n=1 isn’t anecdote when it is your child

The revolution of technology and social media has transformed the way information and knowledge are transferred. There is no greater demonstration of this than in the medical education community, and in particular for the ‘lecture’.  Standards in pedagogy will be forced to rise as excellent demonstrations of presentation content, technique and style are shared in an instant around the world. Currently the #SMACC conferences are assembling a fantastic group of individuals who are leading the way in how audiences can be engaged and enlightened.

At #SMACCGold this year there was on particular lecture that really caught my attention. Cliff Reid talking on “When  should resuscitation stop”.

It is brilliant talk with a well pitched narrative, evidence based insights and a constant return to the human side of clinical practice that is all too often forgotten. It was also conceptually clever as the real theme was when resuscitation shouldn’t stop. As a Paediatrician with a special interest in Emergency Medicine the child presenting in asystole (no movement or electrical activity of the heart) is one of the hardest aspects of my job and the decision on when to stop CPR often a challenging one. It is vital that anyone who works in Emergency Medicine listens to Cliff’s talk and takes home some of his key points:

Never make decisions in isolation of each other and a blood gas should never make your decision for you

(my interpretation and not Cliff’s actual words)

The talk uses two examples, both of children, to demonstrate the huge human factors element to decision making in halting CPR. In one of the cases the child made a full recovery despite nearly being in situation where attempts to resuscitate were stopped (Cliff was clear these were examples and all cases are unique). The cases certainly were unique  – one involving cold water immersion and the other a complex congenital heart defect. What of a potentially more common scenario – sudden infant death syndrome. These are still unique events, there is no other child in the parents’ eyes, like the child you are trying to restore a circulation to. What evidence or anecdote will you use in these situations?  Does the knowledge that one child, in one place, at one time, survived after a heroic resuscitative effort lead you to do the same? What if the parents knew that there are reported cases of children surviving after hours of down time. Could you convince them why you are stopping after 20 minutes if you think the child has never shown any signs of life? Only the clinicians in these unique situations will know the real circumstances of what made them go that extra minute or seek that extra intervention. Encapsulating their gestalt will be nearly impossible – so we are left trying to do the best we can with the information we have available. As Cliff says:

“The important thing about human life is that its about other people – it’s about connection and it’s about love. It’s about our love for other people that motivates us to do everything we can.”  

For these most complex and emotional decisions the chance to reflect before these tragic events can only be of benefit in my opinion. Cliff Reid’s talk is certainly an excellent chance to do that.

2 thoughts on “n=1 isn’t anecdote when it is your child”

  1. Cliff’s talk shows the power of human stories. However we should never forget the larger picture…
    There may be the odd patient that heroic measures will save with meaningful outcome. However there will be multiple patients where allowing families to witness resus attempts (still not routine in adult practice) and when unsuccessful allowing them time and space to grieve where we can make a hideous experience a tiny bit more tolerable.
    A family will never forget the moment they are told a relative has died, using names, listening to memories, allowing them to hold their loved one- all makes a difference. This doesn’t need a gas or ECMO or fancy interventions- it just requires time and compassion.
    We can make a difference no matter what the outcome.

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