Latest / Critical Evidence: Veterinary Emergency & Critical Care / Why the CPR guidelines only suggest atropine
Transcript
- Ken Yagi: It's not really that the evidence itself is patchy or, uh, unreliable. Ken Yagi: You should, even if you don't know what the right answer is, you should verbalize your thoughts. Ken Yagi: Atropine is one of those things that we suggest that is given when you see a non-shockable rhythm. Ken Yagi: When atropine was used, there's actually not a whole lot of evidence that points one way or another. James Notman: Hey, you're here, and Ken teaches RECOVER CPR alongside the guideline writers, and in this episode, we get into Critical Evidence, why limited data isn't bad data, and what those little words on the clinic floor really ask of a team. James Notman: When there's no strong trial data to lean on, but you still have to put a drug or a step into the algorithm, what does that decision feel like from the nursing side? Ken Yagi: Even if the evidence seems a little bit patchy, and even the RECOVER guidelines themselves say this is a clinical guideline recommendation and knowledge gap, and it's-- they're very transparent about that in terms of the RECOVER guidelines, It's not really that the evidence itself is patchy or, uh, unreliable. It's just that because there's not as much veterinary evidence out there available, the level of certainty that we have on whether it actually works with animals is something that, uh, we don't know yet. But the first step is to have guidelines and, train people on it so that they can, act with confidence and very swiftly when an arrest occurs, which is the most important thing, and then the results will follow. James Notman: Right. So when Recover uses that grade approach and it ends up with, say, a suggest rather than a recommend, what does that wording change for how you train people or how seriously they take it on the floor? Ken Yagi: Yeah. A very simple way to think about it is that, uh, when a guideline says recommend, then that means that there's enough evidence or strong conviction from the RECOVER initiative that we're recommending that something happens, and we would hope that everyone will just execute on it. When it says suggest, we have different considerations that we should make to weigh out what is the benefit versus the risk in executing on that particular, uh, suggestion that the guideline makes. James Notman: In human medicine, animal studies are treated as indirect, but in veterinary CPR, those dog studies are the species. How do you think about borrowing that evidence, and where do you feel cautious about stretching it too far for a clinical dog or a cat in front of you? Ken Yagi: It's definitely true that the, the studies that have been conducted for people with animal subjects are, um, actually, uh, beneficial for us because they turn into animal models that, that we are, um, uh, able to apply more directly. So the evidence actually becomes stronger for us, when compared to creating human CPR guidelines. But with that said, most of the evidence that's created in that kind of way is created in an experimental setting, which, uh, means that it's not actually the same setting as in a clinical situation in a veterinary hospital when an actual animal is arresting. So there's a little bit of extrapolation, translation of the information that we need to make in order to make the recommendation. So, um, it's not a perfect world, but, it is stronger evidence nevertheless. James Notman: When you're in a training with nurses or techs, do you actually say, "Look, this is stronger, this is weaker," or is it more about building that reflex to act as a team no matter what? Ken Yagi: Yeah, understanding your level of evidence is definitely important to know what went into the, uh, guidelines and the recommendations that were created. It helps us understand, um, the why behind the what we're asking people to do. But when it comes to executing on the CPR itself, we do, uh, want to get people at the very least to be able to do the right things, that is recommended through the guideline that's been standardized. And then having the understanding which allows them to think a little bit more about why they're doing it that way will allow them to think through the different nuances of the cases for sure. but that, that is a higher level of understanding that, uh, we don't want people taking up too much of their cognitive load, what we call, which is their thinking and focus going into that, and, uh, making sure that the, teams are ready to act, being able to work in a coordinated fashion based on the same understanding of how they're going to perform CPR is going to make it, uh, such that we execute on it the best, most consistently, which will hopefully lead to a better outcome. James Notman: Do you ever find, uh, team members are surprised to hear that some steps are suggested rather than strongly recommended? Ken Yagi: Through my, uh, experience doing the training, they typically don't, um, question it. Actually, if it's on the algorithm, they tend to think that it's something that needs to happen just because it's on there. so, uh, it's oftentimes a next level of understanding that they get when we point out that some of these things say "Recommend," which means do it. And some of them say "Suggest," which means that there's not strong enough evidence for us to fully recommend it every time, that the situation arises, but, uh, consider these points. And then being able to dive into the nuance of, um, what to consider is actually a very good discussion. For example, atropine is one of those things that we suggest that is given when you see a non-shockable rhythm. And what is that consideration that you make between the benefit versus the risk of, uh, atropine is that if you think the arrest is related to a vagal tone issue or a vagal stimulation that led to bradycardia that, uh, led to the arrest, then atropine would make a whole lot of sense as a vagolytic. Whereas if you don't have any of those reasons, atropine actually may not do anything. Now, atropine's an interesting thing where when we take a look at the number of studies that show a successful outcome versus that when atropine had been used versus a negative outcome when atropine was used, there's actually not a whole lot of evidence that points one way or another. Uh, which means that, uh, it might not be beneficial, or we at least don't have evidence that it's beneficial, but it might also not be harmful, or we don't have evidence towards it being harmful. So giving atropine, uh, every time you see a non-shockable rhythm for, uh, CPR in an arrest situation might be reasonable, uh, which is kind of the nuance of taking a look at these guidelines and not treating it as a, uh, like a very strict rule in terms of doing everything on the chart. James Notman: Exactly, and it's that nuance that seems to take real teaching. When you send instructors out to train others, how do you keep that nuance from getting lost as it passes down the line? Ken Yagi: Like I teach with Dan Fletcher, Manu Bhullar, Janie Burkett, the people who are, at the center of writing those guidelines. The extensiveness of their knowledge and the understanding of evidence is incredible. Uh, but with that said, uh, we do have to be very mindful of, uh, making sure that we're very clear about the knowledge behind the guidelines that we en- uh, keep passing down so that everyone can basically speak the same language, explain it the same way, James Notman: When you put those new instructors in front of high-fidelity simulators instead of, say, a lecture, what do you notice about how that experience shapes the way they then talk about the guidelines and the gray areas inside them? Ken Yagi: It is something that is a little bit unnatural, unnatural meaning that it's not the norm for people to try to teach in such an interactive learner-centric approach. Everyone has been used to and we've all grown up sitting in classrooms, listening to lectures, somebody just giving the information to the people who are trying to learn. And so flipping the classroom in that people come in with knowledge from the online course and we're really trying to create a place in which they can apply that knowledge and practice so that they make the knowledge click with the practical aspects of performing CPR. And then the instructors actually have to learn how to do that best. And so I gotta say it's a hard skill to learn, but once you learn it, once you get used to it, and once you get used to seeing how much better the students get through the course of the simulation-based workshop and the facilitated discussion and the coaching that we provide, it's pretty addicting to see how much better of a way that the training works when we do it in this fashion. James Notman: I hear that. When you're watching a team on a simulator, do you see them actually change how they talk about those suggest steps after they've physically tried them in a scenario? Ken Yagi: It definitely shows up during simulation for sure. One of the things that we try to teach through simulation and CPR is that you should, even if you don't know what the right answer is, you should verbalize your thoughts. Because by putting it out there, it means that there are other team members who will hear that, take part in the processing of the information, and then eventually come to the right decision. And so if somebody says that I think we should give atropine here, then somebody else might chime in and say, you're right, this dog collapsed after retching, and that would have been a vagal event possibly, and atropine is very much warranted. So I agree, let's give atropine or something like that. And so it just starts with team communication, verbalizing your thoughts, put your brains together, because even if you can't get everything right every time in a high-stress situation like that by yourself, by having the team there and thinking about it together is how you can execute correctly. James Notman: Hey, thanks for hanging out. Ken reminded me that recommend means do it, whereas suggest means weigh the risk. And hey, in a code, say what you're thinking out loud so the team gets to the right call. Thanks, Ken. If this sparked something, share it with one person who'd find it interesting, and hey, subscribe. Goodbye, see you all next time. That's Second Chance. Practise it before you need it.