A few pointers before I get into this.
- I have worked regularly in a grand total of 1 hospital. It’s in Northern Ireland. I know that place pretty well. This does not qualify me as an expert on the issues involved here. A lot of the rest of this is assumption. If anyone can provide me with a good survey of practice in Ireland I’d love to know.
- I lump UK/Ireland together and I’m aware that it’s silly to consider them homogenous; even across the UK and Ireland there will be local variation. It is also dynamic and progressing Please allow my generalisation for the sake of discussion
- This is my opinion. Consider this a rant. I would love to hear your own thoughts and experiences, especially folk from Ireland if you’re out there.
Jonathan Benger, the guy behind CEM’s part of the must read NAP4 audit (listen to EMCRIT/RESUS.ME interview him on it) and the airway lead for the college, published this article in the EMJ a while back. It’s probably the most current picture of what happens in UK EDs. (Though a survey with a 50% return has its limitations).
Let’s set the scene, from the paper:
- 80% of ED RSIs were performed by anaesthetists.
The sickest patients need definitive airway management and in an emergent manner. This has to be something we can do. And not only just do but do really, really well. In fact we should be doing this better than anyone else in the hospital.
This should not be controversial but it is.
There are all kinds of reasons why EM has turned out this way. We’ll not get into them here.
The two leading areas in Emergency Medicine are arguably North America and Australia and New Zealand. They perform emergency airway management really well as part of routine business.
It’s not that they’re anaesthetists. Its not that they’ve even been trained as anaesthetists, it’s just that they have the appropriate training and work in geographical areas with appropriate systems to deliver emergency airway management.
So what’s stopping us?
I think this is the minor one. Kudos to the the college (who oversee training for both UK and Ireland) who have deemed RSI as a core skill. Trainees are spending time in anaesthetics (and we’ll come back to that), being trained how to manage airways. Trainees coming through are keen to manage airways without reaching for the phone. They have the knowledge, confidence and skills.
This is the real problem. We’re stuck in a kind of Catch-22. We need to do RSIs but we can’t do the RSIs till we’re good enough to do the RSIs, we can’t get good enough at the RSIs till we’ve been doing them and training our own trainees in the ED and not in the OT.
If we were to take over all ED RSI tomorrow, I would have some concerns. We’d do it alright, we’d get away with it. Because the big secret about intubation is that 95% of the time it’s very easy. It’s just that the 5% is the messiest 5% you’ll see.
So what needs to change?
- We all know we’re chronically short on staff, if not real then we’re effectively short-staffed (the pressure being to see and hand over the patient to the admitting team and not stay and provide continuing management for the first hour or two) and if we take over our own airways then we need support from ED management to take the time and staff needed to look after critically ill patients.
- It doesn’t matter if the ED doc is shit-hot with a mac and a tube, if he asks for a bougie and the nursing staff haven’t a clue what one is then we’re in trouble. When the anaesthetists come down to tube, they bring a nurse, and a nice little, organised trolley. And then they have someone with experience of what will be needed. Nurses are life-savers with enough gumption to go behind an arrogant doctor’s back and call for help when the arrogant doctor won’t. (For a great case of that see here for a video that I found via movinmeat)
- We need support from the anaesthetics team. Until we have enough trainees with enough experience and routine practice of ED RSI then we’re
stuckhappy enough for the gas-men to help us out. We can dangle before them the carrot of not getting called in at 4 am to tube for a CT scan 10 years from now. But we need their help and encouragement, not turf-wars and condescension. To quote the wonderfully to-the-point and lucid Domhnall in a comment on a prior post
The patients don’t care who puts the ETT in as long as it gets in there safely and appropriately -it seems to me insane that a territorial urinating exercise should jeopardise patient care! (amen to that sir!)
- We need support from the ICU. As mentioned in the ICU post, I think it’s a good thing that admission to ICU involves consultation with the intensivists, but we need to know they’re supporting us, and not shutting the doors in our face because we tubed a patient and they don’t have a bed. Both intubation and ICU admission have significant gray zones where different individuals will make different calls. The nuance in the decisions should be discussed and not dismissed on the basis of what training background the person came form.
The end-point of this is not for us to be competent in airway management as signed off by the anaesthetists, but to be the experts in ED airway management of the critically ill patient. We need to be better than the gas-people at that. They need to be better at it in the OT and even the ICU, but in the ED it has to be our bread and butter.
Please leave your comments/rant below, would love to hear them.
If you have any tips, especially if you’ve gone from a system where the gas-men used to it and now the ED guys do I’d love to know!
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I just watched the video. Chills. Thank you for posting the link to that.
The situation with the RN’s that were trying to modify the care of the patient (and being ignored) is the exact reason I quit nursing and went to medical school. Arguably I should have stayed in nursing and learned how to negotiate these problems from that perspective, but I think the world also needs more doctors bringing this teamwork/communication message home versus more nurses demanding to be listened to and respected in the workplace (which I agree with, of course!)
Nurses have always been encouraged to be patient advocates (to a point) and doctors are taught to listen to nurses (to a point) but obviously the system breaks down and when it really matters (case in point) neither happens.
It is one of my goals as a future physician to attempt to lead by example in this regard, and I think that going into medicine from my vantage point will enable me to do that.
Have you read “The Checklist Manifesto” by Gawande or “Outliers” by Gladwell?
The checklist really gets into this whole topic (which I find fascinating–obviously) and though I found outliers a bit trite at times the chapter on aeronautical safety really digs into the culture of hierarchy and how things as simple as calling people by their first names (rather than a title like ‘Captain’ or ‘doctor’) improves emergency outcomes because it lends itself to more open communication.
Ok, I am ranting in your comments section when I should be studying for my exams in 3 days so I’ll stop. But thanks again for the post and the link. More food for thought…
cheers for the comment
the heirarchy in clinical settings is problematic to say the least and not sure there’s any easy way round it apart from good relationships. I know that sounds all warm and fluffy but knowing people, beyond knowing just who someone is or their grade can go a long way to helping communication.
i feel much safer in the place where i normally work cause i know i can really trust the people i’ve known and worked with for years.
i think the checklist idea and the stuff from the airline industry can really help, but I think clinical settings are a lot more complex and layered than flight situations and the more humanly complex any situation gets the more likely we’ll manage to fuck-up something as seemingly bullet-proof as a checklist.
good luck on the exams
Hi Andy. I agree that clinical situations are potentially more complex that airline ones, but this is precisely why (Crisis Resource Management) CRM-style principles are important. This woman died because of the lack of a simple approach to a complex problem. Having a plan B in one’s head IN ADVANCE for the “can’t intubate, can’t oxygenate” scenario and being prepared to bail out and use it is what would have saved this woman. This should be ingrained in the mind and processes of every ED doc embarking on every airway, because whether our anaesthetics colleagues like it or not, EVERY ED airway is a DIFFICULT AIRWAY. NAP4 proves this!!!
I completely agree about how different the environment is in workplaces where you know / are known and where you trust / are trusted. I think at the core of that is respect–when people are respected and know their opinions matter, they are not afraid to voice them, despite hierarchies.
Gawande mostly talks about pre-procedural or pre-op checklists…They worked for a long time (doing a massive study with the WHO to formulate it) trying to create very simple, concise, but effect lists. When you read the items it seems almost absurdly simple (or even unnecessary)–there is a point where everyone in the room has to introduce themselves and say their title, a point where each member of the team (in O.R for example) is asked to voice any pre-procedural concerns, and then practical things like confirming patient and procedure, etc. I think the max they allowed on the list was 7 items.
Anyway, the result of the central line checklist studies are AMAZING. If you want I can send on some of the article links. Because of course I had to dig up the citations and check them out for myself 🙂
It’s interesting though, your hesitation over checklists due to the complexity of human vs flight scenarios is a commonly voiced one. I prob would have agreed before reading Outliers and Checklist M because they go into the nature of flight emergencies and I dare say there would be many a pilot who would disagree with your assertion. I also have to think that when your own life is at risk in an emergency, as well as the lives of all of your colleagues and patients, it surely must complicate things. It would be like trying to problem-solve your way through a difficult airway while not only your air supply is dwindling but also that of all your colleagues and patients on the ward.
So, I’ll attempt (perhaps feebly) to bring my rambling comments back to your original post (it’s only tangential thinking if you never bring it back, right?) I think that some of this checklist and teamwork business will mean that those 5% of airways that are difficult are made more manageable. It is simple things, like what you mentioned, having a tray ready with all the possible methods at hand, it is having an independent charter saying things like, “ok that was three attempts with “x” now we need to try “y” or call “Z”, it is having a quick run down before beginning so that you aren’t sending your assisting nurse to go grab a different RSI drug, it is making sure EVERYONE knows how to operate the vent, etc. etc.
In one of my former ED’s mock codes were part of our regular duties and part of the scenarios always involved having things go wonky–of course you can never anticipate every patient scenario and have practiced each one but it certainly made us work better as a unit.
I’m sorry I have no pearls for your transition to ED doc intubation, everywhere I’ve worked in Canada it was only the ED docs (or respiratory therapists) that did them in the A & E, apart from very rare times that the intensivist would, prior to transfer.
I need to go and make myself a coffee now!
Ta for the comments. Maybe I might do a post just on that video!
It seems I didn’t make it clear. I think the check-lists and pre- procedure stuff are great. I’ve read all the papers and it’s great and wholeheartedly I affirm it. I don’t wish to sound hesitant at all. If we listen to it and follow I and learn from things like nap4 then lives will be saved.
I simply mean it’s (obviously) not a perfect system because nothing is.
One of the nuances when things go wrong is a relational/cognitive block and I find that interesting for want of a better word. The checklist stuf goes a huge way to taking that stuff ou of play but we still manage to get round it and every now and again we’ll screw up something as simple as a 7 point check list.
As for the ED intubation stuff we will get there it’ll just take time and a whole lot of effort by lots of other more hard working and smarter people than me!
Oh, ok, sorry I misunderstood! Hahha, sorry for preaching to the choir then!
YES! One of the other things the video made me think of was that relational/cognitive block–and for the life of me I can’t remember the name of the book but will find it–but YES!! Fascinating stuff! The book I am trying to think of actually talks mostly about soldiers to show how our minds short-circuit in times of high adrenaline. Like the WWI soldiers who were found to have been loading/reloading/loading/reloading their muskets but not firing them in battle, etc.
My brother told me a story once of a time when he was in a jump exercise (he was a paratrooper) and had to jump with a left-handed parachute. His CO actually TAPED his left hand to the ripcord so that Shandy wouldn’t forget which side it was on. Shands told me that he laughed at the guy for doing it thinking “duh, I am not going to forget which side the ripcord is on” but when he landed (safely) found that he had completely shredded the right side of his suit attempting to pull the (missing) cord on the right.
I’ve definitely seen that kind of behavior in the ED in trauma situations!! One time I remember seeing a trauma doc completely OCD’ing on cleaning the light on the laryngoscope with a q-tip over and over and over again…while we prep’d for the arrival of an already intubated patient off the mountain. Course I’ve caught myself going around in circles during codes as well! Really interesting human behavior stuff. I’d really like to do some sort of research on these areas of medicine at some point.
I’d definitely say the video is post-worthy. I’ve been ruminating on same since seeing it–just want to wait until exams are done so I can write something half cogent and articulate about it. 🙂
i can think of plenty of panicked moments in myself and plenty more in watching other people.
there was a fairly recent paper (that i can’t for the life of me find at present) i heard about where a team of observers attended each in-hospital cardiac arrest and watched the CPR and counted bagging rates of 60 breaths a minute and the like. it seems the adrenaline is in for everyone in the panic situations not just the patient.
Heh. Indeed. What’s the rule? Check your own pulse first?
Oh I followed you on twitter…
If you know any of the faculty at my school–don’t out me! I am trying to keep the blog on the low down until graduation. 🙂
I enjoyed your post and could rant in harmony with you all day.
Here are some of my thoughts on this, having set up ED RSI programs and taught & published on this area over the years:
The OR is not the place to learn critical care RSI
We will all be dead before the UK & Ireland universally adopts ED RSI by EPs. There is too much dead wood in the specialty, and too little will and too few resources to fix the whole system.
However the problem is not resistance from anaesthesia / ICM, it’s insufficient EPs with the competence, passion, influence and resources to provide a safe 24 hour service and convince our other critical care colleagues that patients are safe without them there.
The good thing is that with like-minded colleagues you can fix this at a local level, as has been done in a number of EDs, large and small.
My tip to trainees is DO NOT be put off by what other people say you should be doing. Decide what kind of EP you want to be, go and get the skills somewhere (eg. in a busy ICU job or Australian ED / retrieval job) and then work with colleagues who share your vision of how EM should be delivered.
If you follow that formula, it becomes relatively easy to make the case for ED RSI, when you demonstrate training, audit, equipment and case review for ED RSI to a higher level than can be provided by services with priorities elsewhere.
Finally – the idea that it’s all sorted in Australia and NZ is a popular misconception. There is a fair share of terrible airway management in EDs here!!
Keep the great posts coming
Your EM brother
Hey Cliff, thanks for the comment
i think that’s the most frustrating part here at present – that the OR is taken as the “gold-standard” both for how and where to learn the skills. And you’re right they’re not the same patients or the same environment.
i sometimes find myself reminding the anaesthetic team that we have CO2 monitoring – something they would never forget if they were in the OR.
I agree i’ve had very little push-back from ICM/Anaesthetics in my own personal experience, though i remember reading some fairly vociferous arguments on the doctors.net forums a few years back.
i struggle to see how we’ll ever overcome some of the hurdles and simple staffing numbers and service pressures spring to mind. I work mostly in a dept with a census of 80000 a year and 4.5 ED consultants, 2 SPRs and 4 or 5 middle grades and 10 juniors. it’s a struggle to get a sedation done never mind EGDT!
When I was in NZ they had similar staffing levels for 35000.
There seems to be a definite commitment to increase numbers but EM isn’t exactly the most popular specialty here. It’s hard bloody work, which is true all over, but it’s hard bloody work and an uphill slog that puts many off
i did some great ICU and retrieval stuff when i worked in NZ and it was a real eye opener to see how things can be done a little different.
eagerly anticipating the next podcast!
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Baling out a struggling anaesthetic junior in resus and getting bollocked for it by an ED consultant: ‘airway is the province of anaesthetics’ was one of the sentinel events that prompted my (permanent) relocation downunder.
Even being competent in airway management isn’t enough, it seems. Cultural change can only come from consultant staff – and it seems the majority prefer the status quo. While Aus/NZ is still the option for british docs preferring to extend their management skills, you may be losing a significant cohort of those motivated for change.
Thanks for the comment
There’s definitely motivated “youngsters” coming through who are keen to see changes, I don’t think they’ve all gone down under. Not yet anyhow!
I agree with you – airway management and RSI in the EC must be a core skill for emergency physicians. I am a registrar in South Africa and luckily the SA system is set up so that this is the case. We are taught airway management even as interns, and in reg time have the opportunity to practise regularly. I dont think I have ever called an anesthetist for a tube! The only thing is (and I think this has been said before) – this change and training needs to come from EM consultants,obviously with back up and assistance from anesthesia and intensivists if neccessary.
Another thing I have found immensely useful in perfecting my airway skills is teaching others to do it – we teach both junior colleagues and medical students on anatomical models and real patients in the EC. I have found that by teaching someone else a skill, it forces you to go through all the steps in your own mind, every time, ensuring better results each time.
Thanks for a great blog. Interesting articles and cases!
Thanks for the comment
I did a couple of months in KZN back in 2003 on my elective. I did more procedural work there than I’ve done in all the years since!
Have always been really impressed with the quality of docs coming out of SA
I think you’re definitely right about the teahing. EM trainees here still have to learn a lot of core skills (like lines and intubation) in other areas. There’s all kids of complex reasons why but It does make it difficult to change.
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Great post Andy
Cliff’s response particularly resonates with me.
I’ve link to this post from the FOAMcc Google Plus discussion on who should manage the ED airway – over 90 comments so far!
Cheers – see you at smaccGOLD next month!
Yeah that’s quite the discussion thread going on over there! It’s been two years since I wrote that post and i now work in a place where i do most of my own RSIs and ICU have been very supportive. The ICU is so big and busy and physically distant from ED that they’re quite happy for us to crack on as long as we communicate well with them. Can’t believe it’s only a month till SMACC, must get my talk written…
Came across your post as I prep for SMACC Dublin. Also, we are now in the process of setting up E.D. RSI as a number of the young E.D. Consultants in my hospitals are keen to do this ourselves.
Any specific advice on how to set this up, having done this yourself a few years ago? Our ICU are a mixed bunch, and not all necessarily support Emerg. Physicians performing this. While I agree that this should not be a pissing contest, I also think that we should be masters of our Department, and not have to ask for permission if we have the skills (somewhat reminiscent of past need for permission to use anything bar midazolam for E.D. sedation).
See you in SMACC DUBLIN
Hi reuben. We certainly didn’t set up something formal, more of our trainees (inc me) have airway skills from various settings and the ICU seem happy for us to go ahead as long as we’re willing to provide ongoing critical care for the patients when they wait in the ED for several hours. I think this is reasonable as if you’re going to tube them then you should be capable and willing to provide ongoing critical care. But remember that this is largely trainees doing the RSIs, both anaesthetic and EM trainees, due to low consultant numbers on both sides (compared to the UK) there’s little consultant involvement. I wish i had something more useful to advise! Make good relationships with ICU is all i would say
Just wondering how things are going with respect to ED RSI’s in your department so many years on? I’m a relatively young EM trainee in the UK and am having significant push back at my suggestion of ED docs doing their own RSI’s. It’s even been suggested to me than non anaesthetic intensivists shouldn’t even be doing RSI’s… I wondered if you had any comments on this?
I would say most of the RSIs in the ED in my current place (which is also where i was when i wrote this piece) are led by EM, more so during daylight hours when a consultant is present than out of hours. The SpRs (in general) are more comfortable with leading an RSI than the non training registrars. There is still plenty of support asked for and received by ICU (which is mainly anesthesia delivered but not exclusively – we have trainees and consultants in ICU who are EM base specialty).
I am a non anaesthetic intensivist and have been doing my own RSIs for years. Naturally i have done a lot more being a dual ICM/EM person.
I am not surprised you receive push back and part of that is very appropriate as there would need to be a significant systems and culture change in your area for that to take place safely. Having a culture change where it is routine and accepted and above all else demonstrated to be safe is key. It is difficult to maintain competence if not doing regularly and naturally consultants are not comfortable in supervising trainees in something they don’t feel competent in themselves.