Education and experience are both important to making a well-rounded provider, and each of the two have distinct advantages. Perhaps the greatest advantage of experience is that it gives you the best ability to recognize situations you’d otherwise only know by description or by photograph.
Nowadays, though, with the Wonders of Modern Technology, we have some tools that can help bridge this gap. Experience is still essential — but there’s no reason that the first time you see a seizure or cyanosis should be in a situation with real stakes.
So let’s go through some of the common medical events and conditions we talk about, learn about, but may not truly know the presentation of until we encounter it.
Agonal respirations are an inadequate pattern of breathing associated with extreme physiological distress, particularly periarrest states (that is, it is usually seen just prior to cardiac arrest, as well as during and for some time after). Although not always seen during arrest, it is not uncommon, and there is some evidence that it may be associated with better outcomes than arrests without agonal breathing. Whatever the case, it can easily be confused for ordinary respiration, leading to the mistaken impression that the “breathing” patient must also have a pulse; this confusion is part of why the American Heart Association no longer recommends checking for breathing as part of layperson’s CPR.
As for healthcare providers, whether we’re able to put the label of “agonal” on it or not, we should be able to recognize from the rate and depth that this is not adequate respiration to sustain oxygenation, and ventilatory assistance (as well as a check of hemodynamic status) is in order. But recognizing the specific nature of this breathing can be a very useful red flag to set your “code” wheels in motion.
Here are a few simulated examples, performed by medical actors. They range in presentation and context.
Finally, here’s a treat — this is a video of a real-life cardiac arrest at a beach in Australia. Starting after the first shock, from 2:39 onward, you can see a great example of agonal breathing. The rest of the video is also a nice example of an honest code being worked in the field — not perfect, but real. (For bonus points, how could their CPR and other treatment have been improved?)
(Thanks to Dave Hiltz for inspiring today’s topic.)