Case was an acute severe/life threatening asthma episode in a young patient.
TECHNICAL FEEDBACK FROM DR. ADAM REID (EM CONSULTANT)
Thanks to those who participated and observed our acute severe asthma sim the other day. Particular thanks to Dr. Lachlan Robinson for stepping up to the plate at the last minute and leading the team in a calm and collaborative fashion.
Main points from my perspective were as follows (more expert and in-depth non-technical feedback to follow from our pilot colleagues!):
- Important for team to be aware of severity of asthma and declare it – as there is a system for working out the severity of asthma episodes it’s a good idea to use it. Making everyone in the team aware that this is a life-threatening episode will sharpen the team’s focus.
- Initiation of immediate therapy for severe/life threatening asthma – this was done well by Lachlan and the team. The initial drugs and doses (nebulised salbutamol burst 2.5-5mg x3, consider continuous if life threatening, ipratropium 500mcg and iv hydrocortisone 100-200mg) should be at a brainstem level for all of us so that we can get management commenced immediately. NB the maximum oxygen flow rate recommended for neb masks is 6L/min.
- Second line if not responding well to nebulisers is Magnesium Sulphate (2g in 100ml over 20-30 mins – can give slower if worried about hypotension).
- We discussed in the debrief what strategies to use if the patient is requiring more than 6L/min of oxygen to avoid hypoxaemia. This would be a time to consider a salbutamol infusion. 5mg made up to 50ml in a syringe driver will give a concentration of 100mcg/ml. Recommended starting infusion rate is 5mcg/min, which equates to 3ml/hr. Adjust as needed based on bronchodilator response and side effects (tachycardia, tremor, anxiety, hypokalaemia). Aim to switch to inhaled therapy as soon as possible as infusions have worse side effects and aren’t any more effective than inhaled (provided the patient doesn’t need more than 6L/min O2).
- Aminophylline can also be given intravenously in acute severe asthma. At present our local guidelines (under the respiratory tab on the intranet) mandate that a consultant physician approves this so always prudent to involve the medical registrar early on!
- We discussed the pros and cons of using NIV for asthmatic patients, and strategies involving low or no PEEP (EPAP) to avoid gas trapping. If you are in a situation where medical therapy is not helping your acute severe asthmatic patient, get help as early as you can. Ventilation of asthmatics either invasively or non-invasively is very challenging and should only be attempted with expert guidance.
Once again, thanks to all who participated, the resus team for technical support and oversight, our pilot colleagues for their expert non-technical feedback, and Robbie Lloyd our resident sim evangelist! Any questions, feel free to contact me.
HUMAN FACTORS FEEDBACK FROM OUR PILOT COLLEAGUES
Good afternoon Robbie, Adam and Lucy,
Today was our 5th simulation. Once again our congratulations and of course thanks to the A&E team for having myself and Dave to observe. Today was a great example of someone being ‘thrown in the deep end’ with the original sim lead suddenly unavailable and a relatively junior doctor given the call up with no prior notice. Arguably, this contributed to the fidelity of the scenario – however, as flight crew, the thought of a sim being sprung upon us last minute might raise a few eyebrows. The issue with aviation sims is that, at present, it effectively dictates our continuation of employment. Perhaps we could learn something from the medical industry’s more ad-hoc approach.
As we upscale the regularity of simulations, we will try to shorten feedback to more salient observations and suggestions. We will, of course, continue to include aviation examples to highlight the connections between our industries.
Regular use of first names.
Empowered assisting nurses to speak up.
Actively listened to colleagues.
Area for improvement
5 readbacks missed. (e.g. hydrocortisone, 5mg salbutamol, 15L oxygen) Try to improve rigour by ensuring ANY specific request (X-ray, ECG) is also read back.
Consider raising your tone if the severity of the situation increases. Remaining calm is essential but it was hard to tell that this was life threatening asthma.
Slightly hunched body language and positioning at the side of the bed made it difficult to tell that the lead was orchestrating the situation. Try to position yourself at the end of the bed as soon as practicable.
Poor readback has contributed to some of the worst aviation accidents over the decades (Tenerife 1977, Western 2605 Mexico City 1979). We have highlighted this on every sim and will continue to do so. What must not be forgotten is the readback from team members for non-drug related requests too. Once airborne, the flight deck door remains locked – this physical barrier between pilots and crew means that there is a high risk of misinterpretation. An example of pilots mitigating this would be during an emergency – we always ask our crew to write down and read-back our instructions in a structured format. Perhaps consider your PPE as the flight deck door.
Good use of ABCDE to review the situation.
The lead was always aware of the patient’s circumstances by regularly asking the patient how they were feeling/using available resources (chest X-ray) to build a ‘big picture’.
Areas for improvement
By using a team member to carry out the ABCDE review, this would have given the lead time to think about other options whilst increasing SA for the chosen team member.
Because the situation ‘felt’ relaxed, this may have been a good opportunity to ensure other team members were fully aware – “how serious do you think the situation is on a scale of 1-10?”.
Using a severity scale of 1-10 is a great way to understand how overworked either you or your copilot are. It may well be that because you have been concentrating on the safe flight of the aircraft, you have missed something significant. If your scores differ greatly, hand over control to your copilot and make sure you raise team SA by running a clear review.
The lead avoided impulsive decisions and followed a structured approach to dealing with the asthmatic patient.
The lead clearly allocated tasks to team members (e.g. helping to sit up the patient, administering drugs).
Areas for improvement
We still feel that the available team members could have been better utilised. If the lead had stood at the end of the bed, this could have enabled him to have a less ‘hands on’ approach.
If you are the clinical lead, task allocation is extremely important, especially when the intensity of the situation increases. In order to preserve your mental capacity and see the ‘bigger picture’, consider keeping your team busy with tasks that don’t require your participation. You can still offer live coaching and maintain standards, for example, by advocating good read-back discipline. In aviation we call this the ‘lazy command’ style.
Good use of available resources to help make the correct diagnosis.
Areas for improvement
Pressure test your diagnosis. “Give me a good reason this isn’t a severe asthma attack?”
Ask team members their opinions or use open questions to challenge your thinking. At one point, one of the nurses asked the lead a question regarding drug dosage – this would have been the perfect time to fire the question back at them.
In all of our sim observations, there has been a lack of pressure testing the diagnosis. The lead has been very good at stating what is wrong with the patient but gives very little opportunity for a colleague to challenge. Perhaps the condition of the patient has changed since your original diagnosis? After an in-flight failure, regular reviews are essential, even after your decision to divert has been made. Perhaps a hydraulic system has started working again, improving the aircrafts capability. “Give me a good reason why we can’t continue to our destination now?”.
- Ensure read-backs for all requests.
- Use your team as much as possible.
- Pressure test your diagnosis even if it appears obvious.
Captain Alex Jolly and Captain Dave Fielding
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