So, hi everybody, welcome to CPR Beyond compressions. My name's Samantha Thompson, and I'm an RVN with a passion for CPR. I believe it should be something the whole team are comfortable doing, and that includes both clinical and non-clinical members of the team.

I'm a qualified teacher, I hold my graduate diploma, my emergency and critical care certificate, but most importantly for you guys, I'm a recovery instructor. So to me, a successful CPR attempt is more than exceptional chest compressions. We need to look beyond that, we need to think about the whole team being listened to, the whole team being able to raise concerns, that whole team being capable, competent in their assigned role.

And to do this we need to use that evidence-based CPR training that's available and delivered to all members of the team consistently and regularly. That must So if we look at CPR and we try and move a little bit beyond compressions, drugs and ventilation, we can show you that actually there's a lot more to it. We need to think about the equipment maintenance.

So when you go to your crash trolley, is that laryngoscope bulb working or is it dead? Oh, has it been restocked? Is everything there that you need?

So has your crush roy been maintained and then the equipment within the crash trolley, has that also been maintained? Simulations are really useful, particularly if we're doing them with a pre and post debriefing. There's something I'm going to talk about in a little bit more detail, but they have a huge role to play.

We need regular training. Always think that we, CPR is a really stressful event and yet the regular training that we do can be somewhat lacking at times. We need to think about debriefs post crash, and this is something that's relatively new to our profession, but something that's been utilised in the human sector for quite some time now.

Like I've mentioned, we, we're wanting to use evidence-based veterinary medicine, so we need to go through those evidence-based guidelines and use those to really determine what we're going to be learning. Closed loop communication is something that is applicable for the entire duration of your time in veterinary, and this isn't something that's CPR specific, but it's something that can be really helpful during an emergency and critical care situation. Clearly, we want great teamwork.

Now that doesn't just happen overnight. That's the result of simulations, of a culture that we create. We want that great team, but we want people to feel like they've been validated and heard and they're part of it.

We want correct monitoring. So again, we're going to talk about that a little bit more, but we really need to make sure that we're actually putting the monitoring on that we need to put on. We also need to think about leadership.

Now, leadership is something that will really make or break, a CPR attempt. Now it's not necessarily, based on patient outcome, and if you remember what I said at the beginning. I very much don't focus on patient outcome.

So the stats for humans are, considerably better than our veterinary stats. But for me, I really want people to feel confident and competent, and to not have second victim syndrome when they go home and maybe a crash shouldn't go well. But that clear leadership is so imperative to this.

It's so, so important. And it's something that perhaps doesn't always come naturally to people, and perhaps sometimes we look to maybe the to not the appropriate person to be our leader as well. Note keeping.

Now, I think historically note keeping was something that we would quite often, allocate to a non-clinical member of the team. The more I teach this, the more I realised that maybe note keeping is probably something that needs to be kept within a clinical member of this, the team. And, the terminology we use, the pace we're working at, can be really challenging even for the most experienced nurse or vet.

But also, we can't really debrief unless we've got good notes. We also can't really learn from anything unless we've got good notes to reflect on. We all know what it's like during a crash, and, you know, the minutes seem slow, particularly if we're the ones doing compressions.

But the time whizzes by and before you know it, you've done an hour of CPR and actually that's, that's a lot of information to be able to recall, so that note keeping is really, really imperative. Moving on, so in the human sphere, team training has been linked to a faster hands-on approach and a reduction in time to defib. Now I appreciate the point around defibrillation may not be relevant to all of us, particularly if we are in primary care and we don't have access to a defibrillator.

But I think it's just really highlighting the fact that that team training really makes your C a lot slicker. And for humans, the time to defib is something that they really look at from, a sort of a measuring perspective as to how successful that training is. So the fact that people get hands on quicker and work through that troubleshooting and get to the defib quicker.

Is actually really important. Now, with humans, they generally will have a cardiac arrest, as their primary cause of arrest, as opposed to in our veterinary sector where we will tend to more have, a respiratory arrest. So we have a respiratory compromise that will generally lead to cardiac arrest.

So for us, there are still times where we would consider defibrillation, but the guidelines just vary a little bit between humans and veterinary. And I think, particularly if you have recently done. A human first aid course, it's worth just remembering this cos they are a little bit different.

And again looking towards the human sector introducing a basic. Basic life support plan has been shown to improve CPR within human bystands. So some of you may have seen the revived campaign that's going around at the moment from the British Heart Foundation, you know, the Saint John Ambulance, Red Cross, everybody is very standardised and unified in the teachings with regards to compressions and ventilations with the human sector.

For us, Recover have started that, and I am gonna get to them, but I think again, just really take away that having that standardised plan has actually improved CPR within the human sector. S How do you use training to improve basic life support? Now first of all, when we're teaching, we really want to think about that baseline.

It's really tempting to jump in feet first, gung ho, creating this amazing training programme, but actually it might not be appropriate. And I kind of learned this the hard way during my teaching days. We need to think about that baseline.

Every person in front of us will be different. And obviously me speaking to you today, I couldn't really figure out your baseline. I can't tailor the session based on everybody's start point.

But actually, if we're creating that in-house training, we probably know what our employees and our team. You know, what their base knowledge is, we know what experience they have. We probably have an idea of what their confidence levels are as well.

So we should really be using that information, OK? We need to think about what does our team already know, what don't they know, what comes up commonly in appraisals. If you are doing debriefs, what's being highlighted in debriefs?

If you've witnessed the crash, what have you seen happening? Is there anything that maybe you do differently? And then getting back to your baseline, what are you currently doing as a protocol?

So taking that time to really look and think about what it is you're currently doing in your practise. So, as a start point. I would recommend recover.

Now, I am a recover instructor, but I'm not financially, compensated for mentioning them. I don't get a referral fee. They have created, the only evidence-based veterinary CPR guidelines.

So this is why I mention them. They spent a very long time looking at all the evidence. A lot of it was human, and kind of getting specialist input as well.

And they have created guidelines, that we can use for our CPR training. The guidelines are currently 2012, and they are being updated and I'm gonna highlight some of the changes that might be coming as we move on. Now Recover do deliver, do deliver online and practical training sessions for all members of the team.

Now the online training is probably some of the most . Probably the best values training I've found in, my 14 years in this industry, particularly as it's something that, you know, when we're at college or university, it maybe has one session, you may get an hour on it. But in reality, the sort of the A&P behind it, the physiology behind it is really interesting, and doing that online course just really gives you that.

Really solid grounding knowledge. And equally, you know, we're all really busy in practise, we're all really time challenged, we're all struggling to fill all this stuff in. So if somebody's doing it and doing it well, use that resource, OK?

And I will always look to recover guidelines and everything I speak about will be based on the recover guidelines because I'm using the evidence-based medicine that we've currently got. Now, This leads us on to the algorithm. So Recover have a set of guidelines, where they've kind of gone through PO questions and they've really discussed why they've decided what they've decided, they're open access, not behind a paywall, so if you do have any spare time, definitely worth having a little read of those.

Obviously we can look at CPD as well. But what they've created is a lovely flow chart that makes it super simple for us to be able to follow. And again, I will quite often go round to practises, and they won't have the algorithm up.

They won't have this in clear sight. And I say to them, you know, it's not an exam, you're not expected to just know what to do. Maybe if you do this a lot, perhaps you work in an emergency environment where you regularly have CPAs and CPRs.

Perhaps you don't, perhaps this happens maybe once or twice a year. Now expecting yourself to remember a logical process like that is really hard. And don't expect other people to either.

So put the algorithm up, print it, put it on your walls. If you can, if you've got anyone going over to America or Europe when they've got Eves and IVEX, try and get some of these posters ordered their beautiful A2 laminated super clear, super easy to follow. And we can see that we've got our unresponsive family patient, and we're gonna start CPR immediately.

We're gonna start with our basic life support. So we're gonna start our compressions and our ventilations, and that alone is what BLS consists of. So once we've got that established, you'll see then that 34 and 5 are generally the things that people maybe get a little bit muddled.

So once you've got your compression started, that patient's been intubated, in lateral, whilst compressions continue and then you've started your IPPV. We're gonna put a monitoring on. So we're gonna get that ECG on and we're gonna get that camera graph on.

They're the most important things you can use during a crash. They're the most informative pieces of monitoring that we can have. We're gonna make sure we've got an IV access, so that's number 4.

And then number 5 is our reversal, so we're still not at adrenaline match screen. We want to to do those reversals. And what we'll quite typically find is that in a high stress environment.

Like I said, BLS, generally speaking, is normally quite well initiated. 34, and 5 tend to then get a bit muddled and people tend to rush for the adrenaline and the atropine. Now what's interesting is if we look at the, the draught.

So this was, public access a few weeks ago, they were asking people to review, contribute, suggest, cos obviously they're basing it on you, on, you know, what you guys need. But we can see they've simplified it. They've also modernised it a little bit, and, jazzed it up.

So it looks quite slick. And at the beginning, it's still very much the same. So shake and shout, call for help, start BLS, and they've broken down what BLS is to the side, and then we're gonna do a rhythm check.

So we're going to pause and do a rhythm diagnosis and a pulse palpation. 23, and 4 are still the same. What they've done is they've just broken up 1 and 2 and put it as dear as in one thing.

So what was 34 and 5 is now 23 and 4, but it's still monitoring IV and reversals. And then we move on to. What we do next.

So we've got the ECG on the patients and we're looking at it. And actually there's some differences with regards to adrenaline and atropine use. So if you have currently got the algorithm printed off in your practise, and then you see this, you can have a look and really consider what might be different.

We're kind of moving towards, atropine once, and that's a little bit different to maybe what we've been doing already. So have a look and see what you're currently doing. The guidelines with the algorithm we just talked about was actually 2012.

So that is, you know, a little while ago. These have been in process for a little while, as we all know what happened between 2020 and 2022. They should hopefully be, released by the end of the year.

So definitely have a look, see what you're currently doing. I'm not saying radically go and change everything right now, but this is just a bit of a heads up of what's maybe coming because the adrenaline and the atropine is changing slightly. Based on the, the, you know, sort of the human side of things, which is actually really interesting if I also would like to go and read about it.

So actually once, like I said, will be a little bit different to what you're doing now, probably, and then adrenaline every other cycle. Just a note with the, obviously the terminology is American, and that comes to be a little bit frustrating. Sort of a quick reference, it doesn't really help from a human factors perspective.

But we're actually kind of moving away from the high dose adrenaline as well. In people that has been linked to poor neurological outcomes. So although you get higher return on spontaneous circulation, the neurological outcomes are a little bit lower.

So if you look at these, these and wonder why, there are obviously PPO questions, and the guidelines to go alongside the algorithm. So if you are the CPR lead or the CPR trainer in your practise, just make sure that you're up to date, . And have all the knowledge, so you can be, able to answer any questions that will come up.

And I think as a trainer, that's really important to be able to do that. People will probably question you, particularly if you are changing things that maybe they've done a certain way for a certain period of time. And being able to have that evidence-based guidelines will really help with your, you know, you really pushing this forward.

So, you've looked at the evidence, you've looked at the guidelines, you've looked at the algorithm. And you've created a protocol for your practise to use. So it may be that you don't have a defib.

So what's your protocol gonna be? You're not gonna be going to those steps, you're gonna be doing something slightly different. That said, again, I personally wouldn't waste time reinventing the wheel, the algorithm's there.

Use it. But now you need to think, think about can you actually deliver that protocol, can you actually work with those guidelines. So you need to do an environment and an equipment audit, .

Audits make people sometimes go ugh, but we do need to really think about, OK, it's all well and good writing this new protocol or creating these new guidelines or introducing the recover guidelines, but if we don't have the equipment to do them, it's gonna probably fall pretty flat on its face fairly quickly. So do you have the equipment listed in your protocol? For example, do you have an Ambi bag?

A lot of people don't, it's something that recover will kind of advocate because it's portable, you can ventilate, you can attach to oxygen. But if you don't have one, you probably need to order one. Maybe you've put a stopwatch into the protocol.

Maybe you said that all timing is being done via a stopwatch. Do you know have stopwatch. All of this needs to be ordered and put in place before you start training.

If you go and start training with half the equipment, again, it's probably not gonna be massively successful. So this is an environment that I would have a look at, this is the environment I used to work in, it all looks fairly good from here. You can see that it's got oxygen, you can see we do have a circuit, and then our crash trolley is nice and easy to locate.

Now what you can't see is the fact that there's a dog park on the other side of that pillar. So this environment looks fab and all the time there's not a dog on the dog park. When there's a dog on the dog park, it's actually very difficult to get that crash crash trolley out.

So for me, I would maybe think about do I need to have a basic life support kit elsewhere, maybe I need to have that in the main wards. This is also in ICU which I'd have to go through dog ward to get. So what if something crashes further down the corridor, what's the plan there?

Just really look at your environment. If you've only got one GA machine, you've only got one means of delivering oxygen. Do you need to maybe think about oxygen condenser?

The, I don't know if you can see it, but just above the incubator on the left hand side of your screen, you'll see a flow metre. So could you maybe purchase one of those that will enable you to deliver oxygen even if your anaesthetic machines in use. So it's just really being a little bit kind of critical, about your current setup and thinking about how it might need to be adapted.

We can have a look in our crash trolley as well, I tend to find people tend to add stuff to their crash trolley that they don't necessarily use in those first few minutes, . Again, you know, you'll kind of be led by your clinicians, and clinicians, if you're here listening, you're probably going to be led by your experience and what you've gone to grab during a pression you've not had. And that's fair enough.

And I think we have to consider the, the geography of our practises. So for me, I find this very counterintuitive because the, where the lady with the apron is standing is actual, injectable cupboard. So, I, to me it seems illogical to make a crash trolley cluttered with medication that is approximately 2 seconds next to it.

However, if you are maybe, ambulatory or you've, like I said, you're very, maybe you're working out separate buildings, some people do, and you, you just, your injectables are maybe held in your operating area, but you've got a separate building where you do your consults. That's not unusual for a practise that has gradually expanded. But you could still have a crash over there.

So perhaps you want to include a little bit more over there because you don't have the ability to run back and forth. What I would say if we think about it, we've still, we've still got to get reversals, that's still 5 steps before we're getting an adrenaline and atropine. And really, a lot of the drugs we're talking about is kind of in our prolonged CPR, or post Ross care, .

So yes, by all means, stock your crash trolley, but just be aware that overstocking it can be just as tricky as understocking it. And for me, one of the quick things I would always do is take any glass vials out of the plastic wrapping, because trying to unpeel that plastic during a stressful situation is really tricky. But audit your environment, audit your equipment, have you got what's needed to introduce the protocol that you want to use?

You may need to order some stuff, some of that might need to go into our caps. So these things, these things take time to plan, you're not gonna be able to change things overnight, as frustrating as that might be, and for somebody who likes to change things, I empathise greatly. So, maintenance, who maintains your crush books.

He maintains the equipment. Do you have a CPR champion in your practise? Do you have somebody who loves ECC and has really taken charge of that crash box?

If they you do and you have, hopefully they're maintaining the equipment, and hopefully it's checked every week. And hopefully it's checked after every single crash as well. Now if you're doing this checking, are you're recording it?

Unfortunately, if you didn't write it down, the argument being it didn't happen. So it's always worthwhile to have a checklist to check the crash box, weekly, monthly, depending on what, what kind of area you're working in, again, what your case load is, what things you're gonna be seeing. I tend to like things to be done weekly because then if a week gets missed, I know they're still done regularly, whereas if you're aiming to do things monthly and a month gets missed, then that's kind of 2 months without it.

So have a little chart and it could be that maybe you are checking the cuffs on your ET tubes. We've had an incident where someone's intubated a patient, they've gone to inflate that cuff because obviously we need to have a cuffed ET tube to IPPV and that cuff's not inflated. So we're probably all in the habit of every time we do an anaesthesia, we inflate our cuffs on our ET tubes, we let them sit on the side whilst we're giving our pre-med and we deflate them, whilst our patient's pre-med is taking effect, and we know that they're patent.

But actually, if you've got a stash of ET tubes in your crash trolley, how often are those cuffs getting checked? I would always have a stash, like I said in my BLS box or my crash box, but then there is an argument to say that if you have a stash in there and you're not using them regularly, there's a chance that you do need to check them frequently because if the cuff is no longer viable, then that's gonna be really frustrating in a crash. So it might be that your checklist for checking your crash box are or all the injectables in date.

How are the ET tubes viable and patent, including the cast, what is the temperature in my crash box, because we need to be monitoring anywhere that medication is stored, and that includes our crash box. And where we store our crash bolts can really affect the temperatures in it. I had an incident where there was a crash trolley, a crash box stored on top of an oxygen condenser, which seemed very logical because it was in theatre and it was a flat surface, and it kind of made sense to keep it there.

The temperatures in that crash box got to 34 degrees. We were shocked. But the oxygen generator kicks out quite a lot of heat.

So if you store it on top of that, they are going to cook, equally if you store it anywhere near an autoclave or a tumble dryer. And it sounds really obvious that sometimes when we're challenged for storage and practises, we do tend to use places that maybe, with hindsight weren't appropriate. But equally, are we storing it in theatre?

Because they, I mean that generally will have a fairly ambient temperature. But if we're storing it in theatre, are we cranking up the temperatures to keep our patients warm? If when that's turned off, is it then freezing cold overnight?

So check the temperature, check your crash box, record this information, record that it's been maintained, because if you have an unfortunate event or an undesired outcome, and it's as a result of a now malfunctioning piece of equipment. You're gonna wanna know it was maintained, you're gonna wanna know why it's malfunctioned, and if it hasn't been maintained, that's not a very nice feeling to live with. That's where we start feeling really guilty and that's where it can really start affecting us is if we know that we could have potentially prevented something happening.

So record it. Who orders the new equipment? Does everybody know what to order the who to order the equipment through?

If we had our checklist, could we perhaps say, if anything is found missing or damaged in this box, please contact the CPR champion or X person in the event that they're not available. Sometimes we have to make things really clear for people, assuming gets us in a lot of trouble at times, and we have to be aware that. Nobody sets out to make a mistake.

Nobody sets out to work to come to work and be lazy or not do things. But you're in the middle of checking the crash box and someone shouts for you to give them a hand, and you go, yeah, yeah, yeah, yeah, cool. Done.

Shut the box and you go off and give them a hand. You've not realised that you're actually meant to go and order something or you're meant to go and mention something to somebody. So if we can make things as clear as possible for people, then hopefully that stuff will be done.

Unfortunately, human error will still happen no matter what we do, but it's taken all reasonable precautions. Do you need extra resources, so you've gone through your equipment, you've gone through your environment. Do you need anything else?

Do you need some drug trucks? Lovely easy access, clear drug charts that someone can just grab in a rush. Just be aware that some of them will have, the UK trade names and the USA trade names.

For me, I feel like when we're doing drugs shots, we should be using the actual drug name and not the trade name. . But again, there's probably this is probably something that you really need to individualise to your practise so that everybody's familiar.

Remember what I was saying about in a stressful situation, you don't want to be looking at a crash box and having to really analyse and think about what drug that is. You want it to be really, really obvious. So just be aware of using generic, charts, just to make sure that they are appropriate to your practise and they are approached to the drugs that you stock, but have a drug chart.

Include things like naloxone as well if you're creating your own. Remember we talked about reversals, so include the drugs that you will commonly use based on the protocol that you've picked. Ideally, a recover poster or algorithm on the wall, multiple ones will be helpful, particularly if you've got multiple people.

And that's the same for drug charts. So the person making the drug decisions will generally be the vet. The person drawing up the drugs may well be a nurse.

Now if they've both got a drug chart that enables them to both double check. So the vet says, I would like 0.3 mLs of adrenaline, and the nurse says, Drawing up 0.3 miles of adrenaline or, oh, on my chart it says 0.2.

Can we double check. So having that information for both parties again is something that can help prevent human error. So we've got our algorithm on the wall.

We've probably got it in our crash box as well, and maybe we've got it stuck in theatre. Maybe we've got 3 copies of it. Great.

We've got a couple of copies of our drug charts, knocking around in a crash trolley, maybe again hanging up in theatre. But we also now need a crash recording chart. Now this is a really good way to get the team involved in this process.

And if you need to create one, ask the team to help design it. They know best how they work and how they interpret things. So get them involved.

It's also a really good teaching exercise because if they're going in adding SPO2 and blood pressure and you've looked at the guidelines and you know that those things aren't something that you're gonna be looking at in a crash, you can then have that conversation with them. You can build in a a checklist into that as well. I like to have a checklist that kind of relates to the 1st 5 stages so I can check those 5 1st stages are actually done.

Recover do have a recording chart available on their website. It's quite detailed, and obviously I love Recover, but they are very much . I kind of designed with like universities and teaching hospitals in mind.

And from my experience of going into general practise and supporting teams in general practise, they're a little bit too much. And when things are a little bit too much, or they're intimidating, or we're not sure what that question's, is asking of us, and we don't know what that box is actually even meaning that we're being asked to fill in, we tend to just not do it. We tend to just kind of steer away from it.

Cause most of us are non-confrontation, we don't really like to be like, oh, I don't know. You don't want to put the wrong thing in, so you just put nothing in, because nothing is better than wrong. So your crash recording chart needs to be clear, easy to use with a checklist, and needs to have only the information that you need in it.

Adding in things will confuse people. Do you need a stock list? Do you need a list of everything that's in your crash box or crash trolley?

And what I also like to do is take a photo of each drawer, as you saw on a couple of slides ago, and then that means that when you're restocking it, you can lay it out exactly how it's meant to be. So everybody knows that they're going in the top left-hand corner to get larynge scope, they're going in the right-hand corner to get the ET tubes, and that's the same. That doesn't change.

You all know what it's like if you go to a cupboard and someone's moved something. 000, it's not there, it's, oh, it's over there. That's delaying and that's confusing and that breaks your kind of pattern matching and the way that we recall things, so we really want to keep things consistent.

And it's all really good having a list of what needs to go in each drawer, but we also need the drawers to be laid out the same as well. Having a picture of each drawer with the contents will enable people when they're restocking the crash trolley to follow that consistent approach. And then like I said, the stock list as well.

So when we're saying we're checking all the injectables, perhaps you break it down even further when you have the re adrenaline, re atropine, trick . Naloxone, so you're constantly really supporting people in this process. Again, I would have all of this ready before I even start my training.

We're not even at the training. This is a lot of prep work. And that's why if you can use stuff that people have already created, as long as it's obviously in line with the evidence that we're looking towards, use it.

So this is my example of CPR record. This is something I've created, unfortunately it's a little bit blurry. I'm not really sure why I've also uploaded a, poor quality one.

So I have really thought about, what I actually want to include on the CPR record, so I would like to have when the compressions are started at, when the crash has been called at, the coordinator. So for me, when we talk about lead, the lead isn't necessarily always gonna be the vet. The lead is the person who's most experienced with CPR.

However, if we have a vet on site then they're probably gonna be the ones deciding on the drugs. So I would have a coordinator and a clinician lead for CPR. We've also got patient names, the patient weight, the date, the species.

Super simples. We've got a log of who's doing what. So we've got the roles that we would expect.

And this can help us when we're allocating roles as well. So we've got a list, who's doing compressions, that's normally more than one person, who's doing ventilation, who's in that drug administration, who's drawing up the drugs. Some of them might be jew, so somebody might be drawing up the drugs and giving the drugs, and somebody might be, timekeeping and scribing as well.

And in a smaller team, that's probably quite common. Now you can see I've also built on a checklist, so our compression started, is the patient intubated, has ventilation commenced, IV has been placed and is our monitoring on. So we have.

So we've made that really clear for people. Unfortunately, I'm having a slight issue with my slides, so I'm just gonna pop back to them and we'll get back to that. PowerPoint has a mind of its own today.

So anyway, as I was saying, compressions have been started, patient's been intubated, ventilation's been commenced, IV has been placed, monitoring has been attached. So we use surgical safety checklists a lot during, GA's and obviously within theatre, but just having this list for the person who's got this in front of them enables whoever it is coordinating to just check that all of this is happening. And then you'll see we've just got adrenaline and atropine, any other notes, and what our end of CO2 is.

We've also broken up each round with an ECG slash pulse check and just reminding us that each round of CPR or BLS is 2 minutes, and at the end of 2 minutes, we're gonna check, we're gonna check for a pulse. And we're gonna have a look at an ECG. So, correct monitoring.

This can require a little bit of training, I would say. We've talked about credit monitoring and I haven't mentioned it. But your cat the graph will alert you to return a spontaneous circulation, so Rosk, and it will also tell you if your compressions are adequate.

So we want an end of CO2 of 15. I think that is changing to 18 in the new guidelines, but anywhere between 15 and 18, you should have adequate compressions. It's the only piece of equipment, only piece of monitoring that is not affected by movement.

Which is why it's really important to have those, pauses and those brakes built in, because we can't really check our ECG while compressions are happening. It's probably not gonna be terribly accurate. So we're gonna have a look at our cap graph and then in our gap, we're gonna have a look at an ECG.

Now if you're not using ECGs regularly in practise, and you've got a machine that can do it, put it on every patient every time, your confidence will increase by doing it. Your confidence might increase a little bit by reading about them, but in reality, looking at them regularly and consistently is gonna be what gives you that ability to recall what you've previously seen, and to confidently diagnose them. We don't want blood pressure and we don't want SPO2, particularly not on our monitoring charts, because that implies we need them to put it on.

And actually, we're trying to make this really slick and strip it back so it's simple and easy to follow. Our SPO2 and our blood pressure rely on cardiac output. We don't have any cardiac output, so they're not gonna be massively informative.

When we talk about the post crash algorithm, those things do come into their own, so we do want to look at their oxygenation. We do wanna maybe do blood gases, we probably will want to get a blood pressure, and obviously if we've got enough people, you might stick your osciometric blood pressure cuff on. But in reality, these are the things that we need to be looking at because this is gonna give us information as to how to use that algorithm.

Now, simulations have been proven human sector to induce a similar stress response when cortisol levels were analysed. So therefore they're a really useful tool when they're done well. So what they've done, and I hate calling them baby doctors and baby vets, and, but I can never remember what the word is.

I think they're like F1s. So they did a study where they took cortisol swabs of, younger doctors during a mock crash, and they compared it to cortisol levels during an actual crash. And the cortisol levels were very similar, which is a really useful point.

Because we can all do things when we're not under stress and we're not under pressure, we can generally do them quite well. And then we add stress and pressure to it and it actually makes our life a little bit more tricky, and sometimes it's hard to be doing those things. Without that, with that stress environment.

So what we want to do is to be able to mimic that stress environment without our dying patient. In order for people to really practise what they're doing. So they're a really useful tool when they're done well.

Now, what we have to not do, and what I've been guilty of in the past, is to throw a cuddly toy on a table and shout, crash and see what happens. I mean, it can be interesting to get a baseline. I would rather use a questionnaire to get a baseline rather than throwing a dog under the table or having a conversation with people.

Like I said, talk about appraisals, debriefs, you can create a questionnaire quite easily, an anonymous one quite easily and, you know, circulate that. You don't have to throw a dog on a table, a cuddly toy. And see what happens, because what will tend to happen is people can get quite stressed.

Some people can be quite anxious about this. And actually what we really want to be doing is teaching that theory beforehand and then having a debrief afterwards. A successful simulation is one with pre and post work, not just dog on a table.

So how I like to teach BLS and how we would generally do that in a simulation is I would use a model and I'd have a maximum of 4 people in a room and I'd pair them off and we'd be focusing a lot on the communication, so that's really one of the key skills that we want to think about and the switchovers. And that comes up again, quite a bit where people are kind of like, oh, you know, I'm, I'm doing my compressions, how do I know someone's gonna take over, what if nobody comes. So hopefully you've shouted crash, you've started compressions, and you're underweight, and your magical second person is gonna appear, and they're going to intubate and ventilate your patient.

We want to really get a nice 2 minute cycle in. Sometimes that can be a bit tricky when there's only two of you to keep an eye on the time. As a rule of thumb, I would say probably by the time you've started compressions, shout of help, helps arrive, your patient's been intubated and ventilation's commenced, you're probably heading towards 2 minutes.

So, a couple of breaths, and then think about switching, and then start your 2 minutes block from when you've switched, cause then you can obviously, hopefully look at. O'clock, or maybe set a timer, or grab that stopwatch if you happen to have it. And, but what we need to be doing is saying to the person ventilating, ventilating, 2 minutes are up, we need to switch.

That person ventilating says, I'm coming in on your right hand side or your left-hand side, whichever side it is. And then you're given a breath, you're doing a quick pulse check as you're switching. So the person who's done the ventilation will give a breath, move in to check the pulse, as the person compression stops, moves over to take her ventilation.

So it's all about talking to each other. Recovery generally advise against switching roles, obviously with compressing and ventilating, we have to switch anyway because we can't compress more than 2 minutes. What I quite like to have is 3 people involved in this.

So I'd quite like to have somebody. Watching and providing feedback on the compressions on the pulse, somebody compressing and somebody ventilating, and then the three of them all just move one place to the left. So you keep that consistency, and then as soon as, once you've kind of got a flow and you've got more people and you've got someone with a timer shouting out every 2 minutes.

If you are doing the timing, give them a 12th warning, so 10 seconds, get ready to switch and then everybody can be ready to quickly move. Have a look at that ECG and then restart compressions. We don't really want any more than 10 seconds, between compressors, because all the time we're not compressing, we've got no cardiac output.

So I like to focus on that when I'm doing my, particularly this is for my new joiners, so this is what I'd expect my new joiners to be able to do. I wouldn't expect them to be comfortable with an algorithm, not even the interns, to be fair, or clinicians, I'd expect them to be able to confidently perform BLS, and then we would work on the ALS side of stuff as well. But also, if you need to move the patients, so perhaps your patient's crashed in an area where you have no oxygen, you've got your ambi bag, you've started your 2 minutes, and we know that's the best thing to do.

We know that starting compression straight away in situ is the best thing to do. But we're gonna need to move that patient, maybe they're in the way, maybe they're really small and actually doing them on a table would be far better, perhaps they're really big, so you want to move them in an area where you can do them from the floor. How would you do that?

You know, how would you have that conversation? How would you say I'm coming up to 2 minutes, can someone grab me a table, or I want to move in the next break, can someone make sure that this area is ready? Practise that.

Because these are the things that when it all goes peak to, they all go peakong. They get muddled, they get confused. And actually, interestingly, the more people involved, the worse the basic life sport, which is a really interesting, little point in the guidelines, actually.

Because I think sometimes we think more people is better, but this is where we can get that confusion and delay, which is, you know, not ideal. And like I've mentioned, this is what I'd expect new joiners to be happy with. This is my baseline.

And that includes the non-clinical team members as well. I'm very pro getting, you know, reception, PCAs, involved in resting and ventilating, particularly for working, maybe on a Saturday morning, where there is yourself as a nurse or a vet, and vice versa, working with another vet or nurse, alongside a PCA and a receptionist, and you've got a patient that crashes, because what they can do versus what you can do. They can only really do compressions and ventilations.

I'm not going to have a normal clinical member of the team drawing up drugs, administering drugs. I would perhaps have the one running a crash if they were confident with the algorithm and they'd had adequate training. But I wouldn't have them ringing owners or anything like that.

So, it's really thinking about what your clinical team can do and what your non-clinical team can do. So I like, to use an Ikea dog. There are these lovely mannequins, one that looks slightly like a dead mole, or the plastic one for Casper, which is super budget friendly.

You can wipe him clean. He is in the wrong position for intubating, which, you know, can be a bit misleading, and sometimes he gives you a little bit of blisters on your hands because he's so rubbery. But he's a great, he's a great aid.

And then we've got the sort of more high fidelity mannequins, the ones that you. Put pulses on and you can put IVs in, and they're fab. They do have a slightly, they do require a bigger budget.

So if you are able to get a needle and thread and, an Ikea dog or other cuddly toy, with an insert, then they can work really well as well. I've also seen people do CPR training for the rolled up bet bed. It's all about positioning, communication, and kind of patterns rather than actually what you've got in front of you.

So don't be put off, you don't need to have a huge training budget to be able to train well. Now, advanced life support. Ideally, we'll be separate for the hands-on sessions.

So I would always see that BLS as an introduction, new joiner, non-clinical activity, small group, allow people to ask questions. The more people, the more intimidating it is, pair them off, really focus, get them giving feedback to each other, get them kind of talking to each other, you know, what's that compression quality like? And obviously, you know, you've precluded this with some theory.

So I would have done a PowerPoint explaining to them, You know, what the compression rate is, what the compression depth is, what the ventilation rate is and why it's different. Avoid kind of, cutting out information for non-clinical team members. I've done this, and I actually had people who didn't feel empowered to kind of really take charge of like those 2 minute rules, because they didn't understand the importance of it.

So, I always start with just saying, you know, some of this, some of the terminology, might be a little confusing. If any of the words are, please put your hand up and ask, and I will explain. But I don't cut out information for my non-clinical team, when I do my training.

I try and make sure everyone has the same. And when you're doing that group training, having a mix of maybe, 2 clinical members and two non-clinical members and pairing them up together, so they can kind of really peer support each other, can be really useful as well. So we've got our basic life support, we've figured out how we're gonna do that, and that is very hands-on alongside a theory session.

Now ALS again, we're working on the theory that we've done some theoretical training with them, maybe they've done the recover online course or perhaps you've set up and you've delivered a PowerPoint. It's entirely up to you. So if you are the CPR lead, and perhaps that is you, you've gone through the algorithm, and the current guidelines, and you've explained to them why putting the ECG on and at what rhythm we would do X with and what rhythm we would do Y with.

But then we need to do simulation. So then, We do need to get our cuddly toy, or I, you know, our lovely Casper, our superstaangly, high fidelity mannequin, and then we do need to run through it. And this is where simulations can be really, really valuable alongside the scenario.

So if you can have two or three scenarios, you know, sort of almost like a script in your head, or you've, done sort of fake monitoring readings, or you've done like a flow chart where if they do Y it goes to this, or you do X and it goes to that. Maybe it's gonna be what your last crash was, maybe you're gonna break it down. And you're gonna give them a scenario of a, a cat that's not been urinating for 3 days and it's come in, collapsed, and as you're triaging it, it goes into CPA.

What you're gonna do next. So you can just give them that scenario. Ultimately, by following the algorithm, it's all going to be pretty much the same, until we get to the ECG rhythm diagnosis, and then it will be, will be different.

But if we can get some pictures of some ECGs, or perhaps you look at you, give them a card that says you look at the ECG and it says you're in VTA, what do you do next? Using the algorithm, they're gonna know what to do next. So we're making this really interactive and really hands-on.

Now, some of the barriers towards training, and I think it's important to talk about this because we can talk about some of the ways around it. So you've, you're the CPR lead, you've gone away, you've done your recovery online, perhaps, or you've done loads of reading, you've sat down with another clinician, maybe it's your clinical director, and you've created these. Beautiful CPR protocols and guidelines that you're really proud of and you just really want to get introduced.

You've done your audit, you've looked at what you need to buy, you need to look, you've looked at what you need to do. You've identified that you maybe need to get yourself a cuddly toy and start, you know, adapting that. But you've got some barriers, OK?

So you've got equipment costs, and that can be a barrier. I would say there isn't anything really in a crash box that is high level expense. When we think about how much our equipment costs within practise, and my bags are relatively cheap, like the IPPV buttons, if you want to use your circuit to do your IPPV, relatively cheap.

. Laryngoscopes possibly not so much, but I tend to use the disposable LED ones because then they don't have bulbs that break . So it might be that you have to adapt, but in reality, what you need is generally what you've already got. Like I said, the mannequin costs can be something, if you are part of a large group or perhaps you can offer training to other practises, maybe you can all kind of contribute to a mannequin that you hold in one place and people can kind of borrow it for a day.

I would say. The, you know, good team training is linked to better BLS, but it's also linked to people feeling like they've done a good job. And for me, the cost of a mannequin will be far outweighed by the fact that my team are happier and more confident with something that causes quite a lot of stress for a lot of people.

Time is really tricky. Time, even, so my role, I was very lucky when I was, in the practise, I was doing a lot of this training. I was the head of training slash clinical services manager.

So I wasn't on the rota and I wasn't really clinical. I was able to really dedicate my time to do this. But even with me doing it, as pretty much my full-time job for a while, I still really struggled because I also needed time for other people to be able to come and attend.

Which is why keeping it a small group, sort of 4 to 6, and really just sort of working your way around the practise, was how I managed to achieve it. And I really had to think about, kind of other people's rotas, and I had to come in sometimes in an hour that maybe didn't really suit me, but it suited them to have that training. And because this was something that our senior management were on board with, this was something I was able to do.

And I would say you do need your senior management team to be on board to be able to overcome some of these challenges, because the time is a very real one. What a lot of the practises have done that I've gone into in-house and trained with is they've just booked off a Saturday afternoon or a Sunday afternoon, and they've booked it off, and everybody's just done it at the same time, because it's something that they felt was really important, and they've seen the value in it. But that is challenging.

As is resistance towards training, and this is very common, particularly when people are maybe feeling a bit unconfident or they don't see the need for change, or they believe what they're doing right now is fine. Really explaining to them the whys, and get it going into the area of the most engagement first, is what we really need to focus on. And our next slide will, will kind of tie in with that.

But this is something I say quite a lot and yeah, it's something I feel quite passionate about that. You know, we talked about all these barriers and we talked about all these expenses. But looking after your team's mental health is more and more than a sticker on a toilet door, OK?

And I've been very lucky to be asked to come and support teams where their senior vet or their senior nurse has witnessed a crash, or they've had an an unfortunate event or a significant event. And one of the actions they've come to is that their team need more training. That is proactive, that is looking after your team.

Sticker doors are great, stickers on doors are great, you know, signposting for mental health support can never be bad. But I do think sometimes we need to be proactive and if there's something that people are struggling with, we need to support them with that training as well. So this is an example of a mannequin.

He's been adapted, as you can see, I've managed to put a little trachea in him so we can't intubate him and we can really get stuck on and do some hands-on CPR training with him. I always encourage people to treat the mannequins like they're real dogs, so we will always be tying in our ET tube, we'll always be cuffing our ET tube. And people will say to me, Oh, I'll do it in the real thing, but we know that's not true.

We know that that's not always the case. So we practise like it's the real thing, and then when it's the real thing, we've got all of that lovely long-term memory and all of those patterns to match, all stashed away, and our amazing brains, that we can recall, and we're doing something that will short term generate, oh, right, if you see that, it will become habit. You know that the more familiar you are with the task, the easier it is.

We all can remember the last, the first time we placed an IV. Versus the last time we placed an IV, the first time we did a dog cash rate versus the last time we did a dog cash rate, we get better with practise. It's just normal.

It's muscle memory. It's building synapse like connections. It's, if you're in psychology, it's really smart and really clever how, how on it our brains are.

So these simulations and doing things like this will help us in the long run. Now, million dollar question, how often? Like I said, I like all my new joiners to go to do BLS, and that'd be what I'd start with, so every, every person who joins the business that I've been involved with will have basic life support training.

Now, when we go on to the next slide, if we look at the guidelines set by Recover and Resosh UK and based on experience. We can kind of collectively work out that all new joiners need to have CPR training, which should include theory and practical sessions. So for example, it could be Watch a webinar and then do a simulation, it could be watch the PowerPoint, or perhaps you deliver a theory every month or 2 months, and all the new joiners need to join them.

This really depends on your kind of retention and turnover and the size of your team as well. One thing to take away is that every time you make a change, every single member of the team have refresher training, and that should involve stimulation. Now I have learned the hard way of this, that an email, a memo.

It does not work. We had a new crash trolley. It had a door that you pulled up and pushed it in, and unless you pulled the door up and in, the drawers didn't open.

And I thought I'd communicated this with all the team. I didn't do a simulation. The first time they had a crash, they couldn't open the crash trolley.

So whenever there's a change, do a simulation, because then you're gonna be using the equipment, using that protocol, and you're gonna be again logging that. So anyone involved in CPR who or who generally will take a lead, should really have more frequent training. So again, smaller practises will probably be everybody, larger practise perhaps if you have an ICU team or a wards team, they would be people that you'd be focusing, training on, but equally, anyone who has a leading role in CPR should really focus on leadership and debriefing, so they should have additional training.

To really help hone those skills that will make a successful CPR. But ideally all members of the team will have a minimum of yearly simulations. Remember to include a range of personnel.

A lot of the guidelines will kind of advise sort of 3 to 6 months regularly. If you aim for every 3 months to have training, in reality, it'll probably be every 6 months. If you aim for every 6 months, it may well fall till every year.

So you just need to think about size of your team, the case load you have. And quite often people will say to me, oh, we don't have, we don't have regular crashes, so, you know, I don't need to do regular training. And I would argue with you that you're the ones who need to do the training.

And that's not in a negative way, but we talked about experience, we talked about gut feelings, we talked about pattern matching. If you are already seeing these once a year, the chances are your confidence is gonna be pretty low. The chances are you're not gonna be able to recall things, you're not gonna be able to do things as quickly or as confidently.

Much in the same way if I asked you to only do a bitch pay once a year, you wouldn't be confident doing that. So if you do them infrequently, this would be where maybe a 3 monthly simulation would be really useful. If you're doing them regularly, that's not to say you can't learn things by doing simulations or refresher training, but you're obviously already doing them regularly, so you've kind of got that hands on.

So yeah, Resosh UK is a really great resource as well if anybody wants any more information about that, and the training. So, we want to really remember closed loop communication. And when I talked about this earlier, I didn't really explain what it was, but I think I alluded to it.

So we're saying, can I have 0.4 mLs of atropine? I'm drawing up 0.4 mLs of atropine.

Like I said. Communication is really important during CPR. It's important throughout our careers, to be fair.

And if we can get in the habit of using closed loop communication always, then we're more likely to use it in a crash. Remember, all of these little habits of the culture we create as well. And if we've got a culture of psychological safety and a culture of people feel heard and where people can ask questions, that culture will transfer into our crash situation as well.

And if you have a culture of good communication, hopefully that also transfers. So if we were to recap We've talked very briefly about most of these things, and I really hope that you guys, can take away a little bit more information, have a bit of an idea of how you're going to tackle your training within your practise, thinking about all of these aspects that need to be included. And yes, compressions, drug and ventilation are really important, and we do want to spend time making sure that people's compression technique is good, that they're ventilating at the appropriate rate for the appropriate duration, and obviously the drug therapy is.

It is important, when we're looking, like we said at the ECGs and our algorithm, but that if we just focus on those three things alone, we won't have effective, CPR for the whole team. And when we, if we just focus on those 3 things for our team training, we won't be looking at the whole picture. And this, we need to look at the whole picture, we need to make sure that all of those little pieces are done.

To party. Now looking towards again the human sector, now this was I'll pop them all up, so this is as a result of a human factors initiative, and this is something that collectively people said really helped when they introduced their human factors initiative. So senior management commitment, you need your senior management team to be on board and committed to this training programme.

If they're not, it will probably fail. They advise training multidisciplinary teams together, which is what we've talked about, we've included clinical and non-clinical. You need to have a flexible train delivery model.

So if you break it up into a theory session and a practical session, and then maybe an hour each, and perhaps when it's the keyword, you can put those two together and you can have a 2 hour session, but perhaps some days where it's a little bit more hectic, you know, you're kind of asking people to do the theory and then you're gonna do the hour practical with them. So it needs to be flexible and that includes your timings as well. You need to really clearly communicate the owners of the training, so people need to be aware of why they're doing this training and what the point of it is.

The context needs to be relevant, so using cases that you've experienced, that people have been involved with, make it relevant. Think about how to measure the success. If you're going to do a questionnaire to get a baseline, can that questionnaire be repeated after your training?

And if people's confidence levels have improved, can you compare to say, actually this is really worthwhile, this is how much people's confidence have improved, so this is something we should think about scaling up. And then that's where it comes into, you know, plan for the scaling up of it. How much can you scale it up to all team members?

How sustainable is it gonna be be to be regular? Use patients' stories. We all know this to be true, and I always remember Elaine Bromley's story, and even when I recall it back, it makes me well up because it's so emotive.

And those things really have impact. Do not be deterred. This will not happen instantly, this will not happen quickly.

There will be resistance, but you need to persevere. So don't be put off. There will be people who are grateful for what you're doing, even if they don't say it.

Find a why, so we all know why we're doing this because our stats are 6% compared to 20% of humans and we want to make them better, and maybe we want our team to feel a bit more confident about it and we want to really minimise that second vi syndrome, so we know why we want to do this. But crucially, we're going to start with the willies. So you're not going to pick the people who don't want to do the training to train.

You're going to pick the people who really want to do the training, the people who want to know more. And then when they're excited about it and they're chatting about it and they're saying how good it was, which it will be, because I have faith in everybody, then that will start influencing the people who maybe don't have the will. And just as a summary, we're gonna review what we're currently doing.

We're gonna create if we need to. We're gonna plan how we're gonna train. We're gonna deliver that training, and then we're going to embed it, so it's gonna become part of our culture.

It's gonna be the norm that every new person has this training. It's become the norm that maybe every January and July, we do CPR training. It's gonna become the norm that we debrief after every crash.

But we're still gonna keep reviewing because things change. We've already talked about the fact that the guidelines are changing. And we still might create something new, we still might need to plan it again because maybe what we've done isn't working.

Quality improvement and clinical governance is a continuous process, and CPR training is the same, so if we follow this framework, we should be right. Now, I hope that was helpful. If you have got any more questions, particularly if you want to know a little bit more about the, technicalities of CPR, then head to the recovery initiative, and they've got all the guidelines on there, all the PPO questions and the algorithm.

I didn't mention at the beginning, because I always forget to, but if you do know who I am, you'll hopefully know that I also run retreats. And if you would like to maybe join me on one of those to maybe learn a little bit more, then, do feel free to. And I believe that is everything.

And thank you very much for listening. And like I said, if you've got any questions, simply pop me an email, I'll get in touch. And like I said, the Recover website is a plethora of information, and I'm sure within Webinar vet there are probably many more webinars as well that will really help, particularly if there's anything on ECG interpretation, or Caography as well.

So yeah, I hope that helps.