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Emergency Protocols for the Spinal Injectionist

This second of two articles addresses the fact that emergencies arise so infrequently that physicians don’t think about or practice emergency protocols in advance and offers suggestions for being prepared to handle complications during spinal interventional procedures.
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On January 15th, 2009 there was a bright blue sky over the Hudson River. This was the backdrop to one of the most dramatic airline emergencies in history. Prior to take-off in New York City, everything was normal. There was nothing during pre-flight inspection that gave cause for alarm. A maintenance check required every 550 flight hours had recently been performed. However safety inspections were not enough to prepare them for what happened next.

The plane took off from Runway 4 at 3:25pm, to begin its ascent to 15,000 feet. However, at 3,200 feet, the plane’s windscreen turned dark brown and the pilots heard several loud thuds. Both engines quickly lost power and the plane started its lifeless decent. Captain Sullenberger called to the air traffic controllers, “Hit birds; We’ve lost thrust on both engines.” A migrating flock of Canadian Geese had flown into the airplane causing both engines to fail. “We’re turning back towards LaGuardia,” said the Captain to air traffic control. “Got emergency clearance if you want to try and land…” air traffic control reported. “Unable,” replied Sullenberger, “…maybe Teterboro?” Teterboro airport in New Jersey was the closest airport en route with the airplanes current direction. Seconds later, Sullenberger reported: “We can’t do it…we’re gonna be in the Hudson.”

Capt. Sullenberger navigated the unpowered plane into the Hudson River. Emergency rescue teams were immediately dispatched and all 155 occupants were safely evacuated as the plane flooded with water. Sullenberger was immediately recognized as a hero. However, he attributed his heroics to his many years of experience and training for emergencies in an airline simulator. He stated, “I think that it allowed me to focus clearly on the highest priorities at every stage of the flight without having to constantly refer to written guidance.”

Memory Retention of Spinal Intervention Emergency Protocols

In the same way, spinal interventionalists should not only be qualified in providing expert procedural care but also in management of emergency situations that arise during performance of procedures. There is an implicit understanding between patient and physician that, should an emergency arise, the physician will be able to provide the care needed to resuscitate the patient. Last month’s article in Practical Pain Management, entitled “Avoiding complications from interventional spine techniques,” described the types of complications that can occur during a spinal injection.1 The purpose of this article is to provide physicians with guidelines for resuscitation should the need arise. Finally, the authors hope to motivate readers to mentally and physically rehearse, on a regular basis, the steps necessary to provide appropriate care in an emergency.

The Advanced Cardiovascular Life Support (ACLS) guidelines have been the gold standard in preparing a physician to care for a patient in dire circumstances. However, a single rehearsal of the ACLS guidelines every two years has been shown to be insufficient for long-term retention of resuscitative care amongst healthcare providers.2-5 Not only does retention of ACLS knowledge decrease with time but so does the quality of ACLS care. In a multi-parameter study of the quality of ACLS cardiopulmonary resuscitation, deficiencies in many parameters of ACLS care were noted including chest compression rate, compression depth, fraction of cardiac arrest time without compressions being performed and ventilation rate—even when well-trained staff performs resuscitation.6 In order to be adequately trained and ready to provide the care needed for resuscitation, additional training is needed.

The American Heart Association (AHA) recommends a renewal of ACLS certification every two years to remain current in practice and skill.7 However, studies have shown a rapid decline in ACLS knowledge and skill shortly after completion of training.8-12 Many have argued that a frequency of every two years is not enough. This argument has been validated by a study showing that professional skills decay significantly with nonuse.13 Arthur et al. expanded on the idea of increasing the frequency of trainings by performing a study using meta-analytical techniques. They found the most important criteria for skill and knowledge retention was the degree of overlearning.13 This is defined as “additional training beyond that required for initial proficiency.”13 These findings suggest a need for continued education beyond the two-year minimum requirement and hint at the possibility that the method of learning can be improved in order to facilitate long-term recall.

The type of learning and training is important for retention of emergency protocols. In a study performed by Rodgers et al to assess written-examination proficiency versus ability to manage an emergency situation, the investigators found no correlation between the two, suggesting that just one method of learning is insufficient.14 This situation is addressed in the ACLS course by involving students in the following activities: “simulated clinical scenarios; demonstrations by instructors or video; discussion and role playing; and practice in effective resuscitation team behaviors.”15 However, similar types of learning are rarely taken advantage of in a clinical setting.

To alleviate this problem, Bryan et al suggest that providers need to be actively involved in the emergency training learning process.16 They recommend asking the providers for their preference in learning styles; whether they prefer a quiz-based, simulation, or oral presentation style, to name a few examples. One solution many providers prefer is simulation-based education that provides a hands-on mechanism for education and retention that has shown positive results.17-20 This technology encompasses a wide variety of techniques to help students retain the material. For example, it can include the use of a video program to facilitate training (e.g., mannequins equipped with technology to provide feedback on the performance of a technique). In a retrospective study to assess the success of simulation-based technology, two groups of participants were monitored during real ACLS events. One group was trained with simulation-based technology and the other was trained through traditional methods. Those who were trained with simulation-based technology were 7.1 times more likely to adhere to ACLS guidelines than those who were trained traditionally (95% confidence interval).21 The researchers concluded that simulation-based training is an effective tool to provide an advanced form of learning that can enhance retention and skill in many emergency situations.

Last updated on: October 5, 2012
First published on: April 1, 2010