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I’m staring at a plastic torso. You know the sort of CPR dummy, with it’s perfectly beige skin, absent limbs, obvious sternal boundaries and that head; with closed eyes, rubber hair and lips the same colour as skin, formed so that they lie permanently apart at all times.
It turns out that an up to date advanced life support qualification and the competence inferred from the fact you have been trusted in employment as an intensive care registrar count for nothing when it comes to a new trust induction. So, I am the intensive care registrar in the trust’s generic, mandatory most basic of basic life support classes. I am flanked on one side by a non-clinical member of staff and on the other by a health care attendant to be, who has never worked in a hospital before.
We watch a video. A robotic fifteen-minute composition where a nurse stumbles upon a plastic dummy in the centre of a clean and perfectly made bed. He calmly calls for help and starts compressions in blocks of thirty. The video tells you not to check for a pulse unless confident to do so and then describes where to place your hands and how to hold them, then the instructor tells us to try this for ourselves. We kneel-down from our chairs and place our hands on our dummies and start, she walks up and down the line and encourages us to move in time with the video; three sets of thirty.
Click-click, click-click, click-click; the usual noise comes from the dummy chest as we start compressions. Over and over to the tune of twenty torsos caving in and out in unison. Around me people are laughing and joking; because they find themselves out of puff or because the experience is a novelty. I am looking at the hollow chest moving up and down and I feel like I need to run out of that room, like I want to escape.
Click-click, click-click, click-click, it continues and each one starts to offend me. There is a rage that starts to smoulder, I realise I resent each one of those absurd and meaningless noises. Click-click, I think of the hanged teenager I worked on the month before, with his huge dilated pupils, bloodshot eyes and laceration mark dug deep in to the right side of his neck. Click-click; I think of the 97 year old man whose bed I stood over after resuscitation had been called off and watched as he lay broken and about to die, again. Click-click; I think of the baby I worked on while a mother stood screaming four feet away. Click-click; I think of the bloodied sheets, the regurgitated food, the dribbling mouths and the lapses in continence that soil the beds of real resuscitation attempts.
Click-click; I think of all the experiences I have given myself to and that, as much as I was just doing my job, there has to be some sort of currency in that surely?
Click-click; it counts for nothing. I am just another new starter at another trust induction, learning basic life support. New job number sixteen, for me; twelve weeks until my next new start.
Click-click; ‘thank you everyone’ calls the resuscitation officer at the top of the room, ‘now we are going to learn how to use a pocket mask.’
By the Secret Doctor
Read the blog and follow @TheSecretDr on Twitter
I think that this type of unthinking inappropriate management demand is actively damaging - worse than unhelpful. It's disrespectful and annoying for you but you recount one instance of something I keep noticing - a set of routine requirements applied to any comer without any thought about the actual situation.
So sorry for you, of course you became angry, but also the wider effect is bad for us all, medics, other staff, retired as well as practising, patients and public. I wish the current 'safety culture' allowed the brains to be engaged. It must be tempting just to grind through the prescribed motions with no tiresome demand to think. These procedures are also an invitation to bad, disrespectful behaviour.
A letter about a man with a terminal diagnosis of mouth cancer being forced to go through months of rules-following by the DWP is circulating on social media: another example of demeaning politically-induced behaviour. None of us are immune to this unthinking abuse.
Sounds like you've had a gut full. I am so sorry as my years as a hospital junior doctor showed me just how valuable anaesthetists are - deceptively relaxed until that crucial moment when something subtle alters and then ready to spring into action. You are invaluable. Sorry about the red tape - we all get tangled in it one way or another - patients and doctors alike. I hate doing DAS28 scores on rheumatoid patients - having to squeeze an obviously painful joint (why can't I just ask them and they tell me if it hurts - why the need to inflict pain?) before we can score the disease activity accordingly. If we don't do it they don't qualify for the treatment. Sometimes they don't hurt in quite enough places so don't qualify anyway. Really, you couldn't make it up.
Thank-you for this - I couldn't agree more! Many of our consultants have recently been forced to do BLS, despite being ALS-qualified (some of whom are arguably amongst the most expert hands-on resuscitationists in the UK) - the rationale often given is that ALS does not prove competence at CPR. If that's the case, then the ALS scenarios should be adapted: CPR is one of the only demonstrably efficacious interventions taught in ALS.
For what it's worth, the queasiness about teaching a pulse check is actually from a study of consultant anaesthetists (DOI: I'm an anaesthetic trainee) - during carotid endarterectomies, blinded consultants could not confirm the presence or absence of a carotid pulse with a high degree of certainty: hence the rationale that other less-experienced clinicians were unlikely to be able to do so in an emergency. The problem occurs when this is extrapolated to telling ICU registrars how to feel for a carotid pulse - which I doubt was the Resus Council's intention!
ALS is already damaging its reputation in other ways - so please let's correct this common problem where a current ALS certificate is not taken as evidence that we are able to perform effective CPR!!! BLS is aimed at healthcare assistants, receptionists, and others that might occasionally have to do basic CPR until the expert help arrives - it is not appropriate for the clinicians who have recently demonstrated that they are the 'expert' help that takes over to fully resuscitate the patient!
I am also sorry you think this way. I am a retired pathologist who volunteers for the British Red Cross and who has to do a BLS assessment every year as does every other volunteer. In my hospital consultant career of I can recall only only 1 occasion I needed to initiate CPR. Likewise only once in 20 years with the Red Cross.
The point about BLS is that it is for EVERYBODY.
I found my training unbelievably helpful as do other volunteers whose natural tendancy is to freeze rather than carry out the simple drills.
Having never performed resuscitation in the course of a 43 year medical career without the patient vomiting (and of course those pocket masks are never to hand when you need them especially in the community) I could not agree more with your condemnation of the robotic thinking that drives these initiatives and the sterile environment of the training sessions that is so far removed from reality that it makes the training irrelevant. But it's throughout medicine isn't it. Whole industries have grown up around infection control, child protection, appraisal and revalidation, and any number of other issues with no evidence base to support their value. And don't get me started on the CQC.......................
As a consultant in anaesthesia and critical care medicine
Have you seen a consultant Anaesthetist at an arrest or initiate an arrest? I have many a time and though ALS trained (most let it lapse) they arent that good at managing arrests outside of theatre or at BLS! Have you seen them in BLS training? Despite yearly updates every year they are not slick and need remedial training. This is quick at specifi to the group. As a trainee we always had group specific training. Corporate induction is all commers. So actually many hospitals try to provide what is needed for different groups of staff!
Have you been to lots of arrests? Have you managed the post arrest patients? If you arrested what would you want? High quality BLS that's what makes a difference to outcome! The difference to survival and then survival to a meaning quality of life!
The thoughts as a trainee change dramatically when you become a consultant
In appropriate CPR is a separate issue to the delivery and training of high quality BLS. To maintain the quality it means that you need to have regular training irrespective of what you do!
How do you replace the system other than adapting it?
Why don't you actually encourage those learning it for the first time or those that don't experience it so when you have a cardiac arrest perhaps you'll be lucky enough to get immediate high quality CPR and safe your life (when appropriate)