Teamwork

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.

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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)
 

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

 

 

 

 

 

 

 

 

The team leader isn’t always the senior registrar (or the Director of ICU)

About four years ago I took some leave from my position and worked in another department for 6 months or so. I didn’t do this because I wanted to, I did it because I had to. That will be a much later post, and is a much different story from this one. I mention it here because the story from this post happened in the midst of the worst week of my career that forced me away for 6 months and nearly out of nursing…

 

IMG_0633

The team leader isn’t always the senior registrar (or the Director of the ICU)…

At the start of our night shift we had an admission. She was a pillion passenger on a motorbike and had gone from the motorbike into a window, which had been thoughtfully opened by the rider of the bike who had been jettisoned though the glass head first, milliseconds earlier. He had died at the scene.

She had a head injury and severe liver damage and multiple long bone fractures and that night would require two operations in theatre and two trips to CT, as well as activated factor VII and the Massive Tranfusion Protocol. We couldn’t bring her ICP below 50mmHg, and she quite frankly had us all concerned.

All that was to come.

Right now she had just arrived in our ICU and had been too unstable for the emergency department to do a head scan, so our job was to stabilise her and get her to radiology on another floor and then back to our floor to OT.

A large team of nurses and junior doctors gathered at the bedside, ready to do what was required. The Director of ICU was the consultant and was standing back, arms casually folded, making decisions and guiding the team. Sometime over the next half hour the night shift doctors started drifting in, taking over from their day shift counterparts so they could prepare for the medical handover round.

Eventually, the consultant decided that if she was going to get to radiology now was the time. I was the ACCESS (or Bay nurse, or float nurse) in the area. He nodded towards me and I started delegating nurses to collect equipment, medications, transfer monitors and test transport ventilators, which is the kind of thing an ICU consultant might not know about. Keeping an eye on our activity and the patient the consultant started filling in the details for the night shift senior registrar.

I work with a truly wonderful team. Most of the senior nurses are interchangeable within roles, although we all have unique approaches to problems and situations. Right now, senior nurses and spare staff were completing delegated tasks, reporting to me and awaiting the next objective. I had people undertaking several steps of the process at the same time. Admittedly, this was before tabards clearly stating “Team Leader” or “Airway Nurse”…

Having been nominated to transfer the patient to CT, the oncoming senior registrar quickly looked around and asked the team at the bedspace if he could have some medications, (he seemed to ask everyone, or no-one, but not any one person) and proceded to list propofol (running already), noradrenaline (also running), vecuronium (infusing due to ICP), morphine (check) and midazolam (you guessed it, also being given) and then added mertaminol (something new).

Not only did he request those medications, he yelled those requests, with strengths and concentrations, and he yelled them over the quiet that had characterised our efforts so far.

Naturally, no-one much paid him attention. Certainly no one dropped what they were doing and ran to the medication room.

In the relative quiet after the senior registrar had stopped yelling, the Director of ICU quietly turned to the senior registrar and said “I don’t think you’re in charge just at the minute, do you?” And pointed in my direction.

A look of understanding crossed the registrar’s face, (the force was strong with this one) and he asked me for his preferred medications. I quickly ran him through what he currently had, and asked two nurses to ensure adequate supplies had been made up for the trip.

The patient was out the door and on the way in less than 10 minutes from the time the decision to go had been communicated.

At the recent smaccGOLD 2014 conference on the Gold Coast, several presenters addressed issues surrounding “tribes”: nursing, medical, ICU, Emergency, Anaesthetics, Pre-Hospital and specialities. (Big shout out to @Socratic_EM, @cliffreid et al.) All presenters promoted a blurring of the “tribes” for the betterment of patient care.

Similarly, recent practice changes and coronial investigations have promoted readily identifiable clothing, tabards of stickers identifying roles in resuscitation or intervention situations, especially when teams are ad hoc and staff capabilities are unclear.

All of these ideas and practice changes are valuable. But that isn’t what this post is about.

When we do know our staff, and we do know our own capabilities, we shouldn’t be afraid to cede responsibility to another with more knowledge of a process or procedure. We don’t lose power or respect, rather we empower others and ourselves.

The Director of ICU wasn’t any less in charge of the situation, and wasn’t any less of a decision maker. He knew what his role was and so did everyone else there. But it had been a long time since he had actually prepped a patient for a trip to radiology.

Even without identifying markers, everyone else knew their roles as well. And amongst the senior staff, any one of us could have coordinated the transfer. It was just via allocation that it was me.

Similarly, if the senior registrar had taken a moment to assess the situation, breathe in, and look – he wouldn’t have been at a disadvantage when it came his turn to lead the team to and from the radiology department, either. We learn these lessons in first aid, in PHTLS, ALS, ATLS and all the other courses we do. Sometimes it is a matter of safety, and sometimes just to ease the wheels of communication and teamwork.