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John Vassiliadis: Courage under Fire


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Vassiliadis inspires with his trajectory from novice to teacher of airway skills and checklist applications.

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John Vassiliadis: Courage under Fire

  1. 1. Courage Under Fire Dr John Vassiliadis MBBS FACEM Senior Staff Specialist Emergency Medicine, Royal North Shore Hospital Deputy Director, Simulation, Sydney Clinical Skills and Simulation Centre Senior Clinical Lecturer, Sydney Medical School LCDR RANR
  2. 2. Road Map • Why are we not perfect and make the correct decisions every time? • Are checklists useful? • Examples of checklists • What makes a good checklist? • RNSH airway registry and lessons learnt • RNSH Airway checklist • Take Home points and Call to Arms
  3. 3. Acknowledgements And Disclaimer • Drs Toby Fogg and John Kennedy • Views expressed are solely my own • No financial interests to declare
  4. 4. Why do iatrogenic errors occur? Assumption: “Do no harm” 1. Beyond our control o o We do not have the knowledge of how to diagnose or treat 2. Swiss Cheese Model1 Combination of organizational, supervision, unsafe act and the precondition for unsafe acts 2. Under our control o o Training and experience issue – junior, inexperienced or ineptitude Human Factors 1. Reason, J. Human error: models and management. BMJ 320(7237): 768-770
  5. 5. Factors that make decision making in a critical care environment difficult? • Us • o Patient factors • o Limited history, emergent conditions, sick, Institution • o Hungry, Angry, Late, Tired Time pressures to move patients, number of staff, supervision Number of decisions made in a shift
  6. 6. What/Who Can We Turn To?
  7. 7. Advanced Life Support for Adults Checklists can Help!! Start CPR During CPR 30 compressions : 2 breaths Minimise Interruptions Airway adjuncts (LMA / ETT) Oxygen Waveform capnography IV / IO access Plan actions before interrupting compressions (e.g. charge manual defibrillator) Drugs Shockable * Adrenaline 1 mg after 2nd shock (then every 2nd loop) * Amiodarone 300 mg after 3rd shock Non Shockable * Adrenaline 1 mg immediately (then every 2nd loop) Attach Defibrillator / Monitor Assess Rhythm Consider and Correct CPR for 2 minutes Hypoxia Hypovolaemia Hyper / hypokalaemia / metabolic disorders Hypothermia / hyperthermia Tension pneumothorax Tamponade Toxins Thrombosis (pulmonary / coronary) Post Resuscitation Care Re-evaluate ABCDE 12 lead ECG Treat precipitating causes Re-evaluate oxygenation and ventilation Temperature control (cool)
  8. 8. What Makes A Good Checklist • Clear, precise, simple, short • Not meant to explain how to do a procedure, it is memory aid, NOT a comprehensive HOW TO GUIDE • Reminder of critical and important steps • Should be a Read and Do • Willing to update and improve
  9. 9. Weakness of Checklists • People must be willing to use them • “Buy in” by teams • You must have a defined time to use the checklist and this must be clear to the team • Defined person to initiate, “champions” or “zealots” • Checklists will not solve every problem, so team must be flexible enough to stop an communicate and work through the problem
  10. 10. RNSH airway registry
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  13. 13. What we learnt • 297 intubations in 18 months - equates to 4 per week • 21% between 24:00 and 08:00 • 30% pt were traumas, commonest indication was overdose (15% of all pts) • Average age 52 • Male : female ratio 1.7:1 • Only 3% of pts had an estimated wt. above 130kgs
  14. 14. What we learnt • Specialists were team leaders in 70% • Registrars/SRMOs had 89% of first looks • Our first pass success rate was 81% • Only 10 patients (3.3%) needed 3 or more attempts • Difficult laryngoscopy (Cormack and Lehane III/IV) encountered in 23% patients on first attempt. This was not associated with the intubator’s grade or airway experience, or the patients condition
  15. 15. What we learnt • Those who have limited experience at laryngoscopy, i.e. SRMOs who haven't done anesthetics, have only a 58% first pass success rate. The data also shows that a prior experience of >10 intubations (a novice was arbitrarily defined as <10 intubations) increases the odds of success on the first attempt by more than four fold compared to a prior experience of <10 (OR: 4.36; 95% CI: 1.81-10.52; P=0.001).
  16. 16. What we learnt o 30% of all 345 attempts were done naked: without the aid of bougie or stylet o Complications occurred in 28% of patients, with a particularly high rate of desaturation (10%)
  17. 17. ED!Intubation!Checklist!! IVI/Drugs Pat ient Team o Fluids connected, runs easily? o Spare IVC? o Monitor: ECG, BP, SaO2. o In hours, ED Senior Dr aware of RSI? o Pre-oxygenation optimal? o Add nasal prongs or NIV o Out-of-hours, if difficulty anticipated, anaesthetics contacted? o RSI drugs drawn up, doses chosen? o Post-intubation anaesthesia plan drugs drawn up? o Patient position optimal? Equipment o All members introduced by name & role and each briefed in turn by TL o Patient haemodynamics optimal? o Fluid bolus? o Pressor? o Difficult intubation plan briefed? o Does it look like it might be difficult: o Difficult airway trolley at hand? o Difficult BVM? o Difficult laryngoscopy? o Anticipated problems – does anyone have questions or concerns? o Difficult supraglottic airway? o Difficult cricothyroidotomy? o Suction working? o BVM with ETCO2 connected? o OPA and NPA available? o 2 x laryngoscopes working? Correct blade size? o Tubes chosen, cuff tested o Bougie or stylet in tube? o Tube tie or tapes ready? o Ventilator circuit attached? o LMA sized & available? o Surgical airway equipment available? Version!1.3! Developed!by!T!Fogg,!J!Kennedy!and!J!Vassiliadis,!RNSH!ED!25/ 10/ 2012
  18. 18. Take Home Points • No one is perfect! We are all human! • We work in a high pressured high stakes environment • Checklists can help if used properly, review your work practices and challenge what you do!!!