The Day the Hard Collar Died – a tribute song

“The Day the Hard Collar Died” (A musical tribute parody)
(sung to music of “American Pie” by Don Mclean)

A long, long time ago
I can still remember how that hard collar used to make me smile
And I knew if I had my dance
That I would collar those people given half the chance
And maybe I’d be happy for a while

But February made me shiver
With every hard collar I’d deliver
Bad news on the doorstep
I couldn’t move my bloody neck

I can’t remember if I cried
When I read the latest ILCOR guide
But something touched me deep inside
The day the hard collar died

So bye, bye, This Hard Collar Lie
It never did any good so don’t ask me why
And them good ole boys were having a good cry
Singin’ this’ll be the day the Hard Collar dies
This’ll be the day that I die

[Verse 1]
Did you write the ATLS book of love
And do you have faith in God above
If the Trauma Bible tells you so?
Now do you believe that hard collars work?
Can they save your bloody pork?
And can you teach me how to resus real slow?

Well, I know that you’re in love with them
‘Cause I saw you practising in the sim
You both kicked off your shoes
Man, I dig those patients going blue, woooo

I was a lonely teenage broncin’ buck
With a pink hard collar in the ambo truck
But I knew I was out of luck
The day the Hard Collar died

I started singing bye, bye, This Hard collar Lie
It never did any good so don’t ask me why
Them good ole boys were having a good cry
Singin’ this’ll be the day the Hard Collar dies
This’ll be the day that I die

[Verse 2]
Now for 30 years we’ve been on our own
And moss grows fat on a rollin’ stone
But that’s not how it used to be
When ATLS sang for the king and queen
In a coat he borrowed from James Dean
And a voice that came from you and me

Oh, and while the king was looking down
ATLS stole his thorny crown
The courtroom was adjourned
No common sense ever returned

And while we read a book on dogma
ILCOR practiced in the park
And we sang dirges in the dark
The day the Hard Collar died

We were singing bye, bye, to This Hard Collar Lie
It never did any good so don’t ask me why
Them good ole boys were having a good cry
Singin’ this’ll be the day the Hard collar dies
This’ll be the day that I die

[Verse 3]
Helter skelter in a summer swelter
HEMS flew off to get some shelter
Eight miles high and falling fast
It landed safely on the grass
The rescuers tried for a forward pass
With the ATLS on the sidelines in a cast

Now the resus bay was sweet perfume
While the nurses played a trauma tune
We all got up to dance
Oh, but we never got the chance

‘Cause the ambos tried to take the field
The HEMS crew refused to yield
Do you recall what was revealed
The day the Hard Collar died?

We started singing bye, bye, to this Hard Collar Lie
It never did any good so don’t ask me why
Them good ole boys were having a good cry
And singin’ this’ll be the day that bloody collar dies
This’ll be the day that I die

[Verse 4]
Oh, and there we were all in one place
A Prehospital generation lost in space
With no time left to start again
So come on, lets  be nimble, lets be quick
Hard collars just make me sick
‘Cause they are the devil’s only friend

Oh, and as I watched hard collars take the stage
My hands were clenched in fists of rage
No Ambo born in Hell
Could break the Hard collars spell

And as the flames climbed high into the night
To light the sacrificial rite
I was laughing with delight
The day the Hard Collar died

I was singing bye, bye, to this Hard collar Lie
It never did any good so don’t ask me why
Them ATLS boys are having a good cry
And singin’ this’ll be the day the Hard collar will die
This’ll be the day that I die

I met a girl who sang the blues
And I asked her for some happy news
But she just smiled and turned away
I went down to the resus bay
Where I’d heard seen the hard collar years before
But the nurse there said no one wanted to play

And in the streets, the children screamed
The lovers cried and the poets dreamed
But not a word was spoken
The ambulance sirens were all broken

And the three men I admire most
The Father, Son and the Holy Ghost
They caught the chopper for the coast
The day the Hard Collar Died

And they were singing bye, bye, to this Hard collar white lie
It never did good so please don’t ask me why

And them good ATLS boys are having a cry

Singin’ this’ll be the day the Hard Collar dies
This’ll be the day that I die

They were singing bye, bye, my Hard collar lie
It never did good so why the hell why

Them good ole boys were drinking whiskey to cry

And singin’ this’ll be the day the Hard Collar dies


Filed under: c-spine, spinal-immobilisation, trauma Tagged: hard-collar, parody

An Essentials LA Short: Save the IV, Give it PO!

Zlatan Coralic (@ZEDPharm), our friendly neighborhood ED pharmacist, saves you time in fast track by sharing common ED drugs with similar PO and IV bioavailability, as well as onset of action. Save the IV, save some money, and save some time.

This segment was one of several practical lectures that we showcased this month in the first of three in-studio Essentials sessions, which are included when you sign up for any Essentials 2016 package. Get ready for our second livestream session on Thursday, January 14, 2016!

EEM_LA_2016_Blog_CommonMedicationErrors_ZC_111215 3

Report from the Section Council on Emergency Medicine: Highlights of the AMA Interim Meeting, Nov 2015, Atlanta, GA

515 of 540 Delegates sat for debate on the Monday opening of the House of Delegates (HOD). We were fresh off a Capitol Club luncheon starring a PBS anchor and Fox News reporter about the current state of Presidential Campaigning. Fascinating but impossible to predict seems the result as all known rules don’t seem to apply.

We typically have a 30-minute opening session of the HOD on Sunday morning. Instead, 90 minutes later the House recessed to reference committees after a lengthy exercise in parliamentary procedure referable to a new rule on “A motion to table” which is not debatable. The AMA recently changed its parliamentary resource from Sturgis to the American Institute of Parliamentarians Standard Code of Parliamentary Procedure. With the addition of this rule, it was used to prevent debate on a subject that the HOD did not seem to want to spend time discussing, namely issues related to Planned Parenthood. Arguments ensued about denial of opportunity for a minority to be heard. The House voted about 350 to 109 to table. Part of this plurality was due to the issue and part probably due to angst against the physician who brought the issue, having brought similar issues to the HOD repetitively in the past.

A special reference committee on the Modernized Code of Medical Ethics heard testimony on the latest Council on Ethical and Judicial Affairs (CEJA) effort to modernize the code.  The code was again referred back for further work based on numerous objections. An example is the Code does not allow a physician to participate in assisted suicide. However many states have laws that allow physicians to do so. California law apparently stipulates that the state law will trump the AMA Code of Ethics. But many states do not have this protection.

Unanimous testimony was offered in support of the medical student resolution to remove disincentives and study the use of incentives to increase the national organ donor pool. Misery and disability due to lack of organs is evidenced every day in our practices. The HOD voted first to support a study on use of incentives, including valuable consideration, second to eliminate disincentives and third to remove legal barriers to research investigating the use of incentives.

The HOD voted to support seeking over the counter approval from the FDA for Naloxone and to study ways to expand the access and use of naloxone to prevent opioid-related overdose deaths.

There were resolutions that touched on balance billing and network adequacy as it relates to emergency services. One was reaffirmed as previous AMA policy endorsing fair payment for emergency care. Another was adopted directing the AMA to advocate that health plans be required to document to regulators that they meet requisite standards of network adequacy, including for hospital-based physician specialties at in-network facilities and supporting that insurers pay out-of-network physicians fairly and equitably for emergency and out-of-network bills in a hospital.

There were again multiple resolutions regarding MOC which were referred to the Board for ongoing action reflecting the productive dialogue between ABMS and the AMA/Council on Medical Education. GME was again highlighted as an urgent need for action to expand GME positions to better match the expansion of medical school graduates.

Medical students proposed multiple resolutions regarding the need to address wellness throughout the medical education/practice environment.

As usual, several educational sessions were also held at the AMA. The AMA website summarizes several of those sessions, including:


Highlights of the opening session were two. First was a presentation by President Steve Stack to Cal Chaney, an executive recognition award for his outstanding contributions to the AMA and ACEP during his many years as staff of the Section Council on Emergency Medicine.  Second was of course an outstanding address by our AMA President, Steve Stack, a speech interrupted numerous times by thunderous applause.  The Board of Trustees members are uniformly complimentary and appreciative of Steve’s service on the Board and his performance as President.  We are justly proud of him and having an emergency physician as President of the AMA. You can see a synopsis of his speech and hear it at the following link:

ACEP and EMRA were also proud to host a reception for medical students attending the Interim Meeting to mingle and discuss careers in emergency medicine with the medical students. In addition to ACEP’s five delegates and five alternate delegates, the EM footprint in the HOD continues to grow and flourish. 21 emergency physicians serve as HOD delegates or alternate delegates for their state societies. Several others serve in key positions on various councils and sections.  Among those emergency physicians, other interested physicians, medical students and ACEP staff attending one or both of the Section Council on Emergency Medicine meetings were:

Nancy J. Auer, MD, FACEP

Mark Bair, MD

Michael D. Bishop, MD, FACEP

Brooks F. Bock, MD, FACEP

Michael L. Carius, MD, FACEP

Ted Christopher, MD

John Corker, MD

Shamie Das, MD, MPH, MBA

Taylor DesRosiers

Erick Eiting, MD

Stephen K. Epstein, MD, MPP, FACEP

Hilary Fairbrother, MD, MPH

Catherine Ferguson, MD

Gary Figge, MD

Diana Fite, MD, FACEP

Wayne Hardwick, MD

Marilyn Heine, MD, FACEP

David Hexter, MD, FACEP

Rebecca Hierholzer MD

Amy Ho, MD

Tiffany Jackson, MD

Jay Kaplan, MD, FACEP

Gary Katz, MD

Seth M. Kelly

Josh Lesko

Marc Mendelsohn, MD

John C. Moorhead, MD, MS, FACEP

Joshua B. Moskovitz, MD, MPH, FACEP

Richard Nelson, MD

Reid Orth, MD, PhD, MPH

Rebecca B Parker, MD, FACEP

Craig Price, CAE

Alexander M. Rosenau, DO, CPE, FACEP

Matthew Rudy, MD

Sarah Selby, DO

Michael J. Sexton, MD, FACEP

Steven Stack, MD, FACEP

Richard L. Stennes, MD, MBA, FACEP

Ellana Stinson, MD

Arlo Weltge, MD

Gordon Wheeler

Jennifer Wiler, MD, MBA, FACEP

Dean Wilkerson, JD, MBA, CAE

Joseph P. Wood, MD, JD, FACEP, FAAEM

Carlos Zapata, MD


CICM Second Part Exam Practice SAQs 25112015

Here are the practice questions from this week’s written exam practice at The Alfred ICU, with recommended reading from’s Critical Care Compendium:

Q1. (from the 2015.1 exam)

Regarding regional citrate anticoagulation for continuous renal replacement therapy (CRRT):

a) What is the mechanism by which citrate provides anticoagulation? (20%)

b) What is the metabolic fate of the citrate? (20%)

c) What are the features of citrate toxicity? (20%)

d) What conditions may increase the risk of citrate toxicity? (20%)

e) What alternative(s) to citrate could you use in a patient with severe HITS? (20%)

Learn more here:


Discuss the role of apnoeic oxygenation in the management of critically ill patients

Learn more here:


The image below shows an EZ-IO device:


a) List indications and contra-indications for intraosseous (IO) access (25%)

b) Describe how IO access is obtained using EZ-IO (25%)

c) List 5 complications of IO access (25%)

d) List 5 laboratory tests that are unreliable from IO samples (25%)

Learn more here:

You can access all the previous practice questions since 2014 here:
See this link on INTENSIVE for exam resources:

The post CICM Second Part Exam Practice SAQs 25112015 appeared first on INTENSIVE.

“Mission Critical” Patient Hand Off

Rom Duckworth is a Fire Captain and paramedic educator from the greater New York City area. A prehospital clinical practitioner, Rom has interest and expertise in human factors, especially mission critical communications.

Rom opened the session by describing mission-critical communications as any exchange of information whose disruption results in catastrophic failure of the mission at hand. He described how his experience in fire/rescue services lead to research in military, law enforcement, aviation, and other industries with an eye towards emergency and critical care medicine. Clinicians may not normally consider routine communications as “mission critical”, but that is because when they fail it is not as obvious as it is in other industries. “When mission-critical communications fail for firefighters, it becomes a headline. When mission-critical communications fail for healthcare, it becomes a statistic.”

In the United States, when the Joint Commission was searching for the root cause for hospital related sentinel events they found that 70% involved communications, with 50% occurring during patient care handoff, concluding “patient care handoff communications have been identified as a critical safety and quality problem.” 1 2 Worldwide the problem has not only been cited by every major healthcare organization, but even the Wall Street Journal in 2006 referred to patient handoff as “The Bermuda Triangle of Healthcare”. 3 Further investigation tied such communication failures directly to treatment delays, inappropriate treatment, omissions of care, increased length of stay, avoidable readmissions, increased treatment costs, and other minor and major inefficiencies and patient harm. 2 4 5

Duckworth says that the key is to focus on four aspects of patient information in order for all attending providers on the healthcare team to share a “mental model” or understanding of what’s going on, and what actions are immediately needed. These four components are, in order, the focused priority for the patient (what is the crux of the problem?), the history of prior care (what got us to this point?), the patient’s current state (where are we right now?), and the patient’s immediate needs (what is the very next thing that needs to happen?). 6

While healthcare providers tend to pay more attention to handoff during pre-alerts, poor handoff habits tend to get established during the regular transfer of low acuity patients. Research shows that ED staff members typically remember less than half of the information EMS crews give them, and that, in surveys, ambulance staff feel that physicians do not pay attention when EMS is handing off patients. 4,7

This is not so surprising when one considers that similar dynamics caused issues in mission-critical communications in other industries.8 Luckily, healthcare can just as easily turn to those industries for lessons learned and potential solutions. 9 10 In one example when Great Ormond Street Hospital turned to Ferrari’s Formula One racing pit stop crew to teach them how to better handoff patient care. As a result, technical errors dropped by 42% and information omissions decreased by nearly 50%.

The central idea is to not just avoid errors but rather to provide a hand off that allows receiving clinicians or teams to “pick up the ball” and continue forward progress, rather than having to start their assessment and treatment as if the patient just fell in from the sky. Rom’s own work has produced five general recommendations for clinicians to avoid failure and improve efficiency during handoff whether sending or receiving information. 11

For clinicians sending report the recommendations are:

Eye Contact: For clinicians handing over patient care, responsibility, and information, it is critical to begin by ensuring eye contact with the person to whom the patient is being transferred. Especially during team-to-team transfers and situations where receiving clinicians are multitasking this sends the message that “We are communicating now, you and I.”

Environment: Whenever possible minimize noise and interruptions by simply closing the door, pulling a curtain, or moving to a slightly quieter area to give report.

Ensure ABC’s: If there is a true “Focused Priority”, it should be immediately conveyed and performed by the receiving clinician or team. If at all possible, while another receiving clinician is identified to take the handoff report.

Structured Report: Numerous standardized report formats exist from MIST (and variations) to the most widely used, SBAR, originally developed by the US Navy Submarine service. Dozens of others exist with much evidence showing the use of any is better than the use of none, but little evidence supporting the use of one over another.

Supply Documentation: Separate verbal reports of the Priority, Past Hx, Current State, Immediate Needs with the many patient details that can be transferred on paper or electronic report. This helps clinicians avoid clouding their report with non-critical information.

For clinicians receiving report the recommendations are:

Eye Contact: With the same benefits, this can be initiated by reporter or receiver of patient care.

Environment: In many Emergency Departments in the US during “Alert” level team-to-team hand offs, the receiving clinician initiates a “moment of silence” so that all team members stop what they are doing and focus on the reporting EMS provider.

Ensure Understanding: Always ask questions if there is any possibility of misunderstanding.

Summarize: Not a regurgitation of the report that was just given, but rather a summary of the receiving clinician’s mental model, verbalized so that it can be error-corrected by the clinician giving report as well as anyone else on the receiving team.

Supplementary Documents: Again, this is not only a mention of the importance of the receipt of paper documents, but, where possible, details and patient monitoring located so that the entire receiving team can see the same information, contributing to that shared mental model.

To conclude his presentation Capt. Duckworth said that “handover of care is one of the most perilous procedures in medicine, and when carried out improperly can be a major contributory factor to subsequent error and harm to patients” according to the Medical Director of the UK National Patient Safety Agency. 12 However, when done properly patient handoff can also provide the opportunity for clinicians to gain a fresh perspective, foster critical thinking and a more collegial experience, and help improve patient satisfaction.


1.        The Joint Commission. Improving Hand-Off Communication. 1, (The Joint Commission, 2007).

2.        The Joint Commission. Handoff Communications. (Joint Commission Resources, 2008).

3.        Landro, L. Hospitals combat errors at the ‘Hand-Off’. (2006). at <>

4.        Hilligoss, B. & Cohen, M. D. in Biennial Review of Health Care Management 11, 91–132 (Emerald Group Publishing Limited, 2011).

5.        Dawson, S., King, L. & Grantham, H. Review article: Improving the hospital clinical handover between paramedics and emergency department staff in the deteriorating patient. Emergency Medicine Australasia 25, 393–405 (2013).

6.        Cheung, D. S. et al. Improving Handoffs in the Emergency Department. Annals of Emergency Medicine 55, 171–180 (2010).

7.        Talbot, R. & Bleetman, A. Retention of information by emergency department staff at ambulance handover: do standardised approaches work? Emergency Medicine Journal 24, 539–542 (2007).

8.        Coiera, E. W., Jayasuriya, R. A., Hardy, J., Bannan, A. & Thorpe, M. E. C. Communication loads on clinical staff in the emergency department. Med. J. Aust. 176, 415–418 (2002).

9.        FOJP Service Corporation. Handoff Communications: Heeding the Call to Change. in focus Journal for Health Care Practice and Risk Management 5, (2007).

10.     Weinger, M. B. et al. Improving actual handover behavior with a simulation-based training intervention. Proceedings of the Human Factors and Ergonomics Society Annual Meeting 54, 957–961 (2010).

11.     Duckworth, R. L. Rescue Digest. at <>

12.     British Medical Association. Safe Handover – Safe Patients. 1, (British Medical Association, 2006).