Slightly Shitty Superpowers…What’s yours?

I was in the middle of a reasonably-under-control shift the other day and suddenly was struck with a feeling that fans of Monty Python will recognise as “wanting to be…A Lumberjack!“

Except that wasn’t quite all there was. Or rather, the feeling I was experiencing was that despite my work performance, the only person able to appreciate the day I was having was me.

We don’t build, or repair, or leave a mark on society. We work with colleagues as a team, but despite that, once our particular shift had gone off, the next shift would have no knowledge of our experiences and challenges. Jokes and anecdotes might filter through handover, but nothing of the details.

Of course, this is how it should be. The purpose of handover is to put the patient first, to ensure safety and continuity of care.

But then a fellow nurse asked me to help her with a patient needing a nasogastric tube. It had been inserted by the ENT fellow and needed replacing.

I have rather an extensive history of placing these. I’m pretty good at them. I called the ENT fellow, who told me of the challenges of placing an NG on this particular patient and wished me well. Call me again if you can’t do it, he said, half-joking.

Now, I’m not perfect and I did not place it the first time. The tube went into the patient’s larynx, curled beautifully at the carina and came back up the bronchus.

But the second time was perfect. I realised this was what I was missing in my day – I hadn’t appreciated my Slightly Shitty Superpower!

We all know how to perform the technical aspects of our roles as nurses. But we know, secretly, we are incrementally better at some roles or procedures than we are others. We might even be slightly better than our peers at a particular “thing” – and here’s the rub – WE ALL HAVE A “THING” – a Slightly Shitty Superpower.

It might be containing faeces in a pad on cleaning an incontinent patient. Or changing bed linen in record time. Maybe you can always hit that vein? Is ABG interpretation your thing? What one thing would you show off or smile to yourself about when you’ve done it well, reliably, every time?

We need to relish and delight in Slightly Shitty Superpowers when we find them. We need to share them with our colleagues, to pass on the tips, the methods and the tricks, and to have just one more “thing” we can appreciate about the uniqueness that we bring to every shift.

What Is The Most Medically Accurate TV Show?

I always nominate a two shows: MASH from the operating theatre perspective and Scrubs for the best overall realism (yes, realism!) in Intensive Care.

I have been a nurse for 14 years now in Theatre and Intensive Care. I don’t watch many medical shows as I get paid for that kind of thing, you just want to leave work at work (people never get this bit – have I seen this show or that show – probably not).

I knew of a doctor who worked on a locally produced medical drama. They’d ask him to nominate a particular procedure/condition that would fit with the story line. Then he’d stand by and watch as the producers/scriptwriters would change fundamental aspects of his input for dramatic effect. It’s hard to respect that kind of TV show, and when you see those kind of changes it’s kind of hard to keep watching.

A big example of this (without giving everyone an education into two specialist areas of healthcare) is when a patient on a TV show is INVOLVED in the drama – you get the patients fears, thoughts, love and wise words for the forlorn or over involved staff member. Some of the ways TV staff get involved can actually be illegal or unethical and subject to sanction by professional or licensing authorities. Great way to lose your job (and ruins your plots for future episodes!)

In the big metropolitan ICU I work, we rarely get to speak to our patients – not a ‘conversation’ anyway ( because of airway tubes and ventilators), and except for our long term tracheostomy patients, it is rarer still to get to know them. We communicate with our trachy patients by lip reading (it takes practice) and charades (most are too weak to write clearly). You can get to know people but we try to keep them socialised not institutionalised – we want them to go back to their lives. TV seems to be the other way round. As it is, most of our our long termers need to be reassured that the rest of the hospital knows what they’re doing – they get quite dependant on the feeling of safety from 1 on 1 nursing. It can be harder still to reassure the relatives!

We do experience our patients through their family and friends. Given it’s often a life threatening experience for our patients, it’s rare to hear anything bad about anyone. I’m realistic and know I’ve looked after some ratbags (or scum and villainy- to quote the wise man.)

We get prisoners with prison guard escorts (and the occasional escape) but most of us never want to know what a prisoner patient has done (I tell myself it’s fraud – if the guards are armed then it’s tax fraud), so we don’t ask. Our professional requirements don’t allow us to judge our patients or change our care, so it’s easier not to know.

Family members pick a number on a monitor and focus on that, and some go and talk to Doctor Google and think they have the answers. Others point all information to a nurse friend or family member who (as an insider into healthcare) just wants to be a friend or family member. Lots of friends and family refer to TV shows as a touchstone “I saw this in House/on ER/Chicago Hope/etc” and then refuse to see the uniqueness of their own situation – “it’ll go how it went in that neat hour long episode and we’ll all learn something”.

All of this can provide drama enough. I had to leave for six months and get counselling related to my experiences in my current job (I’m back now). I’ve known nurses to leave the profession for similar experiences. I can’t talk about them to my colleagues (who all understand anyway).

Unfortunately, it’s hard to translate that into a TV drama. People want details, but don’t need those kind of details. So that doesn’t make for good TV.

There is a succinct example of why it’s MASH and Scrubs that get all the of the everyday workplace experiences right. I’ve never yelled at the TV when those shows are on. I can watch them over and over and tellingly, I still cry at the episodes that remind me of my own experiences – the everyday cycle of life and death they show, and the staff using all the skills they have to do a job that is just not in most people’s idea of normal experience. Especially if they get their ideas from any other medical show I’ve ever seen.

This post originally appeared on Quora.

What advice Would I give an RN Student Whose Final Practicum Was In ICU?

Three things:

Remember you aren’t there to learn how to be an ICU Nurse. If you like the environment and choose to apply for ICU when you are a Registered nurse then education starts from the beginning. Take the pressure off as a student in ICU. It’s stressful enough…
Learn as much about the pathophysiology of the patient as you can. This will help you in working out what is actually going on, goals of care, and how well the patient is responding. This will draw on ALL the knowledge you have ever covered at university.
Practice assessment skills. Look, listen, feel. Become confident in listening to your patient’s chest sounds, feeling all pulses, looking at colours, pupils, etc. You can take your newfound confidence in your skills into any clinical area.

Enjoy!

This post originally appeared on Quora.

Sometimes the “Critical” in Critical Care is Actually Pretty Basic

I’ve never been a ward nurse. Theatre, then ICU. Lots of nursing roles within those areas, but never ward nursing.

One of my favourite nursing roles is the Outreach Nurse. The Outreach nurse is a member of the Rapid Response Team (in our hospital we have RRT’s instead of MERTs or Code Blue – the idea is the same but the focus is on early intervention not rescue and recovery). The usual duties involve going out of ICU into the hospital and working on a referral/followup basis, reviewing patients and contacting (or chasing up) relevant medical teams. Most importantly, we provide clinical support for nurses using advanced assessment skills and education.

Some nurses I meet have the perception that I’m there to check their work (I’m not) or to devise some previously unknown care strategy based on things that we do in ICU. Mostly the role involves two way learning, I teach the ward nurse something that they might not know and I learn from them. Occasionally I get to give ‘permission’ for the ward nurse to do what they think they should do, in situations where they normally wouldn’t – showers at 2am, bed moves at 3am, making difficult telephone calls to family, reminding care teams of appropriate palliation etc.

And increasingly, I’ve been bringing the ward nursing back to ICU.

We had a long term patient, I’ll call Bob (my go-to anonymous name). We really didn’t expect Bob to survive his admission. A long list of complications from surgery resulted in dialysis (the continuous and gentle ICU version, not the large volume suck that is the dialysis of the renal patient). He had very large dressings, poor skin integrity and malaena. The dressings and malaena resulted in further skin breakdown, blood transfusions, and eventually endoscopies for ischaemic ulceraton of Bob’s bowel.

Bob had a few big days. He would have a large GI bleed, dropping his haemoglobin about 30 points, and there would be a large amount of malaena in the bed. He’d required intubation and ventilation for an endoscopy, then extubation overnight. This had happened a few times. It was never clear if he could be successfully extubated after each of these events. It certainly looked like there was less of him left in the bed each time.

Bob’s nurse noticed she had an opportunity between everything else going on to cease his dialysis for a bit and get him out to the verandah. (We have a balcony with a view, power, oxygen and suction). I was her ACCESS nurse. I knew it would be difficult to organise, but we felt it would be worth it for him to see the outside for maybe the last time.

We disconnected his dialysis machine and set it to recirculate (like hitting pause). Recirculation either goes well or it doesn’t. This one was ok for about 10 minutes, then the machine started alarming and after another five minutes we were going to have to replace the circuit.

Oh well. The dialysis was now coming off anyway. We were committed.

We moved the required support equipment out to the verandah, moved Bob in his bed out there and after two fun-filled hours with family he returned to the bedspace.

His nurse ran an ABG on his return indoors. He’d dropped another 30 points on his haemoglobin. And he had more malaena.

Another endoscopy. Another intubation.

I fetched the FFP, the platelets and the packed cells. His nurse gathered the items required for the cleanup. His family, who were still present, were obviously disappointed. They had just spent two hours with Bob and could see the cost on his health.

We paged for the ICU wardies. Our own wardies do regular turn rounds, and are available between times but have other jobs to do outside the rounds. They are very much part of our team, and we are lucky to have them.

Two wardies arrived, and the look of horror at the smell of the malaena was telling. These two had enough experience to recognise the odour, and also what it meant for Bob.

We discussed with Bob and his family what we wanted to get done (namely, a big clean up, gown and sheet change) and then we asked them to step out, promising we would be as quick as we could.

Three minutes later, we asked them back in, we had finished. Quickest everything change I ever saw.

On the way out, one of our wardies asked me if there was much hope for Bob. I replied that I did not think so and that assisting in the clean-up of the malaena was probably the most important thing either of us had done that day. He asked if I was serious and that no-one had ever told him his job was that important before.

After the blood and blood products were administered, and the GI people were ready to go, we again ushered Bob’s family outside and, once again, intubated him with no real idea as to how long he would remain intubated.

Intubation is usually done by the senior registrar, or, if elective and predictable, by the junior registrar as a learning activity.

In Bob’s case, he had been intubated so frequently that most of the senior registrars had at one time or another had a turn.

So I was a little taken aback when the consultant declared there would be no learning (medical or nursing), she and I would intubate Bob, on our own, with his bedside nurse the only other person in the room. This one, she said, would be simple, smooth, and efficient. We would do it this way for Bob’s peace of mind.

Bob got his endoscopy. He also got successfully extubated. He very slowly got better, and out of ICU.

He spent a further 3 months on the ward, and has since gone home to his property a long way from the hospital.

Before he left, he told one of the ward nurses that although he was frequently over the whole admission, he knew he would get better the day of his last endoscopy in ICU. He saw the outside world, and he saw the determined calm effort the staff put in to help put him at ease. And he decided that if we were going to put the effort in, he must be worth it, and he would try as well.

Our attitude didn’t really fix Bob or get him home sooner. But keeping the dignity and humanity of the patient in mind is one of the most fundamental aspects of nursing. I’ve seen it in many different circumstances, but most commonly on wards where there are no machines that nurses can rely on to help instill confidence in the patient.

I think we really got it right that day. And I have the ward nurses I meet as ICU Outreach to thank for it.

Every Day is R U OK? Day…

Gavin Larkin was an advertising “creative” whose father, Barry, committed suicide nearly 20 years ago. He found himself trying to stop the pain of grief his family endured, and decided to do this by asking one question – “Are you OK?”.

In 2009, he established the R U OK? foundation to enable everyone, in all levels of society, to encourage and ask “Are you OK?”

Based on the work of Dr Thomas Joiner, who describes at risk people as having three dominant forces – a feeling of being a burden on others, a belief they can withstand a high degree of pain, and a disconnect from others.

Gavin used his advertising and marketing skills to establish R U OK? Day, an annual day give society permission to ask. He sadly passed away in 2011.
Sometimes we need reminding that health care workers are no different from the rest of society, and that in healthcare, Every Day is R U OK? Day…

Healthcare is hard

So here’s the thing. This is personal. Apart from many useful links, this post is almost entirely anecdotal. And my chest is a bit tight contemplating writing it – so I know it won’t be easy.

I work in a really supportive workplace, which is surprising for the number of staff. In fact, the whole hospital is like that. Nodding acquaintances, people you don’t know, but who you know you’ve seen and will undoubtably see again. You nod hello in the corridor or elevator.

Occasionally, we hear of a colleague from another department who has taken their own life. Usually it is someone you don’t know, like the nodding acquaintance, but someone you do know is connected to them in some way. We wonder what happened, how we could have helped…

In my workplace, we have a loose collection of nurses who take on the role of “Peer Supporter” (I am one – the little sticker on my ID badge identifying me as such is one of the qualification badges I am most proud of). We choose ourselves, or are identified as “the right kind of person” and asked to think about taking the role.

The right kind of person to be a peer supporter is approachable and discreet (when it counts) and has undertaken a short course covering how to encourage someone to obtain help, where to direct someone to help, self-care, and limits of expectations (you can’t save everyone yourself, don’t try).

As stated in the picture above, healthcare is hard. It asks a lot from us. We see things, we do things, we know things. We can’t un-know. And we cope. We have humour. We all know the jokes about going to dinner with a group of nurses (we are apparently the worst at this but I suspect there’s a bit going on in the other professions) and the conversation quickly turns to work. We sometimes find ourselves describing things at the dinner table in company with civilians and everyone goes silent at something we’ve said.

We normalise the abnormal, the difficult and the things that are unknown to everyone else.

Some of us found our way into the industry by accident, we didn’t know what else to do with ourselves, via a calling, family expectations, as many reasons as there are practitioners. But whatever the reason, we know if we wanted easy we would have done something else.

We feel we can deal with what our jobs ask of us. Any pain we experience isn’t the same as our patients’ pain, they’re the injured, the ill, we can give them medications, analgesic modalities from pills to subcut or IV boluses, to PCA’s to epidurals or local anaesthetic infusions, dissociative medications, we can use distractive therapies with them, validate their feelings, ventilate their emotions…

We can have a high degree of pain tolerance. But we might not be equipped to know we even have pain. Ours might not be physical pain but psychic pain. The pain of seeing the same physical pain every day. The pain of coping with what we do.

Then to complicate things, we have the disconnect from others. This can be can be any kind of disconnect. The obvious disconnect in healthcare is the shift work. We work different hours. We work with different people, each of us having our own schedule across the week.

The disconnect can be as a result of the knowledge that we are aware of things about life that others don’t know, and don’t really want to know, despite their curiosity at dinner parties.

Pain and the disconnect can be in any area of our lives and from any area of our lives. Look again at Dr Joiner’s risk factors for suicide. Pain and the disconnect. If we include a feeling of being a burden on others – I don’t want to bother my spouse, my family, my friends, my colleagues…my patient is the one with the problem, I’ll just carry on…

This is personal.

I was that person. I had a run of several difficult situations involving a particular type of patient at work. I had a very high tolerance for pain – I was as capable and as professional as I have ever been in my career. I was working my ICU job, I was working agency in anaesthetics, and I was working in tourism to relax.

Then, one day while completing my bed area checks in my role as an ACCESS nurse, a colleague asked me a surprising question.

“How are things? Are you OK?”

I surprised myself by telling her that I wasn’t. I really was not OK. I was in danger of becoming the one everyone wondered about. I had a plan, I had most of what I needed, I was consciously avoiding certain patients, I was socially isolated due to family dynamics, I was grieving for a family member who had died almost exactly a year earlier (and who was responsible for propelling me into nursing in the first place).

My colleague referred me to one of our Peer Supporters. I saw a work provided psychologist that afternoon. I took three weeks leave, I had six months away from my workplace, but was supported in another role in a different area on reduced hours.

I took up educating (one door closes, another opens). I worked university terms looking after students, and worked clinically back in my chosen area around the university year. When I went back to Intensive Care I undertook a performance appraisal from one of the ICU educators (at my own request) to help me with my confidence. I worked hard to get back to where I was, and I knew I was supported. I’m still trying to get that balance.

But I learned something…

After working 8 years as a theatre nurse, I knew my emotional resilience was good.

After working 4 years in ICU on top of that I knew my emotional resilience was very good.

After having looked after a disabled family member since I was 13 years old (the year I learned how to place NG tubes), with a hospital in the home situation (we had an oxygen concentrator, pulse oximeter, and suction, and my sister would occasionally require IV drug administration via a hickman catheter) I knew my emotional capacity was as good as anyone I worked with.

And still I needed help…

You never know. Until you ask.

R U OK?

If this blog has highlighted issues for you or someone you know please do not hesitate to obtain help. Or call Lifeline 13 11 14.

Do you or a loved one need help? Find help now.
R U OK? is a not-for-profit organisation dedicated to encouraging and empowering all people to ask “are you ok?” of anyone struggling with life. Our vision is a world where everyone is connected and is protected from suicide. This year, R U OK?Day is Thursday 11th September.
Find out more: ruokday.com

Nursing Student 101: What Am I Supposed to Learn Here?

A Nursing Student on Reddit recently asked the r/nursing sub reddit for advice on how to manage an ICU placement as a third year student. They were understandably scared, and uncertain as to what they could achieve that would be useful for them in their future career.

I have helped guide nursing students through placements throughout a large, tertiary referral hospital in the role of Clinical Facilitator. Most of these wards have some kind of specialisation (ie, not a “surgical ward” but an “organ-system surgical ward”). Even our rehabilitation units are specialised.

This was the perspective I tried to give the nursing student on the ICU prac, but it could be helpful for anyone undertaking a specialist placement and who is finding it challenging to see the point…

You need to take these concerns to your facilitator/preceptor for context specific advice on what you should do regarding your fears for this placement. With so many different nursing systems and cultures on r/nursing it will be hard for answerers to assist you in a meaningful way.

On the other hand, as an undergraduate nursing student remember you aren’t there to learn How To Be An ICU Nurse 101. (This is the first point I started my undergraduate students in ICU on every time. Gives permission for a big relaxing breath).

You say the nurses are used to having students – they really aren’t expecting you to be an ICU nurse at the end either. Maybe to have an interest and want to come back, but that’s about it.

‘So what am I there for?’

To learn to be a NURSE. And in ICU you have a unique and peerless opportunity to take advantage of.

‘Why?’

Let’s start with What Does the ICU do…

It looks after really sick people. Medications, ventilators etc. the scary stuff.

From a healthcare system viewpoint it does a few things.

It supports them through critical illness and multiple organ failure or serious injury. It generally doesn’t admit patients on its own – all the patients will be under a treating team. (Usually the speciality of the patient’s primary issue: this might not be the same on discharge from ICU as it was at admission).

It also acts as a safety net for the whole hospital.

The ICU primarily coordinates care between the specialities that need to communicate and work together for the benefit of the patient. That means the ICU staff (nursing and medical) have to know at least a bit about EVERYTHING.

Aside from admitting to other higher level ICU’s it doesn’t generally have it’s own safety net.

All this make it the perfect place to see/hear/experience all the patients you could hope for as a student.

‘So how do I make the most of this opportunity then? I don’t know even a bit about everything?‘

Easy. Ask yourself what you CAN learn that you can use WHEREVER you end up. If you don’t yet really know where that is (even if you liked medical ward nursing, that’s no guarantee of a career there) then look globally.

Despite the monitoring, observations don’t record themselves. What happens if the power goes out? Practice taking all the BPs, pulses (ALL the pulses), looking at pupils, describing colours, warm or cool, and listen to chests.

‘All the pulses?’

ALL the pulses. And ALL the chests. Find out as much as you can. Listen before a suction. Listen after a suction. Listen before and after Physio. Listen before and after turns. Listen to bowel sounds, and maybe listen to heart sounds. Get a library of remembered sounds going. Look at wounds. Do dressings. Take ECG’s. Ask for help.

Ask for descriptors.

Make descriptors up yourself. Practice writing them in notes.

Get comfortable with how to do a manual blood pressure (yes, even in ICU). Not simply a non-invasive BP, but one where you listen. Learn why the automatic BP cuffs are a silly waste of money (and why at 3am the doctor wants you to do a manual one before they get out of bed to see your patient). And when you get the stethoscope out for the BP, Listen to the patients chest again.

‘Er, I did obs in first year…?’

Ask your buddy nurse to relate all that to the disease or injuries of the patient. Then when you get the idea, practice relating all the obs to the buddy nurse. Anyone can take obs. It’s knowing what they mean that’s the hard part.

‘And then?’

Do the same thing with medications, even the IV. Doesn’t matter if you can’t give them. You’ll have to know them. Most of the ones in ICU are used in medical wards anyways. (Ok, there are obvious exceptions to that). But this will help your future practice by increasing your knowledge of pharmacology and physiology.

Oh, and do the obs again after medications have been given or titrated.

See? The drug works!

‘And you said I’m not studying ICU 101?’

But you are learning how to be a nurse. These skills, all this knowledge is transferable. Remember the ICU as safety net bit? If you call for help as an RN, how much more helpful, how much earlier are you going to notice changes, how much more comfortable will you be.

Instead of ‘Er, um, can you come see Mr So-and-so, I’ve got a feeling…’ you will be able to say ‘he sounds like a bowl of Rice Bubbles on his lower right lung, and his sats drop when he’s laying on that side, … … …etc”

Much more helpful. And much more confident.

Enjoy the rest of the prac.

You aren’t psychic. Neither is anyone else.

When I started in Anaesthetic nursing I was preceptored for one and a half shifts. I was task-oriented, which was good as I had demonstrated I could undertake the tasks expected of the role but had no real idea of how much I did not know.

Donald Rumsfeld, the former US Defense Secretary and ground-breaking educational theorist, defined this as the known unknowns. I knew there had to be more to learn, I didn’t know what, and at that time I didn’t know where to start.

The environment in which I was working was an operating theatre suite in a very busy metropolitan hospital. The theatre and the hospital itself were both going through an organisational “down-swing” of morale. I’m sure we’ve all experienced the type: a kind of a “sink or swim” environment, where the old hands are sick of introducing new staff to policies, procedures or even themselves and where the unspoken rule of sink or swim is “just do it quietly, we’re busy”.

So it was as a junior nurse I learnt to ask questions. Many, many questions. I would introduce myself, informing the Anaesthetic consultant or senior registrar that I would ask them questions while we worked. The junior registrars and residents seemed relieved I was offering myself as the person who knew the least, a role some of them must have thought they would never grow out of.

I discovered about the joys of gas dissolvability, of nitrous oxide as a carrier gas (with caution in bowel surgery and never in cranial neurosurgery), of Mean Alveolar Concentrations and the differences between and induction doses of the non depolarising muscle relaxants, in addition to myriad other details.

I continued asking questions when I changed hospitals, moving to a smaller regional hospital with a large obstetric casemix. I learned about the anatomical and physiological changes wrought by pregnancy, about ergometrine, syntocinon, syndometrine, and successfully diagnosed a Mallory-Weiss oesophageal tear in a patient post-epidural hypotension induced nausea. I worked stupid hours.

Eventually I moved out of the public health system and into private healthcare. I was lucky, as by this time I had a fair grasp of the theory behind practice and there are no junior doctors in private practice to use s cover for my learning. Of course, I had long lost my fear of asking questions.

A regular Anaesthetist was on holiday. An anaesthetist no-one had worked with arrived to cover his list, and although we had never worked with her we had heard of her. She was no nonsense, pragmatic, experienced, and seemed to have skipped all the CRM (Crew Resource Management) and communication and conflict theory. It was obvious that there would be no zen-bubble today.

We had paediatric patients on the list. This was new.

I decided I would continue with my usual strategy. I introduced myself, she told me what she wanted, I informed her I had no experience with children, and I would like to know what the major differences were in order to properly anticipate potential issues.

No dice. “Hurry up, we need to get started.”

I’d met the patient and Mum earlier, when waiting for the anaesthetist to arrive. We led them in, got the child monitored, breathed down via a sevoflourane induction. Mum went out, and the child was intubated for surgery.

It was not unsafe, but nor was the process smooth, cool, calm or as controlled as I would have liked. Good learning, I thought.

The anaesthetist was livid. “Damned incompetent anaesthetic assistants who don’t know what they’re doing…waste of effort…” (Just two of the comments I remember hearing). I felt humiliated and frustrated.

Between cases, I gathered my composure and decided this was a conflict worth having. “I told you of my inexperience and asked you what I needed to know to work with you. If you’d worked with me with an adult patient you’d never have dared to call me incompetent. If you answered my questions, all that would have been much smoother. Is this my issue because I didn’t know or yours because you didn’t teach me when I asked?”

The anaesthetist said nothing, and part of me felt I should stop, but a small part was…exhilarated. If this was going to bite me at least it would be worth it.

I continued “So, let’s try again. I’m not psychic, I can’t read minds and I’ve never pretended to. When working with paediatric patients, how do you think, and what do I need to know?”

More silence, and then she actually smiled (well…grinned?). “In twenty years no-one has ever told me that. Usually they’re scared of me. I guess it’s about time…”

I got to learn a great deal about paediatric anaesthesia that day. And I became her anaesthetic nurse of preference when she worked at that hospital. We ended up having some rather good conversations, and a normal working relationship. I learned a lot more working with her after that.

And one afternoon she thanked me for challenging her, as it was “nice to work with someone who was not scared.”

So here is the point:

Healthcare is difficult at the best of times. Working as part of a team is hard, doubly so without effective communication. There are many impediments to communictation, but by far the silliest and most inexcusable obstacle is to assume that the person you are working with can read your mind, and yet we all have colleagues who seem to do just that.

It’s something we all need to remind ourselves of occaisionally.

You aren’t psychic.

Neither is anyone else.

NB: for the uninitiated, a zen-bubble is a bubble of calm created around an urgent or emergency situation by a experienced heathcare professional. They exude a calmness that is infectious and calmer the closer you get. It remains my aspiration to be known for my zen-bubble. You never see them on medical shows on television.

The Sellick Manoeuvre: maybe you’re doing it wrong…

I was NEVER going to write a post about cricoid pressure (it didn’t appear at all in “101 Tips for Anaesthetic Nurses”).

It always seemed so…fundamental to practice as an Anaesthetic nurse that there was nothing left to say. Recent controversies in relation to the application of cricoid pressure in the #FOAMed world left me appreciating that this wasn’t the case, especially as the arguments presented didn’t seem to address all the shades of gray…

The Sellick Manoeuvre, better known as “Cricoid Pressure”, was first described in 1961 by Dr Brian Sellick in a paper titled Cricoid pressure to control regurgitation of stomach contents during induction of anesthesia – preliminary communication.

The application of pressure to the cricoid cartilage was advocated by Sellick following use of the technique on 26 “high risk” patients during induction and intubation. In 23 cases, no signs of aspiration or regurgitation of gastric contents was found at all during intubation, and in 3 cases regurgitation of gastric contents followed the release of cricoid pressure.

In 1961 there was routine use of high tidal volumes (greater than 10ml/kg), trendelenberg (head down) positioning during intubation, and use of barbituate anaesthesia. (The original “planes of anaesthesia” model described the physiological effects of inhaled ether and was easily modified when barbituates came into practice. With current pharmacology practice has changed so much that neither physiological model has much relevance).

For the next 40 years, the Sellick Manoeuvre was accepted practice in Anaesthetics, Intensive Care and Emergency particularly for non-fasted patients or during rapid sequence intubations. This is despite changes to the practice of anaesthesia (and intubation techniques).

However, in the early 2000’s, some aspects of the use of the Sellick Manoeuvre were found to be not as simple as first thought.

Damage to the cricoid, lateral movement of the oesophagus (not posterior occlusion as intended) and triggering of reflexative relaxation of the lower oesophageal sphincter causing regurgitation may all be physiological responses to the application of the Sellick Manoeuvre (Yao, Fontes and Malhotra, 2012).

Not to mention the difficulty in visualisation of the glottis for the laryngoscopist as a result of mobilisation of the larynx, with associated reduction in first-pass intubation.

In fact, a related technique called BURP (Backward, Upward, Rightward Pressure) was developed to improve visualisation of the glottis and therefore improve the incidence of first-pass intubation.

(This man has some serious manoeuvres, but they’re not right either)

http://tomselleck.tv-website.com/

There has been controversy recently within the #FOAM world in relation to the routine application of the Sellick Manoeuvre during intubation and the evidence for or against. Much of the obvious preferences centre around the difficulty in obtaining first-pass intubation due to impaired visualisation. As the chance of aspiration from gastric regurgitation from all causes is reduced by successful intubation, improving the glottic view is the focus of this blog.

The prevailing thought-leader opinion seems to be passionately and firmly in the belief that the use of cricoid pressure is not justified in routine clinical practice. Opinion had been divided into “tribes”: eg. use of the Sellick Manoeuvre may be justified in anaesthesia, but not in intensive care or emergency. Interestingly, College Fellowship exams of all three colleges require that the Sellick Manoeuvre be applied (or at least considered) for intubation scenarios.

Academia (somewhat more staid than #FOAM) seems firmly out to lunch on the matter. Several sources suggest the use of the Sellick Manoeuvre can neither be recommended nor discouraged, citing benefits, drawbacks, and unknowns.

So where does that leave us?

Before throwing the baby out with the bath water, it might be good to look at what the Sellick Manoeuvre actually involves.

Importantly, Sellick’s description of the technique specifies that pressure should be applied via the index finger, after the cricoid carilage has been palpated between the thumb and the 2nd finger (Sellick, 1961: 405). The original Sellick article does not specify which hand should be used or on which side of the patient the person applying pressure should stand. The thumb and two finger technique was the method I was taught, using the right hand (I’m very left handed), standing on the patient’s right.

The Sellick Manoeuvre was one of the first things I learned as a junior Anaesthetic nurse.I was taught by an Anaesthetic nurse, not by an Anaesthetist. Successful demonstration of Cricoid Pressure during a rapid sequence induction was the end point of my preceptorship in Anaesthetics (after a shift and a half).

Looking after the airway is ultimately the Anaesthetist’s responsibility, but it is also the primary reason for the Anaesthetic nurse’s role. If you ask them during their more honest moments, most Anaesthetic nurses will tell you that they don’t really work that hard for their wages. Except during emergencies such as difficult airways. It’s what they have to know, in order to appropriately do, and when.

Over time I have had many opportunities to apply cricoid pressure during difficult airways for prolonged periods. When tired, it is natural to drag your hand (and the larynx) towards you. This can make a difficult airway harder. The last thing you want is to be responsible for a difficult airway. This is your incentive to communicate with the laryngoscopist, to find out what the view of the larynx is like, to make adjustments.

Since I started, I have seen a variety of Anaesthetists, Intensive Care and Emergency specialists and Senior Registrars demonstrate Cricoid Pressure to junior nurses and residents, or attempt to assist each other…

…and they don’t do it very well.

It’s kind of surprising. Anyone other than another Anaesthetic nurse seems to stand either side of the patient or uses either hand, or uses more digits than thumb and first two fingers. Some just…mash…

The lack of practice, consistency and established communication between intubator and assistant mean that it is difficult to know if applying pressure to the cricoid is achieving anything.

It means it is difficult to know if the person applying pressure is moving the larynx laterally, or whether the patient has a deviated trachea.

It means it is difficult to know if the person applying cricoid pressure is applying enough or too much pressure (and the lack of standardisation in technique means it is near impossible to ever ascertain what too little or too much even means).

I’m not suggesting for a moment that there are arcane skills amongst Anaesthetic nurses that no-one else can learn. But I am suggesting that if a group of professionals perform something like the Sellick Manoeuvre repeatedly and as consistently as possible and we still don’t know if it helps or not…

Then have it both ways…

Assess the patient and the conditions. Is there another way? Do you and the person you ask to place pressure on the cricoid have the same expectations? Now is a good time to find out…

Put it on. Try it.

Assess the view. See the glottis? Left, right or anterior? Tell the person assisting.

If it helps, leave it on.

If it doesn’t help, you can always take it off.

Bhatia, N.; Bhagat, H.; Sen,I. (2014) Cricoid Pressure: Where do we stand? Journal of Anaesthesiology Clinical Pharmacology Jan-Mar; 30(1): 3–6.

Sellick, B.A. (1961) Cricoid pressure to control regurgitation of stomach contents during induction of anesthesia – preliminary communication. Lancet (2): 404-406 accessed via www.hneed.com/storage/Original%20Sellick%20Article%201961.pdf

Yao, F.F.; Fontes, M.L.; Malhotra, V. (2012) Intraoperative Management in Yao and Artusio’s Anesthesiology: Problem-Oriented Patient Management (7th Edition). Lippincott Williams & Wilkins. accessed via https://www.inkling.com/store/book/yao-artusio-anesthesiology-fonte-malhotra-7th

“Public Hospitals could save $430m by getting nurses to do some doctor tasks: report” – My Thoughts

My eye was caught today by an article in on the ABC news website.

Public hospitals could save $430m by getting nurses to do some doctor tasks: report – ABC News (Australian Broadcasting Corporation)

The gist of the piece is that “routine” procedures can be easily carried out by nurses at less cost. The author suggests endoscopies, colonoscopies, and sedating patients for low risk procedures.

The author appears to be an economist and public policy academic. This perspective is the only one in current Australian culture that the report makes sense. The Grattan Institute (http://grattan.edu.au/about-us) states that “it is an independent policy think tank providingindependent, rigorous and practical solutions to some of the country’s most pressing problems.”

I don’t have issue with the article per se (although at no point has anyone thought to ask any nurses what they think…) but I am riled by some of the more obvious comments attached below.

None of the Users commenting actually seem to understand the point of the original report or what the people in the modern health system actually do.

Comments all seem to follow a small number of themes:

Just plain bitchy (“… our definition of a colonoscopy was “six feet of fibre optics with an ar*ehole at each end” … Modern nurses are well qualified to replace the current proceduralists” – User discus49, retired anaesthetist) Let he who casts the first stone, sir. You’d know, maybe having been one of the ar*eholes at some point. And I hope I never worked with you.
The “I nearly died from an anaesthetic and I’m not going to let a nurse near me” response. I’m not even going to address this User’s concerns directly, they obviously had a bad experience which has hopefully resolved. They do suggest that nurses “are not trained specialtists” and several other claims not bearing scrutiny. Although I guarantee that what ever happened it was not fixed by doctors alone.
The “perhaps vocational training at a hospital level (as it was 25 years ago) would be a good way to save resources instead of insisting on degree level training” – User cynical wasp, no occupation listed) line of thought. This comment unfortunately represents a large proportion of the general population who don’t understand what we actually do.

Further comments reflect the original article’s assertation that the RN duties of bathing and feeding could be passed on to vocationally trained nursing assistants.

So I suppose what this post is really about is a rebuttal to the “let’s train nurses as we always have” mixed with some thoughts about why nurse sedationists are a bad idea in modern Australia. If neither of these topics interest you, please read something else (really, my opinions aren’t going to change yours…come back though, there’ll be something else later more your style…)

The obvious response is why do we let the public have a say regarding nurse education anyway? Other professions don’t do this. We tend to invite “consumers” onto our Nursing Boards of Registration (the now defunct QNC used to have two such representatives) and as nurses we engage the community with position statements from Nursing Colleges and policy organisations.

In doing so we may educate a percentage of the population regarding the reality of modern healthcare and nurses place within it, but I believe that is the absolute minority. I feel that the vast majority of society only meet nurses when they find themselves in the unfortunate position of needing nursing care.

So should we go back to the old days of signing our (mostly female) young adults over to a regime of residential curfews, administration spies and vocation (read task focused) based training? Should we remove the rights of junior nurses to go “out” for social events (on own time) without the employers permission? Should we leave them without the ability to advocate for their patients, subservient to the requirements of the medical profession, with all the job satisfaction of knowing that if they keep going and achieve another poor pleb will come and relieve them of the burden of the bedpan?

Rather than answer in the manner in which I normally would (No! with references)…

Would we ever expect that surgeons give responsibility for their education back to barbers?

Would we ever expect that in order to save money, the health system sack all the anaesthetists in favour of good, strong sticks for patients to bite?

Would we ever expect that modern dentistry return to the “everything can be fixed with a good extraction” days of the past?

I could go on…(architects? airline pilots? rocket scientists?)

Society has changed. Nursing has changed. There is no real correlation between “what a doctor used to need to know and what a nurse needs to know now” but the body of knowledge involved in both professions does intersect and cover the same ground. One complements the other, not replaces it.

Nurses do and will likely always look after the patient as a person in an attempt to return that person to the best functional state they can achieve. That does involve feeding, and toileting, and bathing. These aren’t things that can always be passed off to another with vocational training. They are further opportunities to assess, to look closely, and they may be the only time available to do so. The fact that these things are not done is not always an indictment on the nurse but a comment on the current conditions in which we work: doing more with less.

The public perception that the nurse is more interested in completing the paperwork (computerised or not) couldn’t be further from the truth to the average nurse. Most could easily have gone for an administration job (without night shift) if that is what they wanted to do. The paperwork is devoted to justifying the hours costed for staffing the ward, and ultimately the costs spent by government in looking after the patient.

Part of my thinking in working in my chosen specialities was the potential for the nurse practitioner role in anaesthetics: the nurse anaesthetist. As alluded to by the Grattan Institute’s report and the ABC article, the role does exist in several countries. One of the prime impediments to adopting such a role in Australia is one of culture.

In the US, nurses have administered anaesthetics (or anesthetics, in American) since the earliest surgeries. Medicine only took responsibility for sedation relatively recently, in the 1960’s or thereabouts (with few exceptions, the people administering drugs to patients during surgery in M*A*S*H* were nurses).

In Australia we followed the English model. Thus doctors have always had responsibility of anaesthesia, and even the anaesthetic nurse role is defined by hospital policy rather than codified by any particular legislation (ANZCA, the College of Anaesthetists recommend that a staff person be provided by the hospital to assist the anaesthetist as required, they shall not be answerable to the surgeon, and shall have 18months ‘suitable’ educational preparation).

In practice, this means that the anaesthetic assistant is a former wardsperson, or some one off the street, or any other background deemed to have satisfied the 18 month rule (no specification is made of what the 18 months should include). Or if you are lucky, the hospital has a preference for Registered Nurses, with their Bachelor of Nursing (3 years) and a Graduate Certificate in Anaesthetic Nursing (1 year). This still isn’t an “I’m better than you are” argument: I can train an anaesthetic nurse in a shift and a half (that was all I recieved at the time) but it’ll take about two years before you really know what you’re doing.

After all that, I could keep someone asleep during surgery whilst the Anaesthetist went to the toilet, I could anticipate, I could intubate and assess, I was handy in an emergency, understood and could administerl all the medications, all the things you would want in an assistant. Once I came to ICU I learned a lot more, all relevant. I have all the experience I need to apply to a US-style program (they call them Certified Registered Nurse Anaesthetists, or CRNA’s).

The US model requires the equivalent of a Masters degree preparation, AFTER the background and preparation and education I currently have. I could do that. But I won’t. Even if we followed the Grattan Institute’s ideas and adopted the system here.

The CRNA model requires supervision. It has been a part of the system since the beginning and the nurses undertake ALL anaesthetics during ALL the procedures a hospital offers. All of them. Patients aren’t always given the choice, and the literature shows there is not a difference in the care from a nurse as from a doctor.

We simply do not have that culture in Australia. Nursing has an image problem (as demonstrated by the comments above indicating a lack of understanding with the staus quo) and the public likely won’t accept nurses in the role (imagine the outcry!!!)

As a child of cost cutting measures, the CRNA model in Australia would be a hard pill to swallow. There are not enough training positions for the doctors, never mind the CRNA’s requiring supervision. It is easy to foresee a potential future where should the adoption of CRNA’s be successful (against all odds) the newly minted CRNA’s are required to fill the backlog of vacancies in rural centres…

Aargh

As a nurse, my interest is in the patient as a person. Not in cost cutting for Government. That’s what the Grattan Institute is for.