The EMBER Project

Building Better Cardiac Arrest Care – Part 1


For many years the approach to patients in cardiac arrest has been held hostage by algorithmic care that stifled innovation and did nothing to improve overall survival. Now a combination of new technology, and a realization that one size does not fit all, has led to innovative approaches in care.

The result is an opportunity to move away from the status quo in favor of approaches designed to fit the needs of local environments – where decisions are driven by real-time feedback on the quality of our CPR and the patient’s pathophysiology in order to achieve the two core goals of advanced cardiac arrest care:

  1. To rapidly optimize cardio-cerebral perfusion.
  2. To find and treat reversible causes of cardiac arrest.

The Building Better Cardiac Arrest Care series is about physiology-driven resuscitation in cardiac arrest care, highlighting new concepts and new tools to improve our approach to these patients.


If you asked me about mechanical CPR in the ED a year ago, I would have said, “why would I want another tool cluttering my resus bay that hasn’t been shown to improve outcomes? Well, we recently got a Lucas CPR compression system in our ED, and its arrival has coincided with a great post by Dr Salim Rezaie on cognitive offloading (using physical action to alter the information processing requirements of a task to reduce cognitive demand) during cardiac arrest. So I’ve decided to put a discussion of the two together, since I think there is no better way to frame the argument for using one than Dr Razaie’s post.

Within the choreography of a resuscitation, multiple critical actions need to occur, but which ones?  Each action we take is a calculated choice. With finite time and cognitive bandwidth, every action we say yes to is also concomitantly a no to others. Small changes in the choices we make to achieve our goals during a resuscitation have the potential to significantly impact the quality of our cardiac arrest care. 


Beyond ACLS: Cognitively Offloading During a Cardiac Arrest

beyond-acls-765x575That’s why I love posts like Salim’s on cognitive offloading during a cardiac arrest. He’s taken the time to deconstruct a standard ACLS approach with the goal of reducing our cognitive burden to give us a better chance at rapidly transitioning to the important task of defining the problem behind the cardiac arrest.

We all know the H’s & T’s and the importance of reviewing potentially reversible causes of cardiac arrest. It’s also no mystery that the faster you can get to thinking about them, the faster you can make lifesaving decisions about care.  But if the basic requirements of the ACLS algorithm keep you incessantly occupied by a multitude of details that demand your full attention (monitoring for quality CPR, issues with IV access, repeated medication dosing, time wasted on prolonged pulse checks) then how realistic is it in the real world of cardiac resuscitation to expect you are going to have enough time to find the cause and reverse the problem?

And what if you’re working in a resource poor environment with too few hands, or you have a patient with difficult access, or is 400 pounds and requires herculean strength to maintain high quality CPR?  Well then, you may never get there at all – or at the very least your arrival may be significantly delayed.

Finding a better pathway to that cognitive space is Salim’s goal. His solution? Leverage the concept of cognitive offloading to get you there faster by rethinking the basic tasks required for optimal perfusion during CPR so you have more time to think.  To me this makes a lot of sense.

A rapid sequence review of recommendations for cognitive offloading during a cardiac arrest

Now on to the Lucas – With Dr Jim Horowitz

Which brings us to mechanical CPR. It turns out that about the same time Salim posted we were getting familiar with our new Lucas device.  It’s benefit is not simply replacing the physical work of CPR with a machine, but reducing the cognitive work needed to ensure your team maintains high quality chest compressions throughout a prolonged resuscitation: watching for provider fatigue, calling for new CPR providers, ensuring the right depth, rate, and quality of compressions, and directing the CPR providers throughout a code are all tasks that distract a team leader.

For Jim (our VTE and ECMO expert and my favorite cardiologist to have at the bedside during an arrest) the benefits of offloading CPR are obvious: it means more time to initiate ECMO.  And as he mentions in the video, mechanical CPR tends to make codes quieter, and makes placing lines and intubation easier during active CPR. This is significant offloading in action and can reduce distractions or delays in getting to that all important cognitive space.

I wish I’d had the Lucas 2 in some of the rural hospitals I’ve worked in, where it was often me and one nurse on an overnight, and I had to grab the clerk to help with CPR. I was lucky if I could get a LMA and an IO in quickly enough to take my turn doing CPR.

Cognitive offloading is something most good Emergency Physicians do intuitively to get through their day, but the concept was never explicitly taught to me during my training. I vote that it should become a core content lecture for every residency program in the country.

More to come.

Thanks to Dr Jim Horowitz for coming and demonstrating the Lucas 2 device to our residents and faculty. You can also download his iBook manual for the Lucas 2  for free here.

(None of us have any conflicts of interest with this device).


The EMBER Project’s Education Manifesto – An Introduction

An underground handbook for surviving and thriving on your shifts as an EP

BPP - Oakland 1969

There is a knowledge gap in Emergency Medicine.  It lies within the difference between the way we teach and the way we learn.  Bridging this gap is the EMBER Project’s educational manifesto of sorts.  It starts with the belief that our continuing education as Emergency Physicians should not be an endless continuation of the traditional didactics we’ve become accustomed to in our formal training as physicians. Instead it should be a more complete and thoughtful examination of what makes us successful in our daily EM practice.

Over time we become suffused with a host of accumulated skills, knowledge, wisdom, tools, and relationships, and we develop conscious and unconscious strategies for success in the emergency department. Sadly, most of this knowledge is not recognized by us or even taught to new physicians, and falls into what I like to call the “crash and burn” school of medical education.

Perhaps because we have had to learn much of it by personal experience, we have difficulty recognizing its central importance in our development as good physicians – much less being able to describe how we became proficient in these areas to others. Teaching is a skill.  We learn by watching others.  I learned how to teach ECG interpretation by being taught by someone else, but how do you teach skills that have never been taught to you?

The second tenet of the manifesto is that physician well-being and patient care are inextricable.  Success in Emergency Medicine starts with accepting that our physical and emotional resources are finite, and that the practice of Emergency Medicine is challenging. For generations I believe that publicly acknowledging our limits and the fear that we will be seen as lazy have been conflated in our profession.  The stereotype of the tireless physician and the fall out from this impossible ideal still haunts us.

We have limits, rather than ignore them, we must learn to minimize the impact  of those things which are a drain on us, and maximize the supportive resources we have around us.  Doing this well is part of becoming an efficient practitioner of the EM art, and is essential to longevity and well-being in our profession.

The Smooth Sailing series takes both of these concepts to heart.  It is a re-examination of our development as Emergency Physicians from a personal well-being perspective, in order to define the strategies that help us develop a sustainable career of continued growth, improve how we care for our patients, and getting you home at the end of hard shifts happy and healthy.

I’m excited to begin exploring what makes us successful and healthy emergency physicians in this series.  I hope you find it as useful and interesting as I do, and that you will share your insights and comments with me along the way.  Perhaps in discussing how we acquire these skills they will become part of a more conscious strategy for success that we will be able to pass on and teach to others.  Stay tuned, the first chapter in this series is coming very soon.  In the meantime please check out the last Smooth Sailing post to get an idea of where we’re headed.

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