Here is the write up from our latest (very challenging) in situ sim. It includes feedback on human factors from our colleagues in aviation.
- 17-year-old girl with a background of anxiety. Deliberate OD of propranolol (unknown quantity).
- Hysterical mother in attendance (superb performance from Dr. Lucy Parker!)
- Initial A-E assessment done. Patient bradycardic and hypotensive.
- Patient deteriorated, went into (Torsades de Pointes (with a good pulse and BP)
This might not have been realistic as propranolol ODs do not usually produce Torsades!
- Pt given magnesium and reverted
- Cardiac arrest
- Initially fine VF, then coarse VF
- ROSC after 3 rounds of ALS
- ITU consultant arrived and patient presented by team leader
Very difficult sim (certainly the toughest I’ve run!). James Everson team led excellently. He understood and verbalised the pathology in play.
The therapies given for a propranolol overdose were entirely appropriate.
He managed his team well (more detail on this from the pilots).
Harriet did well managing the hysterical mother at the beginning of the scenario.
Biggest technical learning point from this sim: when managing any patient who is critically unwell following an OD/poisoning – immediately consult TOXBASE. It gives very detailed guidance on how to manage pretty much anything you can imagine.
In this sim, TOXBASE was consulted (the propranolol page was printed out and brought to the team leader – this was excellent), but it was fairly late on.
MANAGEMENT OF PROPRANOLOL OD
Check out the TOXBASE page for lots of detail on this.
Propranolol has sodium channel blockade effects (as well as beta blockade) and so can behave like a tricylclic antidepressant in OD. ECG looks like a TCA OD (broad complexes). Therefore, give sodium bicarbonate. If QRS remains broad, give more.
Glucagon was rightly asked for… but is needed in massive quantities. This would have been recognised had TOXBASE been looked at more carefully. A bolus of 5-10 mg IV in adults should be administered over 1-2 minutes, followed by an infusion of 50-150 micrograms/kg/hour – this is loads of the stuff.
This patient had a brady- and tachyarrythmia (Sorry James mate). Both were managed appropriately (atropine and magnesium respectively). Intravenous fluids were given for the hypotension which was great. The hypotension in these patients tends to be fluid-resistant and so ionotropes often need to be considered (though in this sim the patient arrested before it was possible to think about this stuff).
In severe cases a high dose insulin and dextrose infusion can improve myocardial contractility and systemic perfusion. It is particularly useful in the presence of acidosis. This was asked for by James after consulting TOXBASE.
Hail Mary treatments worth considering are intralipid and methylene blue. These are NOT on TOXBASE.
When the patient arrested, the initial rhythm was thought to be asystole. It was in fact fine VF and so could have been defibrillated. According to the resus officers this is a common error made. I asked Steve Collins (one of our Resus Officers) to weigh in on this issue:
Historically fine VF was recommended to be managed as asystole; however a more current iteration of the Resuscitation Council Guidelines in April 2017 revised this guidance:
“If the rhythm appears to be VF give a shock, and if it appears to be asystole continue chest compressions.” This includes fine VF.
I accept that in today’s scenario the VF displayed on the monitor was extremely fine and very difficult to differentiate from asystole which may have rendered this an unhelpful example. That said, the learning point is that current guidelines advocate shocking fine VF which is quite different from historic guidance that actively discouraged the shocking of fine VF. From downloading defib files from real (and recent) cardiac arrests we have seen several examples of VF not being promptly defibrillated – We hypothesise that the rhythm may have appeared as fine VF on the defib monitor and as such it has managed as asystole which is at odds with current guidance.
In summary: if it looks like fine VF, defibrillate it.
QUALITY OF CHEST COMPRESSIONS
The data shows an average depth of 6.7cm (aiming for 5cm or one this of chest diameter) and rate of 117 (aiming for 100). Well done guys.
As we get through more of these sims, let’s see if we can get as close as possible to a rate of 100.
HUMAN FACTORS FEEDBACK FROM OUR AVIATION COLLEAGUES
Good afternoon Robbie, another enjoyable sim today with lots of really positive feedback to give to the team. I think the variety of medical scenarios that we are being exposed to strongly reinforces the applicability of our key pillars of Human Factors (Comms, WM, SA, DM). We will provide categorised bullet points, covering positives and areas for improvement and then follow this up with a more detailed analysis, including some aviation parallels. As always, your feedback is greatly appreciated.
– Lead was calm and clear.
– Excellent open questions (Lead – “anything else we need to give?”; Anaesthetist – “what would you like me to do”).
– Good use of first names by all team members.
– An excellent example of readback & cross-checking by the most junior team member (Chinenya). Clear confirmation of the drug and pointing to dosage on the label.
Areas for improvement
– Aside from the above example, over 5 readbacks missed (inc 1mg adrenaline/2g Magnesium/IV Glucagon).
– Lead had a calm tone of voice at all times. Consider an appropriate increase in volume/intonation to gather more information from the distressed parent or to focus your team (“this is a cardiac arrest!”).
– Use the calm start as your ‘Golden 5 minutes’ to express your leadership style and organise your team.
– Good distraction management, plenty of occasions that ABCDE could have been interrupted and not resumed.
– Clear assignment of a team member to look after the parent before workload increased.
– Lead recognised one of the junior staff had made a mistake with obtaining meds. Metaphorical arm around their shoulder which encouraged them to get it right the second time and not ruin their confidence.
– The lead had a very methodical approach to a rapidly deteriorating situation (followed algorithm accurately).
Areas for improvement
– Distribute more tasks. For example, the anaesthetist expressed a need to know what the next steps were – ask them what they think?
– Good prioritisation when the consultant came in midway through ABCDE, however, nobody was tasked with monitoring vitals during handover. “You have control”.
– The team member looking after the parent nominated themselves to assist with compressions. Ensure the role of looking after the parent is clearly handed over to another member of staff to avoid potential distractions.
– The lead regularly used reviews (4 H’s and 4T’s/ABCDE) and broadcasted them to the team ensuring everyone was aware of the patient’s condition.
– A clear interaction with the team member in charge of timings, especially during the CPR 2-minute cycles.
– Excellent followership by the anaesthetist as the patient deteriorated – despite them making it clear they wanted to be updated, at no point did it come across as belittling.
Areas for improvement
– Consider asking team members for their take on the situation. Use severity scale (1-10) as a means of checking team members’ understanding.
– Allocate the ABCDE to a colleague to raise their SA.
– When the consultant arrived, instead of making them wait until a review was completed, ask them to listen in and ask questions afterwards – the handover is then complete.
– Some good open questions allowed other team members to contribute. “Is there anything I have missed?”.
– Diagnosis was clearly announced to the team.
Areas for improvement
– Pressure test your diagnosis. “Give me a reason this cardiac arrest isn’t because she overdosed on propranolol.”
– Avoid rhetorical/leading questions, at one point the lead said “I think we should administer adrenaline do you agree?”
And now for the more detailed analysis…
WORKLOAD MANAGEMENT & COMMUNICATION
The clinical lead displayed an impressively calm, methodical approach throughout the scenario. Body language was comfortable, not defensive, and first names were used throughout. We often say behaviour breeds behaviour and this was a perfect example of this – there was a real sense of composure within the team. It is important that as commander, you have the ability to avoid acting on impulse. How you respond to the first few seconds after the master warning lights illuminate will often shape the outcome.
On this note, we do have times where it is important to highlight the severity of a situation (windshear, engine failure, stall). When the patient went into cardiac arrest, the calm nature of the lead could have been misinterpreted by team members not directly involved with the patient at the time. Perhaps an increase in volume or an announcement of the failure would have been a great ‘attention getter’. “Loss of braking!”.
The patient’s parent was clearly a distraction management issue – the lead initially handled this well by asking a team member to look after them. Unfortunately, the allocated team member changed roles to assist in chest compressions leaving the parent unsupervised. This resulted in the lead dealing with the distressed parent again. To relate this to our experiences in aviation: when dealing with an onboard fire, the senior crew member assigns specific roles to the cabin crew. These roles are maintained unless a clear verbal handover is made “I am the communicator, you are the firefighter” – a lack of controlling the parent at a critical point in the ALS algorithm could have been a serious distraction.
A final point on communication. We were delighted that one of the most junior members carried out a deliberate read-back and cross check of a drug requested for the patient. This involved using a portable electric device to confirm the name and quantity of the drug, and then showing it to the lead before being administered – fantastic work. There were several other occasions where this was missed. We feel we are repeating ourselves, but we can’t stress enough how important readback is. In the Kegworth air disaster (Flight BD92 – 1989), the wrong engine was shut down on approach due to a high stress scenario and a lack of cross checking – 47 passengers lost their lives.
The ALS algorithm lends itself to treating reversible causes in the form of ABCDE/4 x H’s & T’s. This is similar to an avionics review we carry out in-flight once the initial failure has been managed (hydraulics, fuel, electrics). The lead used these reviews at regular intervals to keep the team informed and maintain high SA. That said, it would have been nice to see a review delegated to a colleague. This would have been a great way to encourage their participation.
Checklist discipline in aviation is essential, if we get interrupted, we must resume from the original point, or if uncertainty exists, start again. It was pleasing to see the same discipline used in the ABCDE, ensuring that until each item was covered, there would be no progression. Please remember that whenever distractions exist such as the consultant arriving, the lead must ensure someone is constantly monitoring the vitals. “You have control, your instruments”.
Pressure testing your diagnosis after an in-flight failure is essential (“tell me why this isn’t a hydraulic leak”). Quite often it creates healthy discussion and opens the floor to colleagues who may have a different opinion. Give yourself the chance to actively listen to concerns from teammates before making an informed decision. If the aircraft state is constantly changing, regular reviews of your original decision are essential. “With fog developing at our diversion, is the aircraft still capable of an auto land?”.
Once again well done to everyone involved!
Captain Alex Jolly and Captain Dave Fielding