bystander CPR? Methods- Electric survey via Amazon's crowdsourcing platform- Mechanical Turk. Participants were English, >18 and familiar with CPR principles Mechanical Turk- have “master users” people achieve this rate by apparently having a history of completing other surveys out appropriately in the past (essentially successfully answering planted “attention” surveys which suggests that they are actually reading the surveys) Participants were asked 11 multiple choice questions and one free text- “ Do you have any ideas on why women may be less likely to receive CPR than men when they collapse in public?” Free text responses were coded and major themes were identified by using an inductive qualitative method. 548 subjects 542 completed surveys average age 38 equal number of males and females about 1% of participants were transgender 81% White 7% Black 6% Asian 3% Hispanic 45% college diploma ½ were trained at some time in CPR (top reasons for training were cited a work or volunteer related requirement) 24 had actually done CPR on a collapsed person- Three major themes evolving: 1) Sexualization of woman's bodies (40% of men mentioned versus 29% of women) - fear of making incidental contact with a woman's breast “I think that people are afraid to touch the breast region, so hesitate to administer CPR” - fear of being wrongfully accused of sexual abuse “Bystanders, especially male bystanders, may be afraid to touch women especially in the chest area... anxious that their help my be unnecessary and therefore touching may be misconstrued” “Men are afraid of seeming like perverts” 2) Perception that women are weaker and frailer and thus at greater risk for injury if CPR was not really needed “People might be afraid of hurting them since women tend to be smaller and more fragile looking than men” 3) Misperception of what actual distress looks like in females ”They are not known to have as many heart attacks in public, they are known to be healthier” “ Maybe people assume they are being dramatic and overreacting so CPR isn't needed” Interestingly in the open- ended responses it was frequently implied by use of pronouns that the bystander initiating CPR would be a man. Along these lines, this European paper hints that gender related issues may also influence who steps up to start CPR. My (liberal) summary of paper: “Look I'm not super thrilled about the idea of touching a woman's breast and quite frankly I'm a little scared about being accused of sexual assault. And also, if I'm honest, I'm a little suspicious that the woman might be collapsing from something less serious, because most cardiac arrests seem to happen in guys. Finally, if I do start CPR on a woman and they really didn't need it, I'm afraid I might accidentally physically hurt her. Five take home points As more than 60% of cardiac arrests do not get bystander CPR, please consider sending out these CPR videos from the American Heart Association and The British Heart Foundation to friends or family members to teach and/or reinforce basic CPR principles as good CPR doubles to triples survival rates. There are innate biological sex differences associated with out of hospital cardiac arrests including: 2/3 of cardiac arrest occur in men who collapse on average collapse about 7-10 years earlier than women. Men are also more likely to have an initial shockable rhythm. Gender related issues, which can notoriously sneak under the radar if we don't intentionally look for them, can also impact cardiac arrests. The study we talked about today suggested about a 5-6% absolute differences in public bystander CPR rates with men receiving more CPR. Concerningly there is similar research suggesting gender based inequities of both the EMS and hospital management level of cardiac arrest and we will continue this discussion in part 2 of our series. Although more deductive research is needed, there are hints that some of these gender related CPR differences are rooted in concerns surrounding sexuality, perceptions about fragility and misconceptions that collapsing women are unlikely to be having a cardiac arrest. The first step to gender- based gaps in cardiac arrest is to simply validate they exist. If you teach CPR, recognize and normalize that for some learners, invading someone's personal space can feel totally awkward and then encourage them to mentally rehearse different scenarios in which they visualize themselves successfully starting CPR. Using tools like the womanikin can help. As it appears that only about 30% of people who already know CPR, will actually step up to do it, we must work on ways to close this gap. Considering the introduction of stress inoculation and introducing things like Mike Lauria's breath, talk, see and focus technique holds promise. Other references High Sensitivity Troponin and Gender Differences in treatment after ACS North Carolina's Heart Rescue Intervention Article about CPR and Good Samaritan laws
Show Notes for Episode Twelve of seX & whY: Sex and Gender Differences in CPR Part 1 & 2 Host: Jeannette Wolfe Guest: Dr Justin Morgenstern Two big databases surrounding cardiac arrest Cares- Cardiac Arrest Registry to Enhance Survival which is based on information from national EMS data input via the NEMSIS national EMS information system ROC- Resuscitation Outcomes Consortium (ROC) 2011-2015. The ROC is a network of National Institutes of Health -funded clinical trial network evaluating out of hospital cardiac arrests that collects data from 11 different sites around the United States Here are two great articles that cover this material in depth AHA 2019 stats When the Female Heart Stops: Sex and Gender Differences in Out-of-Hospital Cardiac Arrest Epidemiology and Resuscitation What we know Over 350,000 people will have a cardiac arrest this year Men account for about 2/3 of OHCA average age for men 66 average age for women 72 About 20-25% will occur in public place Men are proportionately more likely to collapse in public place than women (19% versus 8.4% in one study) About half of cardiac arrests are witnessed (about 37% by layperson and 12% by EMS) compared to men, women have higher rate of unwitnessed arrest. (46% vs 52% in one study) Bystander CPR doubles to triples rates of survival Rates of bystander CPR are highly variable and depend heavily upon where you live and its demographics with CPR being less likely to be started in predominately minority and lower socioeconomic communities. Overall, it appears that about 35-40% or cardiac arrests will get bystander CPR Where you live is also dramatically associated with your rates of leaving the hospital neurologically intact. One study that examined 132 different counties showed, depending upon the county, functional recovery rates ranging from 0.8%-20% (which again, is likely heavily influenced by variations in CPR and AED use.) CARES data bank stats suggest that out of hospital cardiac arrest (OHCA) 28% live to hospital 8% leave neurologically intact Usually less than 20% of initial rhythms of OHCA are shockable though sex difference here also (one study 29% men vs women 16% with initial shockable rhythm) Per one survey about 2/3 of people has some type of CPR training with 20% being currently trained CPR training noted to be lower amongst Hispanics, elderly, lower income, less formally educated Of those trained in CPR only about 1/3 of people will actually step up and do it when indicated First study Gender disparities among adult recipients of bystander cardiopulmonary resuscitations in the Public from Audrey Blewer in Cir Cardiovasc Qual Outcomes 2018 Primary study question- is there an association between an individual's biological sex and the likelihood they will receive bystander CPR Resuscitation Outcomes Consortium (ROC) 2011-2015 This was a retrospective analysis of data collected in a prospectively for several clinical trials in out of hospital cardiac arrests from 7 of these sites. Exclusion: Traumatic arrest Occurs in a residential institution or hospital Less than 18 CPR initiated by someone who was not a layperson (police EMS doc) The variable they used in logistic regression modeling included whether event was witnessed, location, layperson CPR, time of event, and basic demographics including age, race, gender Nontraumatic out of hospital cardiac arrests 19331 events Mean age 64 63% male 17% public location (3297) 82% private (15788) Overall 37% received CPR (38% of men and 35% of women) If collapse occurred in public place 45% of men and 39% of women If collapse occurred in private place 36% of men and 35% of women received CPR Overall: Males had 29% increased odds of survival Bottom line: If you have a OHCA in public you are about 6% more likely to receive CPR if you are a man than a woman This is not the only study showing gender differences in CPR here is a Netherland study and an avatar study which also highlight these differences. There are also studies suggesting subtle gender differences in EMS treatment of chest pain/cardiac arrest: time to CPR, time to first rhythm strip, IV placement, medication administration likelihood of getting lights and sirens or aspirin Ok so why is that happening? So first let's talk about some general barriers to stepping up and doing CPR in public- A 2008 study by Swor in Annals of EM interviewed almost 700 bystanders to an OHCA. Although about ½ of the bystanders had previous CPR training only about 20% actually started doing CPR. Cited barriers to doing CPR included: - feeling of panic (reported by about 38% ) - concern of doing it incorrectly (9%) - concern they could cause harm (1%) - reluctance to do mouth to mouth (1%) In another study which surveyed community members from areas in which there were low rates of bystander CPR to understand why the rates were so low, answers included: - fear of getting sued - emotional overtones of the situation - lack of knowledge - situational concerns A different study suggested that disagreeable physical characteristics- read dentures and vomit- might hamper CPR initiation. Overall you are more likely to step up and do CPR if CPR training within last 5 years (OR 6.6) in public (OR 3.1) see them collapse (OR 2.3); bystander has greater than a high school education (OR 2.0) So the next question is, are these the reasons why there is a gender difference in who gets bystander CPR or are there additional factors to consider. Second study Public Perceptions on Why Women Receive Less Bystander Cardiopulmonary Resuscitation than Men in Out of Hospital Cardiac Arrest Perman Circulation 2019 Primary Question- what are the public perceptions as to why women are less likely to get bystander CPR? Methods- Electric survey via Amazon's crowdsourcing platform- Mechanical Turk. Participants were English, >18 and familiar with CPR principles Mechanical Turk- have “master users” people achieve this rate by apparently having a history of completing other surveys out appropriately in the past (essentially successfully answering planted “attention” surveys which suggests that they are actually reading the surveys) Participants were asked 11 multiple choice questions and one free text- “ Do you have any ideas on why women may be less likely to receive CPR than men when they collapse in public?” Free text responses were coded and major themes were identified by using an inductive qualitative method. 548 subjects 542 completed surveys average age 38 equal number of males and females about 1% of participants were transgender 81% White 7% Black 6% Asian 3% Hispanic 45% college diploma ½ were trained at some time in CPR (top reasons for training were cited a work or volunteer related requirement) 24 had actually done CPR on a collapsed person- Three major themes evolving: 1) Sexualization of woman's bodies (40% of men mentioned versus 29% of women) - fear of making incidental contact with a woman's breast “I think that people are afraid to touch the breast region, so hesitate to administer CPR” - fear of being wrongfully accused of sexual abuse “Bystanders, especially male bystanders, may be afraid to touch women especially in the chest area... anxious that their help my be unnecessary and therefore touching may be misconstrued” “Men are afraid of seeming like perverts” 2) Perception that women are weaker and frailer and thus at greater risk for injury if CPR was not really needed “People might be afraid of hurting them since women tend to be smaller and more fragile looking than men” 3) Misperception of what actual distress looks like in females ”They are not known to have as many heart attacks in public, they are known to be healthier” “ Maybe people assume they are being dramatic and overreacting so CPR isn't needed” Interestingly in the open- ended responses it was frequently implied by use of pronouns that the bystander initiating CPR would be a man. Along these lines, this European paper hints that gender related issues may also influence who steps up to start CPR. My (liberal) summary of paper: “Look I'm not super thrilled about the idea of touching a woman's breast and quite frankly I'm a little scared about being accused of sexual assault. And also, if I'm honest, I'm a little suspicious that the woman might be collapsing from something less serious, because most cardiac arrests seem to happen in guys. Finally, if I do start CPR on a woman and they really didn't need it, I'm afraid I might accidentally physically hurt her. Five take home points As more than 60% of cardiac arrests do not get bystander CPR, please consider sending out these CPR videos from the American Heart Association and The British Heart Foundation to friends or family members to teach and/or reinforce basic CPR principles as good CPR doubles to triples survival rates. There are innate biological sex differences associated with out of hospital cardiac arrests including: 2/3 of cardiac arrest occur in men who collapse on average collapse about 7-10 years earlier than women. Men are also more likely to have an initial shockable rhythm. Gender related issues, which can notoriously sneak under the radar if we don't intentionally look for them, can also impact cardiac arrests. The study we talked about today suggested about a 5-6% absolute differences in public bystander CPR rates with men receiving more CPR. Concerningly there is similar research suggesting gender based inequities of both the EMS and hospital management level of cardiac arrest and we will continue this discussion in part 2 of our series. Although more deductive research is needed, there are hints that some of these gender related CPR differences are rooted in concerns surrounding sexuality, perceptions about fragility and misconceptions that collapsing women are unlikely to be having a cardiac arrest. The first step to gender- based gaps in cardiac arrest is to simply validate they exist. If you teach CPR, recognize and normalize that for some learners, invading someone's personal space can feel totally awkward and then encourage them to mentally rehearse different scenarios in which they visualize themselves successfully starting CPR. Using tools like the womanikin can help. As it appears that only about 30% of people who already know CPR, will actually step up to do it, we must work on ways to close this gap. Considering the introduction of stress inoculation and introducing things like Mike Lauria's breath, talk, see and focus technique holds promise. Other references High Sensitivity Troponin and Gender Differences in treatment after ACS North Carolina's Heart Rescue Intervention Article about CPR and Good Samaritan laws
SMACCForce: Force of habit-effective situational awareness in resuscitation by Mike Lauria
SMACCForce: CRM Panel Discussion with Clare Richmond, Neil Jeffers (Pilot), Per Bredmose, Mike Lauria, Tom Evens
Beat The Stress Fool!
The dasSMACC (social medial and critical care) conference was recently held in Berlin. Simulation was a theme woven throughout the conference, and we thought a simulcast episode recapping on some of the messages and themes was timely. Smacc has arguably redefined the way we think about medical conferences – great speakers, great messages, hard core critical care in an engaging format. This year, simulation activities were embedded in main stage talks, workshops, panel discussions and the ‘Sim Haus’ we previewed in a recent Simulcast episode. A series of linked main stage talks from Clare Richmond, Chris Hicks and Jon Gatward gave us a framework for thinking about simulation modalities and matching method to objective. Following the journey of a head injured patient, we saw performances by actor Renee Lim, the incredibly realistic manikin made by Lifecast, and how end of life discussions, organ donation, cognitive biases can be addressed using simulation just as well as the action sequences involving airway management of a head injury. Also on the main stage - Brian Burns opening talk wasn’t about simulation, but rather was a futuristic trauma simulation in which he demonstrated the ways technology might improve our pre-hospital trauma care in the not too distant future, including drone delivered blood products. Jenny Rudolph gave us a practical insight and skills for dealing with ‘WTF’ moments, by seeking out the underlying frames for behaviour we find annoying or disappointing. She led a whole of audience exercise in resetting our response from unhelpful emotion to curiosity, bringing to life her longstanding work in double loop learning and debriefing using advocacy inquiry. The interprofessional panel discussion (aka ‘the tribalism panel’) sparked conversations about how simulation can be an agent of culture change, but also how deliberate our strategies need to be in making our educational outcomes truly interprofessional. Both Jesse and I were involved in the education panel on Day 3 where simulation was again a core theme, especially as it pertains to preparing learners for the future, connecting with quality improvement in hospitals, and integrating into everyday work. Walter Eppich’s work on how to take our debriefing skills into the clinical area through coaching conversations received a lot of attention. As the Twitter moderator, Jesse wonderfully captured some audience questions and responses in this storify. Pre-conference workshops on Debriefing, Leave the Sim Lab behind and Stress Inoculation were a chance for attendees to deep dive with internationally respected faculty. Jan Schmutz presented his recent work on team reflexivity in the debriefing workshop (an enlightening read, but you will need to concentrate). The last of those workshops connected with a presmacc meeting in London – the Performance Psychology in Medicine Seminar. This fantastic program connected the worlds of high performance in pre-hospital care, other healthcare, elite sport and on stage. The event highlighted work like Mike Lauria’s Psychological skills to improve emergency care providers performance under stress, and others like Vicki Leblanc. The Sim Haus was a dedicated physical space within the conference venue, which housed industry displays and ‘meet the experts’ session. There was some fascinating new technology and an atmosphere of sharing sim ideas and challenges. Where to for more? Feel free to go back to #dasSMACC and also #simHaus, and of course wait for the talks and podcasts to be released on the smacc website and podcasts over the year. Next smacc conference is in Sydney February 2019
This week, the podcast features a talk on Visualization given at the All NYC EM conference in October 2016. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_81_0_Final_Cut.m4a Download One Comment Tags: All NYC EM, Human Factors, Performance Psychology, Sports Psychology Show Notes Read More EMCrit: EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria Read More
This week, the podcast features a talk on Visualization given at the All NYC EM conference in October 2016. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_81_0_Final_Cut.m4a Download One Comment Tags: All NYC EM, Human Factors, Performance Psychology, Sports Psychology Show Notes Read More EMCrit: EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria Read More
Today, I am joined by my friend, Mike Lauria, to interview Gary Klein, PhD. Dr. Klein is a masterful cognitive psychologist. He is known for many groundbreaking works, including: the Recognition-Primed Decision (RPD) model to describe how people actually make decisions in natural settings; a Data/Frame model of sensemaking; a Management by Discovery model of planning to handle wicked problems; and a Triple-Path model of insight. He has also developed several research and application methods: The Critical Decision method and Knowledge Audit for doing cognitive task analysis; the PreMortem method of risk assessment; the ShadowBox method for training cognitive skills. He was instrumental in founding the field of Naturalistic Decision Making. The Books Sources of Power This is the one that got Mike and I started as Klein Fanboys Streetlights and Shadows The absolute best compilation of Dr. Klein's decision-making concepts that are directly applicable to medicine Seeing What Others Don't Next up on my reading list Recognition Primed Decisionmaking Wikipedia Link for RPD Sites and Links Dr. Klein's Company Shadowbox Training Articles Mentioned in the Show Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol. 2009 Sep;64(6):515-26. Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches. Journal of Cognitive Engineering and Decision Making Additional Related Stuff Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. Effects of reflective practice on the accuracy of medical diagnoses. Going fast might not induce more error, it's about experience and if you have the patterns to recognize: Disrupting diagnostic reasoning: do interruptions, instructions, and experience affect the diagnostic accuracy and response time of residents and emergency physicians? Slowing down doesn't help. Slow is just slow. Smooth is FAST, and smooth is about economy of cognitive resources and movements The relationship between response time and diagnostic accuracy. The etiology of diagnostic errors: a controlled trial of system 1 versus system 2 reasoning. The Checklist Manifesto: How to Get Things Right Descartes' Error: Emotion, Reason, and the Human Brain Now on to the Podcast:
Ep #19 Equanimity, Puni & Parachuting: Evolving Concepts in Optimizing Resuscitation Performance w/ Mike Lauria @ResusPadawan Happy #EMSWeek #EMSStrong #EMSNation AMPA – Air Medical Physicians Association https://www.ampa.org/ #CCTMC17 Training Announcement – Critical Care Transport Medicine Conference http://www.iafccp.org/events/EventDetails.aspx?id=177507 4/10/2017 to 4/12/2017 When: April 10 - 12, 2017 Where: Map this event » Wyndam River Walk Hotel 111 E. Pecan St. San Antonio, Texas 78205 United States Contact: Pat Petersen ppeter1111@aol.com Sponsored by @PerfectCPR Apple Watch App with Audio and Haptic Feedback to Optimize Cardiac Arrest Training and Improve Quality of CPR Delivery PerfectCPR.com Query us on Twitter: www.twitter.com/EMS_Nation Like us on Facebook: www.facebook.com/prehospitalnation Wishing Everyone a safe tour! ~Faizan H. Arshad, MD @emscritcare www.emsnation.org
Veteran Airforce Pararescueman turned critical care paramedic, Mike Lauria discusses the
The grand finale of our interview with Mike Lauria.
This episode is all about how we can change the way we make decisions under duress.
We go back to the drawing board on initial and continuing education and procedure instruction.
The CPR guys have a chat with Mike Lauria about what's wrong with the current status of EMS education.
Today, I interview Mike Lauria on the concepts of toughness and resilience.
Mike Lauria is a military pararescueman and civilian paramedic who recently gave a great talk that pulls together all of the current main areas of high stakes decision-making psychology. I got a chance to pick apart items of his talk with him and we recorded this podcast. I can guarantee that there will be stuff in here that you can use on your next job, whether at work or at a motorsport event.
You'll be hearing more from Mike