Recognize the Peak of “Mount Stupid”

This morning I used the 25 to 300 grams recipe. It’s good. Have to use really coarse grounds though. I used 45 on my Niche burr grinder today. I suppose I need to go to 48.

RINSE

I quickly wanted to touch upon a comment I made on yesterday’s post regarding central line cold infusion catheters. It sounds cool and I believe the city hospital adjacent to mine still does it. But cooling pads with Arctic Sun is probably the way to go. The RINSE trial (Rapid Infusion of Cold Normal Saline) came out in 2016 and the results showed large volume cold infusions during CPR decreased chance of ROSC for initial shockable rhythms. Also, it showed showed no difference in mortality outcomes at discharge. The trial was stopped early due to different resuscitation management at each hospitals. It’s really hard to conduct these types of trials because it’s almost unethical to withhold known treatments that could literally be life or death. Other studies showed that it was good for initial cooling but bad for maintaining hypothermia. That being said, I guess it might not be a good technique in the ambulance or in-hospital if we have the Arctic Sun. Or if it was a PEA or asystolic arrest, we could do it prior to the hospital.

HALO

Second thing I wanted to quickly jot down: I watched a talk by George Kovacs, MD (a well known EM doc from British Columbia) who co-founded the Airway Interventions and Managements in Emergencies (AIME). The talk was about difficult airways and using a Bougie to increase first pass rate success for endotracheal intubations. Really cool stuff! It’s cool for me more in theory because I rarely get the chance to intubate (performed a total of two in my career). But I do assist with them so it still helps tremendously. He spoke about techniques with a bougie (preloading an ETT) and methods of confirmation. You can use “hold up”, which is basically the bougie stopping when it hits the right main-stem or you can have a second operator feel the trachea above the sternal notch to feel it. You can also use “clicks” of the tracheal cartilage; but in an emergency situation, that’s not always the easiest thing to do (Kovacs says your anxiety goes up and HR>150bpm — makes sense). He also mentions to be careful with the D-grip for the bougie. You can get lock up because the bougie may usually reach 30 cm. But he also made two points that I found so, so interesting:

“High acuity, low occurrence.”

In short, it’s called HALO. It’s such a catchy phrase and it means so much. How does one train to do these types of procedures (such as intubation for me). For others it could be performing a cricothyrotomy. These are high stake procedures in life-threatening situations. I guess the answer is keep reading and keep practicing on mannequins and sequences in your head. If you’re in the CTICU, opening the chest bedside as part of your CALS is also pretty HALO.

Walk towards the “Plateau of Sustainability”

Another thing I came across from watching Kovacs talk is the “Dunning-Kruger Effect”. This was for all types of people but I think it really resonates with medical providers!

You come out of training, residency, or your program thinking your hot stuff. You have all the confidence in the world but you’re at the “know-nothing” on the X-axis. And I love how there’s something called the “Peak of ‘Mount Stupid’. Once you realize that you’re not a hot shot and you know nothing, your confidence drops. I believe I was on “Mount Stupid” not too long ago. I hope I’m on the slope of enlightenment now and hope to reach the “Plateau of Sustainability”. This curve really resonates with my post a last week about trying to be the master of your craft. I really want to achieve “Guru” status on the competence scale. But to be a guru in airways, one has to perform around 150 airways (some studies show). That’s a tough HALO.

Dk

Darren is a physician assistant specializing in Cardiac Critical Care in New York City. Passionate about resus, shock, PE, cooking & coffee.

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