Follow recent news and developments in our programmes and interesting links to articles of interest in resuscitation and acute care

Management of Choking

Posted by Resuscitation Skills on June 23, 2017

Management of Choking: News Article

First Training is our sister company specialising in First Aid training courses. Earlier this week, Billy Doyle, Resuscitation Skills lead instructor appeared on the AM Breakfast TV show and gave a brief summary of how to manage choking after host Duncan Garner's close call with his son. Click on image below to visit NewsHub.


Chronic Unease in Resuscitation: Lessons from Oil & Gas

Posted by Resuscitation Skills on March 06, 2017

Chronic Unease In Resuscitation

Billy Doyle Lead Instructor Resuscitation Skills

"Chronic unease refers to the experience of discomfort and concern about the management of risks. It is a healthy scepticism about one's own decisions and the risks that are inherent in work environments."

The concept of Chronic Unease was originally developed by the oil and gas industry (Royal Dutch Shell Oil) as a feature of working towards the goal of zero harm within their industry. When things go wrong on a oil drilling rig it goes spectacularly wrong and results in catastrophic harm including massive loss of life, environmental damage and financial loss.

It is proposed that as an organisation, being in a constant state of unease at every level of human interface from the worker on the front-line to senior management and executives critically supports their safety record. 

Chronic Unease is a mind set that fosters a healthy world view that:

  •  ''Even though I do not expect something to be wrong, I am constantly on guard and prepared for when it does go wrong."
  • "I am constantly looking for weak signals that maybe an early indication that there is a hole in the system and this event no matter how minor could lead onto greater failure so I will act now."
  • "I will question assumptions and withhold jumping to conclusion"

What can we learn from the concept and attributes of Chronic Unease in resuscitation?

Let's look at the components that engender a state of Chronic Unease and draw some parallels to managing a clinical team in a high stakes medical scenario.

Imagine a 55 year old male presents to your accident and medical clinic. He looks unwell. He is short of breath and complaining of chest discomfort. He is triaged as urgent and wheeled into resus. Your small team of one nurse and another medical colleague goes to work, an ambulance is called as is the cardiology registrar at your local hospital and yes it looks like this gentleman is suffering an acute coronary syndrome with elevated ST segments in lead II,III,AVF and V1 & V2. He is struggling. Looks ashen and something deep inside screams : "Uh-oh."

Just another STEMI? Fingers crossed he makes it to hospital?

I'm not going to run through the clinical management of this situation, rather view this situation wearing a cloak of Chronic Unease to see what thought processes and actions might augment how we manage human and clinical resources in order to be prepared if this patient 'circling the drain' suddenly suffers a cardiac arrest.

Attributes of Chronic Unease

  • Safety Imagination

The ability to mentally project the development of a situation into the future based on its current state.

The thinking here is to use sound clinical judgments based on good evidence on the potential clinical picture that may develop. Get real. Sure, everyone has the potential to suffer cardiac arrest, but there are prodromes that stratify some more likely than others. When that signal is present, acknowledge it, even declare it to the team so they share your mental model of the situation and share your unease. Activate help early, (even if it is eventually not required). If a crises develops you do not want to be behind eight-ball.

In this clinical situation a clinician adopting safety imagination might preemptively place defibrillation pads, they might clear the bed space of clutter, they might pull the team aside and pre allocate roles and tasks that maybe required. The bag-mask resuscitator might be pulled out from the draw and assembled. The suction made ready. All "just in case.

  • Pessimism

A personality trait reflecting a tendency to resist complacency and to anticipate failure.

Are you some one who with a little voice in their head that runs scripts like: "No... can't be that bad, he'll be fine,everything is O.K...," despite compelling evidence to the contrary?  There are a number of scripts that can run contrary to the reality of any given situation and these are complex cognitive errors beyond the scope of this article. Suffice to say, a personality trait that resists the urge to dismiss weak signals when events are unravelling takes discipline and practice. It needs to be a habit.

Is there anything wrong with being pessimistic, resisting the urge to be complacent and therefore taking steps to anticipate failure?  Its all about context. If you've developed the habit of pessimism, this trait runs subconsciously in the background of thought and becomes dominant when you're receiving weak signals that something is wrong.

A clinician may also take a healthy dose of pessimism when planning resuscitation skills. Sure, we all like to think we can perform advanced airway skills like endotracheal intubation and high-quality CPR. The answers to pessimistic questions might scale back you're immediate expectations of what you think you should do to a more realistic position of what you can do in reality.  Pessimistic questions might include:

"But when was the last time I did that, do I have skilled help to assist, do I have the right equipment, there are only two of us here. How long could we realistically do effective chest compressions?"

  • Vigilance

The ability to notice and identify (weak) signals of risks in the environment.

In the context of the oil and gas industry, this may mean paying attention to hazards such as liquid spilled on the bottom of a stairwell or a pressure alarm that is intermittently going off for some unexplained reason.

In our clinical situation the weak signals may be subtle. A 1 or 2% drop in oxygen situations. A 5 mmHg drop in systolic blood pressure. The patient might be fidgeting and constantly fiddling with their nasal prongs where as previously the seemed settled, possibly indicating a subtle change in their level of consciousness. Over all not drastic changes, no single signal means much, but combined may signal something more sinister. Combined with safety imagination (remember these judgments are based on good evidence) weak signals like these should trigger further unease and prompt action to avert or plan for crises if possible. 

  • Worry

A tendency to worry about risk and safety.

Lets be clear. The workplace is no fun if everyone is worried all the time and in the extreme, worry can produce pathology. A tendency to worry is however the counter balance to complacency. 

Dr. Lauren Fruhen: Chronic Unease: A state of Mind for Managing Safety. Centre for Safety. The University of Western Australia

  • Experience

Whether you have been involved in an incident before. 

It is true clinicians can have thought biassed towards the frequency of past events. If a new  event presents similar to one encountered previously clinicians can be drawn to favour a clinical diagnosis based on the previous like case.

The same goes for crises. It is human nature to over react to a situation if a previous event like the one encountered didn't go well or had less favourable outcomes. Reflecting on previous crises and the lessons learnt can strengthen performance in the future. Experience of similar adverse events in the past gives the clinician a 'heads-up' to the present and might shape an accurate mental model of the situation that others may not share as they may not have read the signals of an unfolding crises.

At the same time, other members of the team may have experienced an adverse event more recently than the lead clinician and they have a 'heads-up'.  A flattened hierarchy is encouraged so team members, no matter their position in the hierarchy or profession are encouraged to speak up: "The last time I saw a patient like this he suffered a cardiac arrest" maybe all it takes for a team member to jolt a team out of complacency into a state of chronic unease.

  • Thinking

Ability to question assumptions and not jumping to conclusions.

Thinking is complex. Explaining thinking even more-so. If we accept the reality that human thinking can be flawed, that we will and do err with alarmingly frequency, then that mindfulness will serve us well when analysing thought through the lens of Chronic Unease.

Crises and high stakes situations rob us of the time required for slow powerful thought so there is a tendency to revert to rule-based thinking during a crises. Rightly or wrongly, this default thinking can expedite a solution (if the right rule is applied for the right situation). An individual with a habit of Chronic Unease accepts there are occasional failings in their own and the team's reasoning and the rules used to solve problems. They remain open to the possibility of other solutions and encourage input from others. Because they have accepted these human factors they use cognitive aids such as algorithms and check-lists to guide problem solving and formulating a management plan.

In our clinical case,  examples of where a state of Chronic Unease shapes behaviour might include accessing cardiac arrest algorithms and quickly reviewing the first few steps (just in case). It might include ignoring an underlying assumption that the ambulance will only be five minutes away because it always is. Continually questioning the clinical evidence you perceive matches your assumed clinical diagnosis and cross-checking your thinking with others. Seeking expert help early and constantly avoiding the temptation of jumping to the conclusion when the patient shows signs of improvement with a script like : "Everything Is O.K, everything will be O.K." is an attribute of Chronic Unease.


Chronic Unease is not a novel concept. It is used in many high stakes industries such as oil and gas and the aviation industry. 

Resuscitation Skills includes and supports the inclusion of instruction in effective teamwork and communication in the Advanced Resuscitation Courses on offer. Its inclusion in such courses is long over due.

Perhaps the attributes of Chronic Unease offers some solutions for a healthy approach to pre-crisis phase of medical emergencies. 

Very little, (if anything) is published on the attributes of Chronic Unease in medicine. It would be a fascinating investigation.

I welcome comments and thoughts. 

[email protected]



FREE-ONLINE Advanced life Support Quiz now available

Posted by Resuscitation Skills on October 14, 2016

Our new e-learning content to support our standard resuscitation courses is now available. All advanced support courses will have access to our pre-course learning package to prepare you for your best performance while on our courses. A free on-line quiz is available for all to try. Test your knowledge in advanced life support by taking our sample on-line quiz. Take as many attempts as you like. Take as long as you like. Go for 100%!

Coming soon

Soon we will be publishing a wide range on e-learning initiatives to support our standard courses and will be offering accredited stand alone courses in a wide range of topics relating to resuscitation and acute care. Book mark this page to follow this development!

Pre-course e-learning makes an impact on course quality

Posted by Resuscitation Skills on

Pre-Course Learning Makes Impact

Our online pre-course learning package was implemented over a month ago and our results to date prove this learning strategy is making an impact.

All course participants gain access to the package when they enroll on any of our advanced life support courses. The software sends as progress updates so we can see a participant's progress and their over all results.

Material includes:

  • Review of the basic life support guidelines
  • Review of Anaphylaxis management
  • ECG recognition
  • A 50 question assessment that provides instant results and prompts/ links to material for further learning needs if required

What we've noticed

  • Less need to discuss changes to basic life support means more hands on practice
  • Less need to review recognition of life threatening arrhythmia means more time in simulation
  • A great under standing of the management of anaphylaxis means improved management during simulation (including earlier administration of adrenaline, statement of stridor and more complex management such as inotropic support implemented)
  • An opportunity to immediately practice effective team leadership tools during simulation from knowledge gained prior to attending course


Here's some feedback from recent participants:

...pre-course online reading is very helpful.

Useful use of pre-course e-learning material, more hands on time.

...on-line ECG was great

The quiz was good- perhaps some recommended links relevant to particular questions maybe helpful

Pre-course material was very useful. It had precise information and easy to remember. ECG video easy to follow and remember.

The Future

We're adding more and more modules to our pre-course package. The vision is to dramatically increase hands on simulation time during our courses and enhance individual performance as well as develop team performance. Remember once participants are enrolled, access to the material is open and on going meaning participants can visit the package as often as the desire to refresh knowledge at any time.

Check out our Free sample packages




Team Resource Management: why team work matters

Posted by Resuscitation Skills on

Medical crises are in the main unexpected events that create a unique set of challenges to a health care team. There are  multiple physical tasks to complete and the mental demands for even experienced individuals can be over whelming. These demands include:

  • Extreme time pressures
  • Information over load
  • An uncertain clinical diagnosis and the effects of our treatment
  • Uncertainty about the skills and abilities of the resuscitation team
  • Challenge group dynamics as individuals react differently under duress
  • Team members deploy to a crises at different times and arrive at different times
  • Events that occur infrequently require seldom used skills and knowledge to problem solve commonly driving solutions that are "rule based" and these rules are seldom used creating cognitive challenges for a team leader 

Good team work is no accident. It is a co-operative effort of the team members to achieve a common goal. That goal in resuscitation is delivering good resuscitation practice to achieve the best possible clinical outcome for the individual patient involved.

Providing good team work is not as easy as it sounds and like any team (for example a sports team), developing individual technical skills forms only part of the picture. The team needs effective leadership, structure, communication patterns and an appreciation of how and when each required task should be performed to reach the end goal of a successful resuscitation.  The skills and behaviors to lead a team differs from those required to be an effective team player and while this presents a unique challenge to training teams it also presents an opportunity for all providers to have an appreciation of how their own behavior contributes to effective team work, to provide the best possible outcomes for the patient. 

While various skills and behaviors that contribute to effective team work can be disseminated and taught to individuals there can be little doubt that team performance is best improved when a team trains together.  Effective teams train together. They train together in the space they will need to perform with the equipment they have to use. 

Resuscitation Skills provides such training. We take a high fidelity patient simulator into your work space and rehearse a medical crises. Not only are technical skills such as using a defibrillator and performing CPR practiced but all the elements of developing good team leadership and effective team player skills and behaviors are coached, critiques and developed so your team is better prepared for such events.  

Check out this service by clicking on the picture below. Its surprisingly cost effective! 

Also, watch this space for the release of our specialized course Team Resource Management. A course specifically developed for Urgent Care doctors or any acute care provider to develop improved team leadership performance during a medical crises: Due for availability in early 2017.



[email protected]







NZRC CORE Courses - changes to resuscitation courses

Posted by Resuscitation Skills on

The NZRC conducted a review of CORE earlier this year and the result is a change to the resuscitation courses delivered by accredited NZRC instructors. Resuscitation Skills will start delivering the new courses as soon as they 'come on-line' from the NZRC. The courses have been simplified and new reading resources have been developed. Essentially the "level" system will disappear and two levels of resuscitation courses take their place as well as the option to attend a non-assessed modular skills programme.

  • CORE Immediate
  • CORE Advanced
  • CORE Skills

The NZRC has provided an implementation explanation of how each course meets the needs of the previous provider levels. Click the NZRC Icon below to read more...

2018 Course Dates

Posted by Resuscitation Skills on

Advanced Life Support Courses 2018

We've put together an exciting course calender for 2018 with more Advanced Life Support refresher courses, more NZRC CORE ADVANCED and IMMEDIATE courses and several dates for our new 2-day version of ACLS and PALS.

Look on our website under "Our Courses" to find out more!

Don't forget we have the ability to run courses on-site and tailor make on-site simulation sessions so your team can practice dealing with emergencies in your work space.

Later in 2018 we will be launching a new courses : Advanced Life Support in Remote Settings.

This course is specifically designed for clinicians operating in austere or remote settings and will focus on the challenges on providing Advanced Life Support with little resource supported by tele-medicine. This new and exciting course will be facilitated in a remote setting in New Zealand offering the opportunity to practice skills in a realistic remote settings.



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Very well run course, presenters well organised, professional and clear. Practical skill stations very helpful. Over all great courses.
Oral Surgeon Auckland
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