Cardiopulmonary resuscitation is an intervention that every physician should apply when needed. But, some departments may be deficient in emergency intervention due to the low probability of encountering emergencies in working life [1-3]. The most important factor is early intervention in emergency conditions [4]. And the anxiety of the physician does not interfere with correct intervention. Also, while precise levels of stress and anxiety can increase the creativity and development of health care workers, when stress is intense, attention, concentration, and learning decrease with growing concern, mistakes are made in work done [5-6]. The resuscitation would be successful at certain level stress [7]. There are very few studies comparing the different branch of physicians in resuscitation.

In this study, we aimed to compare and evaluate the knowledge, skills, and concerns of physicians in various departments about resuscitation with a wide participation.

This survey study was conducted with the approval of the Ethics Committee of the Education and Research Hospital of Health Sciences University, Konya, 48929119/774, on physicians who were different departments between 1 April 2019 and 1 November 2019. With permission from the authors, we created a survey on a web-based (appendix). The questionnaire developed based on the 2015 ERC (European Resuscitation Council) guidelines prepared by ILCOR (The International Liaison Committee on Resuscitation) recommendations [8]. 

The survey has included 14 questions, and the answers to questions have been either presented in an appendix. Respondents had to answer all questions for the survey to be validated. The study was available online, and a total of three reminders have been sent. Potential respondents were physicians working in hospitals affiliated with the Turkey national health system. The questionnaire has been prepared by using the Google forms program, has been sent to physicians working in clinics. Potential participants have been contacted through an e-mail that included a brief introductory note, instructions, a link to the survey, and the authors' contact information. Participation was voluntary and anonymous. The National physicians' Societies have sent the connection with the study through their mailing database to active members and maintained its availability on their official website throughout the seven months. Participants have been asked to respond to a web-based questionnaire, and feedback has been received from 343 participants. 

Statistic

The IBM SPSS Statistics for Windows 10, version 22.0 (IBM Corp., Armonk, N.Y., USA) has been used to perform the statistical data analysis. Demographic data and results for the multiple-choice questions have been presented as frequency and percentage. Responses for the questions have been given as frequency and rate calculated. Mann-Whitney U test was used for ordinal variables. It was conducted to compare the results between the departments of physicians. Results were shown in mean± Standard Deviation (S.D.), and two-sided statistical significance was set at 0.05.

We analyzed 343 surveys. There were statistically significant differences between the participants in their ages, gender, and experiences (p<0.001, p<0.001 and p<0.001). The overall survey results are detailed demographic data, experiences, and the current position was presented in Table 1. 

When physicians were asked for "Do you think you have enough knowledge about airway management, and about CPR?" most of the physicians thought that they had an average knowledge about airline management, and about CPR (36.7% (n = 126) and 38.2% (n = 131)) in Table 2. There were statistically significant differences between the participants in the answers to question 5 and question 6 (p<0.001 and p<0.001). 62.5% of anesthesiologists said that they were quite adequate for airway control, while 100% of biochemists said that they knew airway control but not enough. And 62.5% of anesthesiologists noted that they were quite qualified for CPR, while 100% of pathologists said that they had CPR knowledge, but not enough.

When were physicians asked for "Have you received any training in airline management, CPR, intubation, defibrillator device, and its use?” Most of the physicians thought that they received both theoretical and practical training about airline management, CPR, intubation, defibrillator device and its use (63.5% (n = 218), 63.7% (n = 219), 59.5% (n = 205), and 46.5% (n = 160)) in Table 3. There were statistically significant differences between the participants in the answers to question 7, 8, 10, and question 14 (p<0.001, p<0.001, p<0.001, and p<0.001). 79.2% of anesthesiologists said that they received both theoretical and practical training about airline management (question 7). 50 % of ophthalmologists said they had not received training about airline management. But the highest rate of response (the answer to "I received both theoretical and practical training about airline management") was for pediatricians (88.9%). 79.2% of anesthesiologists said that they received both theoretical and practical training about CPR (question 8), while 100% of biochemists and pathologists said they had not received training about CPR. But the highest rate of response (the answer to "I received both theoretical and practical training about CPR") was for general surgeons (88.2%). 

The other was question 10. About this question, 75% of anesthesiologists said that they received both theoretical and practical training about intubation, while 100% of biochemists told that they had not received training about intubation. But the highest rate of response (the answer to "I acquired both theoretical and practical training about intubation") was for brain and nerve surgeons (%100). 58.3% of anesthesiologists said that they received both theoretical and practical training about the defibrillator device (question 14). 100% of pathologists told that they had not received training about the defibrillator device and its use. But the highest rate of response (the answer to "I received both theoretical and practical training about intubation") was for emergency medicine and internal medicine (%100). 

The physicians were asked that "Do you have any information about the CPR guidelines published by ILCOR (World Resuscitation Committee) in 2015?" most of the physicians thought that they had no information about the CPR guidelines (61.8% (n = 212)). Question 12 was, "Have you used an oral airway before?" And most of the physicians thought that they used an airway before (78.4% (n = 269)). Question 13 was, "Did you breathe the patient with a bag-mask before?" And most of the physicians thought that they breathed the patient with a bag-mask before (84.5% (n = 290)) in Table 4. There were statistically significant differences between the participants in the answers to question 9, 12, and question 13 (p<0.001, p<0.001, and p<0.001).

About question 9, 54.2% of anesthesiologists said that they had some information about the CPR guidelines. All of the dermatology, ophthalmology, psychiatry, biochemistry, and pathology physicians noticed that they had no information about the CPR guidelines. But the highest rate of responses (the answer to "I have some information about the CPR guidelines") was for internal medicine (57.1%). In question 12, 100% of anesthesiologists said that they used an airway before, while 100% of pathologists said they didn't use an airway before. And about question 13, 100% of anesthesiologists told that they breathed the patient with a bag-mask before, while 100% of biochemists and pathologists said they didn't breathe the patient with a bag-mask before.

When physicians were asked for "In case of respiratory or cardiac arrest, do you have fear and anxiety when you need to intubate immediately?". Most of the physicians thought that they had no fear and anxiety (21.9% (n = 75), but the rates of the answer" I have a lot of fear and anxiety" were very similar (18.7% (n = 64) in Table 5. There was a statistically significant difference between the participants in the answers to question 11 (p<0.001). About the question 11, 20.8% of anesthesiologists said that they had no fear and anxiety, while 100% of infectious disease physicians and pathologists noted that they had a lot of fear and anxiety about respiratory or cardiac arrest situations. But the highest rate of responses (the answer to "I have no fear and anxiety") were for emergency medicine physicians (57.1%).

Our study results demonstrate the awareness of cardiopulmonary resuscitation knowledge among the physicians. Our first assessment was about having enough knowledge about airway management and CPR. 

In a recent study, 41 medical students completed their first year of study to measure their level of knowledge about CPR. These students were trained for three months and six months, and then the exam was conducted. It was emphasized that long-term education is essential in acquiring CPR skills [8].

In another study by Heitmiller et al. [9] a questionnaire was administered to pediatric anesthetists for seven months. As a result, the knowledge level of the participants participating in AHA's CPR programs at regular intervals was found to be more successful. 

In our study, for questions 5 and 6, 62.5% of the anesthetists stated that they had sufficient knowledge about CPR and airway management with the highest rate. On the other hand, for biochemistry and pathology, 100% of physicians stated that they did not have enough knowledge about CPR and airway.

The other questioned (question 7,8,10, and 14) was that "Have you received any training in airline management, CPR, intubation, defibrillator device, and its use?" In the study of Hasegawa et al. [10] Health workers in 10 health centers in Japan were studied, and it was recorded that up to 90% success in intubation success was achieved as a result of airway training that was taken intermittently and lasted for one year.

One review of CPR-related knowledge level studies looked at 336 articles. In the studies carried out in health professionals, employees who have been trained up to 2 years were observed. As a result of all these studies, it was concluded that CPR knowledge and skills need more extended and modernized training to be permanent [11].

In the study conducted by Semeraro and his friends in Italy, 47 anesthetists were included in the study. The results of the participants who took the ERC course were compared six months after the pre-training. As a result, it was observed that periodical training increase CPR knowledge and skills [12].

Another evaluation was related to defibrillation training. Ahmed, Safa Mahmoud, and colleagues studied that 50 nurses before and after the defibrillator training performed with the test partner. And there was noticeable progress. At the end of the program, there was a 3-fold increase in the knowledge and skills of nurses [13].

The positive contributions of education received in the light of all these studies to health knowledge and skills were clear. In this sense, in our research, when the rates were examined, it was stated that pediatricians and general surgeons received both theoretical and practical training more than airway management and intubation. In defibrillation, brain surgeons indicated that they received the highest level of training. We think that the reason for this surprising decrease in anesthesiologists is the fact that they did not consider periodic training. Also, the lowest rate was in the departments that were less likely to face such conditions, such as biochemists, pathologists, and ophthalmologists.

Another striking question (question 9) was whether they had information about CPR guidelines. In a study of CPR guidelines, 120 cardiologists were included in the study. The theoretical knowledge of cardiologists and ERC 2015 guidelines were compared, and it was concluded that the ERC guidelines had more effective information capacity [14]. When the answers in our study were examined, it was seen that anesthesiologists, family physicians, and internal medicine physicians had similar information about the guidelines. The departments which did not know the guidelines were dermatology, ophthalmology, psychiatry, biochemistry, and pathology.

In question 12 and 13, they were asked whether they used airway and bag masks. In a multicenter study of 401 patients, the importance of the use of a bag-mask was investigated mainly in critically ill patients. In conclusion, it was concluded that the use of bag masks is as critical as intubation to prevent hypoxia in these patients [15]. In our study, while all anesthesiologists answered yes to the question of whether they used oral airway and bag-mask, pathologists and biochemists stated that they never used it.

One of the most important questions was whether they have fear or anxiety in the event of any cardiac or respiratory arrest. In a letter examining the fear and anxiety of cardiac and respiratory arrest in health care workers, it was stated that this was caused by fear of harm to patients. As a solution, it was emphasized that the frequency of training based on guidelines should be increased [16]. When we look at the results of our study on fear and anxiety in cardiac and respiratory conditions, the highest anxiety and fear belong to infectious diseases and pathology doctors. However, the least fear and anxiety belongs to emergency specialists. At this rate, we think that it is normal for emergency physicians to be the most confronted department.

When we look at similar studies in the literature, it was observed that CPR success evaluations were performed among the different departments [17]. As a professional group, nurses were separated according to their work in different wards, and CPR knowledge level measurement studies were conducted [18]. In this sense, we did not come across a study in the literature, such as our study, in which a large number and type of physicians participated. At the same time, anxiety and level of knowledge were evaluated together.

When we look at the limitations of our study, it would be more standard to have the doctors working in these different departments in advance to have a more effective evaluation and to make this evaluation with specified time intervals. However, this time, it would be not very easy to determine the level of knowledge that existed.

As a result, new studies are needed by expanding our working group. In our study, we think that especially anesthesiologists may be critical in determining where they are in this evaluation. We believe that this kind of work will open the way for a consultation with our colleagues on the issues they are experienced.

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