Courage Under FireDr John Vassiliadis MBBS FACEMSenior Staff Specialist Emergency Medicine, Royal North Shore HospitalDeputy Director, Simulation, Sydney Clinical Skills and Simulation CentreSenior Clinical Lecturer, Sydney Medical SchoolLCDR RANR

Road Map• Why are we not perfect and make the correct decisions

every time?

• Are checklists useful?

• Examples of checklists

• What makes a good checklist?

• RNSH airway registry and lessons learnt

• RNSH Airway checklist

• Take Home points and Call to Arms

Acknowledgements And Disclaimer

• Drs Toby Fogg and John Kennedy

• Views expressed are solely my own

• No financial interests to declare

Why do iatrogenic errors occur?

Assumption: “Do no harm”

1. Beyond our controlo We do not have the knowledge of how to diagnose or treat

2. Swiss Cheese Model1o Combination of organizational, supervision, unsafe act and the

precondition for unsafe acts

2. Under our controlo Training and experience issue – junior, inexperienced or ineptitudeo Human Factors

1. Reason, J. Human error: models and management. BMJ 320(7237): 768-770

Factors that make decision making in acritical care environment difficult?

• Us• Hungry, Angry, Late, Tired

o Patient factors• Limited history, emergent conditions, sick,

o Institution• Time pressures to move patients, number of staff,

supervision

o Number of decisions made in a shift

What/Who Can We Turn To?

Checklists can Help!!During CPRAirway adjuncts (LMA / ETT)OxygenWaveform capnographyIV / IO accessPlan actions before interrupting compressions

(e.g. charge manual defibrillator) Drugs

Shockable* Adrenaline 1 mg after 2nd shock

(then every 2nd loop)* Amiodarone 300 mg after 3rd shock

Non Shockable* Adrenaline 1 mg immediately

(then every 2nd loop)

Consider and CorrectHypoxiaHypovolaemiaHyper / hypokalaemia / metabolic disordersHypothermia / hyperthermiaTension pneumothoraxTamponadeToxinsThrombosis (pulmonary / coronary)

Post Resuscitation CareRe-evaluate ABCDE 12 lead ECGTreat precipitating causesRe-evaluate oxygenation and ventilationTemperature control (cool)

Advanced Life Support for Adults

December 2010

CPR for 2 minutes

CPR for 2 minutes

AssessRhythm

Start CPR30 compressions : 2 breaths

Minimise Interruptions

Start CPR30 compressions : 2 breaths

Minimise Interruptions

Attach Defibrillator / Monitor

Attach Defibrillator / Monitor

What Makes A GoodChecklist

• Clear, precise, simple, short

• Not meant to explain how to do a procedure, it ismemory aid, NOT a comprehensive HOW TOGUIDE

• Reminder of critical and important steps

• Should be a Read and Do

• Willing to update and improve

Weakness of Checklists• People must be willing to use them

• “Buy in” by teams

• You must have a defined time to use the checklist andthis must be clear to the team

• Defined person to initiate, “champions” or “zealots”

• Checklists will not solve every problem, so team mustbe flexible enough to stop an communicate and workthrough the problem

RNSH airway registry

www.airwayregistry.org.au

www.airwayregistry.org.au

What we learnt• 297 intubations in 18 months - equates to 4 per week

• 21% between 24:00 and 08:00

• 30% pt were traumas, commonest indication wasoverdose (15% of all pts)

• Average age 52

• Male : female ratio 1.7:1

• Only 3% of pts had an estimated wt. above 130kgs

www.airwayregistry.org.au

What we learnt• Specialists were team leaders in 70%

• Registrars/SRMOs had 89% of first looks

• Our first pass success rate was 81%

• Only 10 patients (3.3%) needed 3 or more attempts

• Difficult laryngoscopy (Cormack and Lehane III/IV)encountered in 23% patients on first attempt. Thiswas not associated with the intubator’s grade orairway experience, or the patients condition

www.airwayregistry.org.au

What we learnt• Those who have limited experience at laryngoscopy,

i.e. SRMOs who haven't done anesthetics, have only a58% first pass success rate. The data also shows that aprior experience of >10 intubations (a novice wasarbitrarily defined as <10 intubations) increases theodds of success on the first attempt by more than fourfold compared to a prior experience of <10 (OR:4.36; 95% CI: 1.81-10.52; P=0.001).

www.airwayregistry.org.au

What we learnto 30% of all 345 attempts were done naked: without the

aid of bougie or stylet

o Complications occurred in 28% of patients, with aparticularly high rate of desaturation (10%)

www.airwayregistry.org.au

ED!Intubation!Checklist!!

Version!1.3!Developed!by!T!Fogg,!J!Kennedy!and!J!Vassiliadis,!RNSH!ED!25/ 10/ 2012

Pat ient

o Pre-oxygenation optimal? o Add nasal prongs or NIV

o Patient position optimal?

o Patient haemodynamics optimal?

o Fluid bolus? o Pressor?

o Does it look like it might be difficult:

o Difficult BVM? o Difficult laryngoscopy? o Difficult supraglottic airway? o Difficult cricothyroidotomy?

IVI/Drugs o Fluids connected, runs easily? o Spare IVC? o Monitor: ECG, BP, SaO2. o RSI drugs drawn up, doses chosen? o Post-intubation anaesthesia plan -

drugs drawn up?

Equipment

o Suction working? o BVM with ETCO2 connected? o OPA and NPA available? o 2 x laryngoscopes working? Correct

blade size? o Tubes chosen, cuff tested o Bougie or stylet in tube? o Tube tie or tapes ready? o Ventilator circuit attached? o LMA sized & available? o Surgical airway equipment available?

Team

o In hours, ED Senior Dr aware of RSI?

o Out-of-hours, if difficulty anticipated, anaesthetics contacted?

o All members introduced by name & role and each briefed in turn by TL

o Difficult intubation plan briefed?

o Difficult airway trolley at hand?

o Anticipated problems – does anyone have questions or concerns?

Take Home Points• No one is perfect! We are all human!

• We work in a high pressured high stakes environment

• Checklists can help if used properly, review yourwork practices and challenge what you do!!!