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Synopsis How can we identify STEMI in patients with ventricular paced rhythm? Can we use the Sgarbossa Criteria? Below you’ll find what’s most likely (and hopefully) the silliest, catchiest and nerdiest talk on this topic recorded at the ECG masterclass from SWEETS2019. In it, Jonathan Ilicki, Alex Szeps and Elena Sgarbossa delve into how we best assess these patients. Here, first, is a bit more detail. So what are the Sgarbossa criteria? The Sgarbossa Criteria are three ECG rules that were developed by Dr Sgarbossa in 1996: Concordant ST elevation ≥ 1mm in a lead with a positive QRS complex (5 points) ST depression ≥ 1 mm in V1, V2 or V3 (3 points) Discordant ST elevation ≥ 5 mm in a lead with a negative QRS complex (2 points) 3 or more points has been shown to be highly specific (98%) for ACS in patients with LBBB​[1]​. Life on the Fast Lane has a great ECG database with a page about the Sgarbossa criteria. So can I use this for patients with ventricular paced rhythm (VPR)? There is limited research (key articles below​[2–7]​), but what has been published to date indicates the criteria are very specific, but not sensitive for ACS in patients with VPR​[8]​ (open access here). Amal Mattu has a great ECG resource called ECG Weekly. Here is an episode where he discusses using the Sgarbossa Criteria for Ventricular Paced Rhythm. This sounds great! Could anything possibly be better than the Sgarbossa criteria? Interestingly, the Smith-modified Sgarbossa Criteria have recently been shown to have superior sensitivity and specificity to the original criteria​[9]​. It wasn’t included in the presentation as it’s tricky to fit the phrase “Smith-modified Sgarbossa Criteria” into a song… Dr Smith is an ECG wizard (and also a really nice guy) and has a great blog entirely focused on how to get better at assessing ECGs. Here are a couple of posts on assessing for ACS/ACO in ECGs with VPR: Anterior MI in paced rhythm Ventricular paced rhythm and chest pain Case illustrating false positive Sgarbossa criteria Ventricular paced rhythm and chest pain again Enough of that – here’s the talk https://youtu.be/mtqhnmasaiA Audio Slides Credits Alex Szeps – find his music here on Spotify! Elena Sgarbossa – for impactful research and generous participation Therese Djärv, Jonas Willmer – for serendipitous questions Emil Boström, Niclas Lewisson, Lesli Liljegren, Johanna Berg, Lina Holmberg, Patrik Nilsson – for recording what is most likely the internet’s only song on ventricular paced rhythms A patient that permitted us to write a case report​[10]​ and spread the knowledge about how to identify ACS in ventricular paced rhythms Swedish Emergency Talks References 1. Tabas J, Rodriguez R, Seligman H, Goldschlager N. Electrocardiographic criteria for detecting acute myocardial infarction in patients with left bundle branch block: a meta-analysis. Ann Emerg Med. 2008 Oct 1;52(4):329-336.e1. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18342992 2. Herweg B, Marcus M, Barold S. Diagnosis of myocardial infarction and ischemia in the setting of bundle branch block and cardiac pacing. Herzschrittmacherther Elektrophysiol. 2016 Sep 1;27(3):307–22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27402134 3. Freitas P, Santos M, Faria M, Rodrigues G, Vale N, Teles R, et al. ECG evaluation in patients with pacemaker and suspected acute coronary syndrome: Which score should we apply? J Electrocardiol. 2016 Sep 1;49(5):744–8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27430208 4. Sgarbossa E, Pinski S, Gates K, Wagner G. Early electrocardiographic diagnosis of acute myocardial infarction in the presence of ventricular paced rhythm. GUSTO-I investigators. Am J Cardiol. 1996 Feb 15;77(5):423–4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/8602576 5. Bertel N, Witassek F, Puhan M, Erne P, Rickli H, Naegeli B, et al. Management and outcome of patients with acute myocardial infarction presenting with pacemaker rhythm. Int J Cardiol. 2017 Mar 1;230:604–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28040280 6. Macfarlane P, Browne D, Devine B, Clark E, Miller E, Seyal J, et al. Modification of ACC/ESC criteria for acute myocardial infarction. J Electrocardiol. 2004 Jan 1;37 Suppl:98–103. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15534817 7. Maloy K, Bhat R, Davis J, Reed K, Morrissey R. Sgarbossa Criteria are Highly Specific for Acute Myocardial Infarction with Pacemakers. West J Emerg Med. 2010 Sep 1;11(4):354–7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21079708 8. Jothieswaran A, Body R. BET 2: Diagnosing acute myocardial infarction in the presence of ventricular pacing: can Sgarbossa criteria help? Emerg Med J. 2016 Sep 1;33(9):672–3. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27539980 9. Meyers H, Limkakeng A, Jaffa E, Patel A, Theiling B, Rezaie S, et al. Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of left bundle branch block: A retrospective case-control study. Am Heart J. 2015 Dec 1;170(6):1255–64. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26678648 10. Ilicki J, Bruchfeld S, Kolsrud B, Böhm F, Djärv T. Sgarbossa criteria used to identify cardiac ischemia in patient with ventricular paced rhythm. J Electrocardiol. 2018 Jan 1;51(5):830–2. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30177322

Synopsis This is the talk by Richard Lyon at The Bick Sick in Zermatt, 2018. Richard goes over initiatives taken to improve what were dismal outcomes in Scotland in the out-of-hospital cardiac arrest population. Tune in to hear about the marginal gains approach applied with attention to every little detail. Learn how to improve your clinical audit data to allow feedback to the clinicians and how to lead the way forward in your own organisations and communities. Finally, some thoughts on how new and upcoming technology can be harnessed to provide even better care for this patient group. Video Audio Slides References Surviving out of hospital cardiac arrest at home: a postcode lottery? (Lyon et al, EMJ 2004 open access) Variability in cardiac arrest survival: the NHS Ambulance Service Quality Indicators (Perkins et al, EMJ 2011 open access) The Wissenberg et al study from Denmark (JAMA 2013 open access) The GoodSam App Equivalent apps in Denmark are Hjerteløber (register as CPR provider) and Hjertestarter (find nearest AED) Save a life for Scotland Matrix, the movie (if Ken Milne does must-know 80s film references, we’ll do the 90s) Vinnie Jones teaches CPR, the full clip Support Richard’s research and learn to make your own Mars bar fritters Speaker bio Dr. Lyon is a consultant in emergency medicine and clinical lead for Medic1 at the Royal Infirmary of Edinburgh. He is associate medical director of Kent, Surrey & Sussex Air Ambulance and chair or Pre-hospital Emergency Care at the University of Surrey. Born in Luxembourg, he became a volunteer fireman at the age of 15 and developed an early passion for pre-hospital emergency care. He completed a unique doctorate thesis on out-of-hospital cardiac arrest (OHCA) – the TOPCAT study, which has formed the basis of a successful programme of work to improve outcome from OHCA across Scotland. He is active in resuscitation and trauma research and was proud to be part of the winning BMJ Awards Emergency Medicine Team of the Year. He has won numerous national and international awards for his work and in 2017 was awarded an MBE in Her Majesty The Queen’s Birthday Honours for services to emergency healthcare. Find him here twitter email Pubmed Before you go, don’t forget to share widely, options below leave a comment and join the #FOAMed conversation in general connect with the scanFOAM project and team on Twitter, Facebook, Instagram or write us an old fashioned email get the new stuff via RSS

Synopsis This is James DuCanto‘s talk at the airway session of The Bick Sick in Zermatt, 2018. Jim is well known in the FOAM sphere and beyond for his passion on airway management and is a very dedicated and ingenious inventor of equipment for airway simulation and airway management. Jim is tinkerer of epic proportions and is always great fun to hang out with as there’s bound to be some new crazy contraption he wants to show off. I for one personally feel his beeryngoscope deserves a lot more recognition (no, I don’t think it’s trademarked yet, but it ought to be). Here it is out in the wild at #smaccUS. https://youtu.be/o3_DMrWVQSY On a more serious note, in recent years Jim has focused a lot of energy on the SALAD concept (Suction Assisted Laryngoscopy Airway Decontamination) which essentially is continuous large bore catheter suctioning of the upper airway through the whole intubation process. He has demonstrated it at numerous conferences throughout the world including at iterations of SMACC. The amount of flights cases he drags around the world for his SALAD teaching is quite insane and a testiment to Jim’s no holds barred approach to airways. If you get a chance to try it out do take it as it’ll probably be your one shot at intubating a regurgitating wookie with a laryngoscope blade fitted to an axe. Follow Jim down the rabbit hole of contaminated airways in this talk. Video https://youtu.be/uSYFamlG_N0 Audio Slides Related resources Mostly from Jim’s slide set Jim’s website SALAD 2.0 video General Description of system and demonstration by Jeff Hill of the University of Cincinnati’s EM Program Product page of SALAD Mannequin, Nasco Video of the University of Wisconsin HEMS Fellow with the “Static” Excercise Video of the University of Wisconsin HEMS Fellow with the “Dynamic” Excercise Video of the University of a Wisconsin HEMS Attending taking on the SALAD Simulator System construction—how to build your own SALAD training system Before you go, don’t forget to share widely, options below leave a comment and join the #FOAMed conversation in general connect with the scanFOAM project and team on Twitter, Facebook, Instagram or write us an old fashioned email get the new stuff via RSS

Synopsis Geir Strandenes’ talk at The Bick Sick in Zermatt, 2018. Geir does a tour de force on blood transfusion, its history, physiology, the evidence base and ongoing developments in prehospital transfusion practice in both civilian and military settings. He specifically adresses how to apply principles of damage control resuscitation to remote locations and the introduction of fresh whole blood prehospitally from the point of injury onward. Geir represents the THOR network (Trauma Hemostasis and Oxygenation Research network). You can find a lot more information on their website. Video Audio Slides Before you go, don’t forget to share widely, options below leave a comment and join the #FOAMed conversation in general connect with the scanFOAM project and team on Twitter, Facebook, Instagram or write us an old fashioned email get the new stuff via RSS

Synopsis The Big Sick conference in february 2018 was a hugely rewarding, small-format conference that brought resuscitation nerds together in the perfect setting of Zermatt, Switzerland. Top speakers and top talks, but the conference was a total blast not least because the group of delegates was very sociable and interested in learning from each outside the sessions as much as during them. Other commitments have postponed editing, but the talks are now getting ready to go online and we hope you’ll find the content was worth the wait. We will release talks intermittently these next few months awaiting the next installment in february 2019. Here first is a talk by prof. Samuel Tisherman from Baltimore’s shock trauma center on deep hypothermia as a means to buying time in refractory traumatic cardiac arrest. He describes the history of how this therapy was developed from early animal models up until the current human EPR-CAT trial. Video Audio Slides Before you go, don’t forget to share widely, options below leave a comment and join the #FOAMed conversation in general connect with the scanFOAM project and team on Twitter, Facebook, Instagram or write us an old fashioned email get the new stuff via RSS

Synopsis Cliff Reid and Brian Burns are known world wide for their work in prehospital education, training and research, most notably at the Greater Sydney Area HEMS service. We were fortunate to have them come visit at the REPEL course and they kindly agreed to give a talk each at Odense University Hospital. Here’s Brian’s talk on the efforts required to securing optimal team performance from an organisational and systemic view point. This is very applicable to other prehospital services and the GSA HEMS service sets an admirable example on transparency in education and data sharing. Related FOAMed GSA HEMS website, for educational goodies and information on the service Cliff Reid’s talk from the same day on training HEMS teams Video Audio Slides Before you go, don’t forget to share widely, options below leave a comment and join the #FOAMed conversation in general connect with the scanFOAM project and team on Twitter, Facebook, Instagram or write us an old fashioned email get the new stuff via RSS

Synopsis Cliff Reid and Brian Burns are known world wide for their work in prehospital education, training and research, most notably at the Greater Sydney Area HEMS service. We were fortunate to have them come visit at the REPEL course and they kindly agreed to give a talk each at Odense University Hospital. Here’s Cliff’s talk with 10 lessons from his many years developing a world class HEMS training programme. Related FOAMed The GSA HEMS website for educational content and info on the service Brian Burn’s talk from the same day on governance and the systemic view on obtaining high performance teams Cliff has loads of amazing resus and training related musings on his blog resus.me Video Audio Slides Before you go, don’t forget to: share widely, options below leave a comment and join the #FOAMed conversation in general connect with the scanFOAM project and team on Twitter, Facebook, Instagram or write us an old fashioned email get the new stuff via RSS

Speaker: Olav Schjørring Event: Copenhagen Critical Care Symposium 2018 Session: The Magical Mystery Tour – sepsis 2018 Return to index Synopsis Olav Schjørring giver en opdatering på best evidence i forhold til iltnings-mål ved sepsis Video https://youtu.be/https://youtu.be/KFwgECwSalw Podcast Slides Before you go, don’t forget to: share widely comment below and join the #FOAMed conversation in general connect with the scanFOAM project and team on Twitter, Facebook, Instagram or write us an old fashioned email get the new stuff via the newsletter (sign up on frontpage) or via RSS

Speaker: Thomas Birkelund Event: Copenhagen Critical Care Symposium 2018 Session: Det ustabile kredsløb – kardiovaskulære resuscitation Return to index Synopsis Ove Bergdal gennemgår erfaringer med og tilgang til E-CPR/ECMO i Aarhus Video https://youtu.be/https://youtu.be/4TUijMzyJbA Podcast Slides Before you go, don’t forget to: share widely comment below and join the #FOAMed conversation in general connect with the scanFOAM project and team on Twitter, Facebook, Instagram or write us an old fashioned email get the new stuff via the newsletter (sign up on frontpage) or via RSS

Unconscious patients are tricky They can be out cold due to several reasons and they refuse to tell you what’s wrong with them. How can you quickly find the cause of their altered mental status? What key aspects should you address in your initial assessment? What about gastric lavage? Antidotes? Do you always need a CT? What pre-test probabilities exist for different causes and what findings in your initial assessment have strong likelihood ratios? In this talk from Karolinska’s GULD series, Jonathan Ilicki offers a structured and evidence-based framework for assessing the unconscious patient. It covers topics such as: why mnemonics like HUSK MIDAS and AEIOU-TIPS can be bad how to avoid naloxone-induced pulmonary edema how age, blood pressure and neuro findings can help you identify the cause of altered mental status when one should consider gastric lavage  and much more The lecture’s in Swedish and has English subtitles. Video https://youtu.be/O2A33la_Abw Audio Slides https://www.slideshare.net/madsastvad/snkt-medvetande-jonathan-ilicki-for-scanfoam   References 1234567891011121314 1 Forsberg S, Höjer J, Ludwigs U, Nyström H. Metabolic vs structural coma in the ED–an observational study. Am J Emerg Med 2012; 30: 1986–90. [PubMed] 2 Forsberg S, Höjer J, Ludwigs U. Prognosis in patients presenting with non-traumatic coma. J Emerg Med 2012; 42: 249–53. [PubMed] 3 Ikeda M, Matsunaga T, Irabu N, Yoshida S. Using vital signs to diagnose impaired consciousness: cross sectional observational study. BMJ 2002; 325: 800. [PubMed] 4 Penninga E, Graudal N, Ladekarl M, Jürgens G. Adverse Events Associated with Flumazenil Treatment for the Management of Suspected Benzodiazepine Intoxication–A Systematic Review with Meta-Analyses of Randomised Trials. Basic Clin Pharmacol Toxicol 2016; 118: 37–44. [PubMed] 5 Ngo A, Anthony C, Samuel M, Wong E, Ponampalam R. Should a benzodiazepine antagonist be used in unconscious patients presenting to the emergency department? Resuscitation 2007; 74: 27–37. [PubMed] 6 Singh P, Richell-Herren K. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Flumazenil and suspected benzodiazepine overdose. J Accid Emerg Med 2000; 17: 214. [PubMed] 7 Haverkos G, DiSalvo R, Imhoff T. Fatal seizures after flumazenil administration in a patient with mixed overdose. Ann Pharmacother 1994; 28: 1347–9. [PubMed] 8 Benson B, Hoppu K, Troutman W, et al. Position paper update: gastric lavage for gastrointestinal decontamination. Clin Toxicol (Phila) 2013; 51: 140–6. [PubMed] 9 Westergaard B, Hoegberg L, Groenlykke T. Adherence to international recommendations for gastric lavage in medical drug poisonings in Denmark 2007-2010. Clin Toxicol (Phila) 2012; 50: 129–35. [PubMed] 10 Yoshino T, Meguro S, Soeda Y, Itoh A, Kawai T, Itoh H. A case of hypoglycemic hemiparesis and literature review. Ups J Med Sci 2012; 117: 347–51. [PubMed] 11 Ohshita T, Imamura E, Nomura E, Wakabayashi S, Kajikawa H, Matsumoto M. Hypoglycemia with focal neurological signs as stroke mimic: Clinical and neuroradiological characteristics. J Neurol Sci 2015; 353: 98–101. [PubMed] 12 Luo S, Michler K, Johnston P, Macfarlane P. A comparison of commonly used QT correction formulae: the effect of heart rate on the QTc of normal ECGs. J Electrocardiol 2004; 37 Suppl: 81–90. [PubMed] 13 Glimåker M, Johansson B, Bell M, et al. Early lumbar puncture in adult bacterial meningitis–rationale for revised guidelines. Scand J Infect Dis 2013; 45: 657–63. [PubMed] 14 Ninio J, Stevens K. Variations on the Hermann grid: an extinction illusion. Perception 2000; 29: 1209–17. [PubMed]

Synopsis Stuart Duffin is an intensive care doctor & anaesthetist working in Stockholm, Sweden. In this talk from #SWEETS17 he looks at the difficulties front line clinicians face when predicting prognosis in severe traumatic brain injury. How can we possibly be able to look reliably into the future to allow us to make the right decisions? How can we avoid falling into the fallacy of the self fullfilling prophecy and not even knowing it? Video https://youtu.be/O2A33la_Abw Podcast Slides https://www.slideshare.net/madsastvad/head-injury-a-hard-nut-to-crack  Prognostication calculators IMPACT CRASH More from Stuart Connect on twitter References 1 Chestnut RM, Ghajar J, Maas AI, et al. Part 2: Early indicators of prognosis in severe traumatic brain injury. Journal of Neurotrauma 2000; 17: 555–555. [Source] 2 Collaborators MCT, Perel P, Arango M, et al. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ (Clinical research ed) 2008; 336: 425–9. [PubMed] 3 Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS medicine 2008; 5: e165; discussion e165. [PubMed] 4 Hemphill JC, White DB. Clinical nihilism in neuroemergencies. Emergency medicine clinics of North America 2009; 27: 27–37, vii–viii. [PubMed] 5 Nelson DW, Nystrom H, MacCallum RM, et al. Extended analysis of early computed tomography scans of traumatic brain injured patients and relations to outcome. Journal of neurotrauma 2010; 27: 51–64. [PubMed] 6 Izzy S, Compton R, Carandang R, Hall W, Muehlschlegel S. Self-fulfilling prophecies through withdrawal of care: do they exist in traumatic brain injury, too? Neurocritical care 2013; 19: 347–63. [PubMed] 7 Thelin EP, Johannesson L, Nelson D, Bellander B-M. S100B is an important outcome predictor in traumatic brain injury. Journal of neurotrauma 2013; 30: 519–28. [PubMed] 8 Scotter J, Hendrickson S, Marcus HJ, Wilson MH. Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis. Emergency medicine journal : EMJ 2015; 32: 654–9. [PubMed] 9 Sandsmark DK. Clinical Outcomes after Traumatic Brain Injury. Current neurology and neuroscience reports 2016; 16: 52. [PubMed] 10 Carney N, Totten AM, O’Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2017; 80: 6–15. [PubMed]

How low a pH can the human body handle? How bad is acidosis in cardiac arrest? Is there any point attempting to resuscitate a cardiac arrest patient with a pH of 6.8? In this lecture from #SWEETs17, Jonathan Ilicki presents a poem covering cardiac arrest physiology, acidosis and the extreme boundaries of the human body. Discover what acidosis does to the human body and how low we can go! UPDATE Chris Turner contacted us in the comments to let us know about what seems to be the world record in extreme acidosis and cardiac arrest. Unfortunately, that case wasn’t identified prior to the lecture and was therefore not included. The case lives here. And in the words of Chris himself: “There may be more…” Video https://www.youtube.com/watch?v=K-5LG53cV9E Podcast Slides Slides as pdf About Jonathan Emergency Medicine Resident, Clinical Innovation Fellow. EM resident at Karolinska, Stockholm. Special interest in arrestology and EBM. Find him on linkedin. Email: j dot ilicki at gmail. More content on his youtube channel He promises to be on twitter soon… Credits Swedish Emergency Talks 2017 (www.sweets.nu/en) Johan Smedbäck (recording), Therese Djärv & Susanne Rysz (peer review) Music: Decktonic (http://freemusicarchive.org/music/Decktonic) More from SWEETs17 Stay tuned for more talks from SWEETs17 here on scanFOAM. Also, make sure to follow the SWEETs team on twitter. References Gaskell WH. On the Tonicity of the Heart and Blood Vessels. The Journal of physiology 1880; 3: 48–92.16. [PubMed] LEDINGHAM IM, NORMAN JN. Acid-base studies in experimental circulatory arrest. Lancet(London, England) 1962; 2: 967–9. [PubMed] Edmonds-Seal J. Acid-base studies after cardiac arrest. A report on 64 cases. Actaanaesthesiologica Scandinavica Supplementum 1966; 23: 235–41. [PubMed] Soler NG, Bennett MA, Fitzgerald MG, Malins JM. Successful resuscitation in diabetic ketoacidosis: a strong case for the use of bicarbonate. Postgraduate medical journal 1974; 50: 465–8. [PubMed] Orringer CE, Eustace JC, Wunsch CD, Gardner LB. Natural history of lactic acidosis after grand-mal seizures. A model for the study of an anion-gap acidosis not associated with hyperkalemia. The New England journalof medicine 1977; 297: 796–9. [PubMed] Weil MH, Rackow EC, Trevino R, et al. Difference in acid-base state between venous and arterial blood during cardiopulmonary resuscitation. The New England journal of medicine 1986; 315: 1616–8. [PubMed] Bozzuto TM. Severe metabolic acidosis secondary to exertional hyperlactemia. The American journal of emergency medicine 1988; 6: 134–6. [PubMed] Martin GB, Nowak RM, Cisek JE, Carden DL, Tomlanovich MC. Hyperkalemia during human cardiopulmonary resuscitation: incidence and ramifications. The Journal of emergency medicine 1989; 7: 109–13. [PubMed] Seguchi M, Jarmakani JM. Effect of respiratory acidosis on hypoxic newborn myocardium. Journal of molecular and cellularcardiology 1989; 21: 927–34. [PubMed] Shapiro JI. Functional and metabolic responses of isolated hearts to acidosis: effects of sodium bicarbonate and Carbicarb. TheAmerican journal of physiology 1990; 258: H1835-9. [PubMed] Orchard CH, Cingolani HE. Acidosis and arrhythmias in cardiac muscle. Cardiovascularresearch 1994; 28: 1312–9. [PubMed] Opdahl H. Survival put to the acid test: extreme arterial blood acidosis (pH 6.33) after near drowning. Critical caremedicine 1997; 25: 1431–6. [PubMed] Refsum HE, Opdahl H, Leraand S. Effect of extreme metabolic acidosis on oxygen delivery capacity of the blood–an in vitro investigation of changes in the oxyhemoglobin dissociation curve in blood with pH values of approximately 6.30. Critical care medicine 1997; 25: 1497–501. [PubMed] Warner OJ, Palazzo FF, Ward ME, Waldmann C. Survival after cardiac arrest with a pH 6.6. Resuscitation 2001; 49: 213–5. [PubMed] Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation 2004; 109: 1960–5. [PubMed] Makino J, Uchino S, Morimatsu H, Bellomo R. A quantitative analysis of the acidosis of cardiac arrest: a prospective observational study. Critical care (London,England) 2005; 9: R357-62. [PubMed] Spencer C, Randic L, Butler J. Survival following Profound Lactic Acidosis and Cardiac Arrest: Does Metformin Really Induce Lactic Acidosis? Journal of the Intensive CareSociety 2009; 10: 115–7. [Source] Funk G-C, Doberer D, Sterz F, et al. The strong ion gap and outcome after cardiac arrest in patients treated with therapeutic hypothermia: a retrospective study.Intensive care medicine 2009; 35: 232–9. [PubMed] Spencer C, Butler J. Survival after cardiac arrest and severe lactic acidosis (pH 6.61) due to haemorrhage. Emergency medicine journal : EMJ 2010; 27: 800–1. [PubMed] Di Rollo N, Caesar D, Ferenbach DA, Dunn MJG. Survival from profound metabolic acidosis due to hypovolaemic shock. A world record? BMJ case reports 2013;2013. DOI:10.1136/bcr-2012-008315. [PubMed] Ganga HV, Kallur KR, Patel NB, et al. The impact of severe acidemia on neurologic outcome of cardiac arrest survivors undergoing therapeutic hypothermia.Resuscitation 2013; 84: 1723–7. [PubMed] S F, F H, S W, W S, G P, G G. Prehospital measurement of arterial base excess and its role as a possible predictor of outcome after out-of hospital cardiac arrest.Emergencias 2013; 25: 47–50. [Source] Ncomanzi D, Sicat RMR, Sundararajan K. Metformin-associated lactic acidosis presenting as an ischemic gut in a patient who then survived a cardiac arrest: a case report.Journal of medical case reports 2014; 8: 159. [PubMed] Paz Y, Zegerman A, Sorkine P, Matot I. Severe acidosis does not predict fatal outcomes in intensive care unit patients: a retrospective analysis. Journal of criticalcare 2014; 29: 210–3. [PubMed] Williams KB, Christmas AB, Heniford BT, Sing RF, Messick J. Arterial vs venous blood gas differences during hemorrhagic shock. World journal of critical caremedicine 2014; 3: 55–60. [PubMed] Smith SW. Cardiac arrest, severe acidosis, and a bizarre ECG. 2015. http://hqmeded-ecg.blogspot.dk/2015/01/cardiac-arrest-severe-acidosis-and.html. Park JS, Lee BK, Jeung KW, et al. Reliability of blood color and blood gases in discriminating arterial from venous puncture during cardiopulmonary resuscitation. The American journal of emergency medicine 2015;33: 553–8. [PubMed] Spindelboeck W, Gemes G, Strasser C, et al. Arterial blood gases during and their dynamic changes after cardiopulmonary resuscitation: A prospective clinical study.Resuscitation 2016; 106: 24–9. [PubMed] Allyn J ’er^ome, Vandroux D, Jabot J, et al. Prognosis of patients presenting extreme acidosis (pH textless7) on admission to intensive care unit. Journal ofcritical care 2016; 31: 243–8. [PubMed] Llitjos J-F, Mira J-P, Duranteau J, Cariou A. Hyperoxia toxicity after cardiac arrest: What is the evidence? Annals of intensive care 2016; 6: 23. [PubMed] Ilicki J, Djarv T. Survival in extremely acidotic cardiac arrest patients depends on etiology of acidosis. Resuscitation 2017; 113: e25. [PubMed]

This is a complementary blogpost to my #smaccDUB talk “How Students Can Choreograph Their Own Education”. I was thrilled to be offered the opportunity to talk about my passion – medical education, and how I think we can benefit from adding to our current views and knowledge on the topic. My main take home messages from the talk were: Know your educational psychology and theories because with the current approach in medical education we may be creating the exact problems we’re trying to avoid Introduce the art of reflection EARLY to start the journey from frustrated, unaware and overconfident novice to flexible, creative and adaptive expert Go to the sim like you go to the gym because being an awesome doctor takes training, and training takes time, repetition and reflection You can check my entire talk below. Video https://youtu.be/dJrS0Wk7mDM Cast Slides In this blogpost I’ll try to elaborate in more details on these topics than the above 20-25 minutes at #smaccDUB allowed for. Behaviourism I started off by stating that medical education as we know it today is often behavioristic in its approach. And since I’m not a behaviorist I won’t call that right or wrong. But if we only use a behavioristic approach we end up creating learners for whom confidence = competence and we don’t really want that. Many of the courses we attend both early and late in our career make use of a behavioristic approach. This means it sees learning as applying knowledge to a learner who is treated as a blank slate. The teacher is an instructor that knows what is right and what is wrong and the goal is to condition the learner into “correct” behavior by giving negative feedback (“punishment”) on poor behavior and positive feedback (reinforcement) on good behavior. A true behaviorist believes that a stimulus will lead to a response, just like Pavlo Skinner and Thorndike did with their dogs, rats and cats. A true behaviorist doesn’t believe reflection is necessary to learn. Stimulus and response is all that matters. To ensure learning has taken place you instead assess your learner with pre-post intervention assessment; you test and maybe even assess in clinical context by the use of checklists (and if you start thinking about competency based education and assessment right now, this goes for that as well). Also, in behaviorism the learner is driven by external factors and especially the fear of punishment. In education that is what we know as the fear of failing which is why we know the knowledge of a test waiting at the end of the semester enhances learning. In the end you trust that the experiences the learners have gained will transfer to other situations. Does behaviorism work: Yes! and I have nothing against this approach, just be aware of the side effects to it. The problem Take a look at the Dunning-Kruger effect below. Every time you use the stimulus-response you may correct behavior and you may create learners that do as you say. But since reflection isn’t a part of the equation, they don’t know why. They will pass your OSCE, MCQ or assessment, but they don’t know how they did it. They are just trying to please you and avoid failing. As their instructor you will feel “safe” because they have demonstrated the skills in this particular setting. You will give them positive feedback on how they performed in this very specific setting and they will leave feeling very confident and believe you, when you and your test told them, that they are also competent. You have created a routine expert that thinks that confidence = competence in the real world and pushed your learner all the way up Mount Stupid where the view may be amazing, but there’s a steep and dangerous fall waiting because you didn’t tell them how their newly acquired skill may be challenged (and inadequate) in the real world.   Humanism Now, let’s say we look at learning from a more humanistic point of view. Sometimes medical educators think that humanism is in opposition to behaviorism. It is not. It is just a different approach and an approach I also think you can make use of and should know the limitations to. Students like this approach. https://twitter.com/StarSkaterDk/status/746030112181788672 They like it because it allows them to really dive deeply into topics they are interested in. By all means do not kill that intrinsic motivation by thinking humanism is just some touchy-feely stuff. It is not. A central theory in humanism is Maslow’s hierarchy of needs and the belief that learning is about self-actualization. You believe that your learners are on a path to finding and unleashing their true potential and you as their facilitator will try and help them by supporting them in that quest. Student will learn a lot from a humanistic approach. And they will learn a lot about how they learn and how to find literature on a topic. The challenge of course is to make sure that they will cover the entire needed curriculum based solely on intrinsic motivation. That is probably not realistic ;-). That is why, just as with the behavioristic approach, we end up with fragmented learning disconnected from prior learning and knowledge and learning that is also disconnected from reality. And we end up just where we ended earlier: On the top of Mount Stupid. This time the learners just think they know everything because they think they’ve read and understood everything. They (We!) of course have not. We should aim to minimize the Dunning-Kruger effect. Not by avoiding the use of the humanistic and behavioristic approaches, but by adding to those.  https://twitter.com/cgraydoc/status/743433657302523904 Constructivism So many of you may think that the answer is right in front of us with constructivism. In medicine constructivism is often what we think of as “problem based learning” (PBL) And PBL does go a long way to try and solve the problem of transfer of learning. In PBL the facilitator aims to create an environment where the learner can grow and where students construct knowledge via active engagement in their environment. The educator will facilitate use of prior knowledge and experiences and they will ask questions. This is an active learning strategy that requires engagement from both student and teacher. And therefore also requires a lot of the educator in terms of knowledge, self reflection, awareness of own limitations and TIME. Hence, most PBL takes place at the university and not bedside where time and resources are very limited. A constructivist also believes in learning as a process of making “schemes” and since much of the PBL is self-directed and time with the facilitator is limited the challenge is to ensure that existing schemes are connected and combined in the right way. Even though PBL may solve the cognition part of transfer of learning, it doesn’t necessarily bridge from theory to practice in the more complex clinical setting. The main problem I see with PBL at the moment is that it exists within a behavioristic curriculum where the goal is still right or wrong. I suggest we need to go beyond constructivism and learn even more about education theory. First of all: Know your learner! https://twitter.com/_NMay/status/743434193523318784 Connectivism This has nothing to do with age or “learning styles” (I met many non-millennials, reflectionists and introverts at SMACCDUB who were still learning through social interaction ;-)), but everything to do with realizing that the curriculum in medical school and beyond is probably too narrow-minded. Instead, I would love to see learners of all levels involved in curriculum design. Allow for, and encourage engagements outside the curriculum and recognize that searching for literature and finding knowledge and answers are also a core skill for a future excellent doctor. Get familiar with connectivism and use it to encourage your learners to “connect” as well. With each other and #FOAMed. Encourage the development of personal learning networks through twitter, blogs, and other social medias, and realize that critical appraisal is something they should train and learn also in the online and social environment. So if we want our learners to move from unaware, frustrated, under-competent and overconfident fools towards creative, flexible and adaptive experts we need to aim for adaptive expertise in medical education. How do we do that? Adaptive expertise Take a look at the curve by Daniel Schwartz and colleagues from Stanford on transfer of learning below. Now if we put it on top of the Dunning-Kruger then we might explain the process something like this. Aim for adaptive expertise by walking in the optimal adaptivity corridor. Adaptive expertise is not something we are particularly familiar with in medicine. A simplified suggestion might be to provide and allow for the following three fundamental principles Question everything! Reflect to facilitate deeper learning Train in a minimal-risk or risk-free environment When you do that, you walk hand in hand with your learner up Mount Stupid in small steps and, just when they feel confident, you challenge them on their believes. You make them reflect, you question their assumptions, you have them challenge each other, yourself and and everyone they meet. They learn that confidence does NOT equal competence in all situations. They learn that their solution to the problem is not the only one. They learn that there is more than one solution to every problem (even when an algorithm is involved!) and that other people’s experiences may add value to their toolbox for future use. That way you end up moving in little steps in the adaptive corridor. Instead of rushing up Mount Stupid. So educate your learners where you make use of all educational theories. Train your learners. By all means assess and correct and inspire and support interests. But on top of that REFLECT. https://twitter.com/ercowboy/status/743435456466006016 SIM like you GYM The third suggestion in adaptive expertise is also training in a risk-free environment and that’s why I introduced the “Sim Like You Gym” that quickly found it’s way to twitter as a bit of a meme: https://twitter.com/Inject_Orange/status/743436337777348608 Open up the sim centers and other training environments where training is low-risk or preferably completely risk-free. And I mean really open up. In terms of accessibility, “opening hours” and the faculty. Invite students into your faculty, you may end up training their reflective skills from early on and end up with some very skilled educators to recruit from to future projects and positions. Not a bad side effect. Involve students in your faculty! Where I work, at Copenhagen Academy for Medical Education and Simulation, we do just that. Students have developed a course on patient safety for the Copenhagen med schoool. They do peer-to-peer teaching, teach resuscitation guidelines to peers and non-peers, develop ultrasound apps and participate with many functions in simulation training as operators/technicians, standardized patients, confederates in scenarios etc.  Our simulation center is open to the students’ own educational initiatives, for instance research or courses developed by students for students in their spare time. Courses in surgical skill training and emergency medicine and procedures have been designed by students and run for years, to allow students to take responsibility for their own education. Involve students in choreographing their own education and know and appreciate that education takes time and practice. And requires spaced repetition. https://twitter.com/hm_clancy/status/743436013515706369 So “Sim Like You Gym”:  Do a “cardio” class on Monday, kettle bells for your brain on Wednesday (maybe do that one everyday!) and “pulmonary” class on Fridays. End each sessions with reflection and debriefing and stop thinking that more scenarios will do the trick. It’s in the reflection in the debrief that the real learning takes place. https://twitter.com/HumanFact0rz/status/743435585025613824 So by going to the sim like you go to the gym. You repeat and refine. You build “muscles” by training your cognition, by making new patterns and connections in your brain. You find out many new solutions to the same problem and you train in different teams with different people. This increases and develops creativity and flexibility and of course makes you an adaptive soon-to-be expert. Warning! Side effects: Plenty..…If you train repeatedly with different team members you may expand your network, gain new friends and help reduce tribalism! Finally – Thanks for all the feedback from friends and new friends on my talk. I enjoyed giving this talk with you as my audience and every single tweet, comment and email has meant a lot! See you at #dasSMACC. 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