ARHT Surgical Airway Skills Session

One of the challenges of resuscitation and pre-hospital medicine is that there are multiple high-risk but rarely performed procedures that clinicians must be ready to perform. The difficulty is that we may go our entire careers and only perform them once or even more likely never. However, the difference from success and failure for these procedures can mean life or limb. Consequently we must remain competent despite the challenges with practice.  There is an excellent article that articulates these issues by Cliff Reid & M Clancy which I highly recommend reading (for anyone interested in the topic).

(a primer video I integrated into a recent cric teaching session to get our participants into the mood!)

These life-saving, rarely performed procedures happen to be an interest of mine. It’s a fascinating exercise in education and cognition to maintain competence in performing these procedures yet have virtually no real-life patient practice. The likely result is that clinicians are not competent or they do not remain competent in performing them. More optimistically, some clinicians will maintain their skills through simulation. However, I would bet that a survey of most staff emergency physicians would reveal virtually no hands on practice of many of these life-saving procedures. One of the most talked about and important of these procedures is the surgical airway (or cricothyroidotomy). This is only performed when a patient who requires emergency airway management but they cannot be intubated or ventilated. For most of us, we’ll go through our careers never performing one. But every time we intubate a patient, there’s a risk that this scenario could develop and we’ll have to act accordingly.

At ARHT last week, I ran an inter-professional session for the paramedics, doctors and crewman on surgical airway performance (or cricothyroidotomy). The goal was to integrate our new cricothyroidotomy task trainers into the educational curriculum and combine them with some group discussion and simulation. For those looking to do replicate the event or simply looking for ideas, I will outline our session.

In addition to the introduction of our new task-trainers we also used this opportunity to review our performance of surgical airway. From an educator’s perspective, the most important step for success of this session is preparation. Those who know me, know that I’m not a detail oriented person but planning for everything from big picture stuff to the smallest detail can make a huge difference. In an effort to encourage the sharing of information (FOAMed) I’ll describe our itinerary.

Before the session I sent 2 emails. Our group is relatively new to the flipped classroom, or sending material first then promoting discussion within the classroom/learning site. Something I took home from SMACC 2013 is start with videos (easy to digest material) if you’re implementing a flipped classroom approach for the first time. A follow up email was sent with the videos again and this time along with 2 articles:

  1. Cricothryoidotomy bottom-up training review: battlefield lessons learned
  2. Emergency Surgical Airway: 24 successful cases leading to a simple “scalpel-finger-tube” technique 

Introduction

  • The learning outcomes were outlined
  • The MOST important aspect was to outline the ground rules and expectations. In our case, we were not using this session as an evaluation but instead as an opportunity to practice and engage our entire team. If you are evaluating learners, let them know!
  • We used  both task trainers and simulation to ensure an environment that promotes psychological safety  and learning for all participants

Content Presentation (using powerpoint)

  • I kept this short – about 20min so that everyone remained engaged (some of our doctors have fairly short attention spans!)
  • Review the indications (contraindications…not really any), complications and considerations in performing a surgical airway
  • Review the controversies regarding surgical airway (more to come on this in a later post)
    • preferred technique (surgical vs. percutaneous)
    • vertical vs. horizontal incision
    • team positioning
    • Integrated 2 videos – the impact of engaging the audience is impressive…especially when you have the luxury of using some pretty amazing footage
No better way to encourage participation than some pointing and asking people directly! (not my finest picture during a lecture...)

No better way to encourage participation than some pointing and asking people directly! (not my finest picture during a lecture…)

Task Trainers

  • We had 3 stations of task trainers with inter-disciplinary teams (paramedic, doctor, crewman)
  • Teams rotated every 15 minutes
  • Station 1 – pediatric needle airways
  • Station 2 – open/surgical cricothyroidotomy using a variety of tools & instruments
  • Station 3 – participants were blindfolded, relying on their tactile sense and team communication to complete the procedure
Our cric station set up. A variety of equipment that allowed participants to try various methods

Our cric station set up. A variety of equipment that allowed participants to try various methods

Our crew practicing a surgical airway on a task trainer

Our crew practicing a surgical airway on a task trainer

Several participants trying out a needle jet ventilation technique

Several participants trying out a needle jet ventilation techniqu

Brainstorming session

  • While we already have a cric kit in our packs, we used this opportunity to discuss the equipment that participants used in the task-trainer session
  • Then we packed a cric kit following this discussion (based on consensus) for a team to use in the next section – an outdoor simulation
  • This usablity testing allowed participants to directly observe their decisions for kit composition in practice!

Simulation

  • 3 volunteers (crewman, doctor, paramedic) representative of our duty crew at ARHT
  • Participated in a simulation of a patient with a trapped patient, unable to be extricated and deteriorating mental status and respiratory status. There was considerable
Debriefing after the manikin was successfully rescued from under the trailer! He got a cric and was ventilated by our team! Disclaimer...no manikins were harmed during this educational session (except a few cuts to their necks)

Debriefing after the manikin was successfully rescued from under the trailer! He got a cric and was ventilated by our team! Disclaimer…no manikins were harmed during this educational session (except a few cuts to their necks)

Debriefing

  • Debriefing of the simulation and the entire day
  • We used this opportunity to ask participants what equipment, methods and preferences they would like integrated into our standard operating procedure

This entire process included usability testing for participants – allowing them to use different techniques & equipment they may otherwise not try.  This also provides an additional opportunity for inter-professional education that is extremely important for such a high risk, rarely performed procedure. Proper planning and training for all team members involved will only make the process better.

The importance of simulation in usability testing and hazard identification

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Auckland ED is conducting a lot of simulation training currently, with a recent focus on airway management.

Last week a teaching session was delivered by Sam Bendall (an Auckland HEMS doctor) on ‘intubation as a team sport’, which covered human factors in ED airway management and included the use of adjuncts like airway checklists. While Auckland HEMS has an RSI checklist, a similar tool has not been finalized for Auckland ED – this is under consideration currently. Following that teaching session, several airway checklists had nonetheless made their way into our resuscitation areas.

High-fidelity simulation training took place this afternoon, led by Sam, Mike Nicholls (another HEMS doctor), and Nancy Mitchell (Nurse Educator).

The first scenario involved a relatively junior team undertaking an emergent RSI. They performed admirably, and the outcome in practice would have been safe and successful. As an observer however, it was apparent that an airway checklist would have contributed to their confidence and comfort levels. (My personal opinion is that we should start using a checklist for ALL ED RSIs, independent of team seniority)

While watching the simulation I spotted a checklist taped to a whiteboard on a side wall. I assumed that was the airway checklist, and thought ‘that’s a clever position – it means the airway assistant can read out the checklist immediately prior to the RSI. They haven’t used it, I must bring this up at the debrief’.

At the end of the debrief, I inspected what I thought was the airway checklist, and found this:

HCA checklist

It wasn’t an airway checklist at all, but a restocking checklist!

The actual airway checklist was here…

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Tray following RSI (this is NOT how we set up!) Airway checklist bottom left

taped to the top of the airway trolley (logical) but unfortunately covered up by the airway tray, which is removed from the trolley and placed on top when setting up for airway management. This is a good example of a latent hazard.

I found a second copy of the checklist taped to the desk at the entrance to the resus bay – this is where the scribe (usually one of the senior nurses) stays during a resuscitation:

photo(2) copyAlthough this desk is frequently cluttered with paperwork during a resuscitation, accessing the checklist would be a simple matter, and would be done so by a senior person.

After looking at the positioning of these checklists, I came to two conclusions:

1) Simulation is a powerful tool for testing the usability of a new item or technique and identifying hazards

When considering logistics/ergonomics/equipment what actually happens in real life may differ from what we envisage mentally when we introduce something new. Simulation introduces stress, time-urgency, ergonomic elements and personnel elements that can rapidly reveal whether something new is going to be useful or not, or whether its introduction has inadvertently created hazards

2) We need to actively manage the environment we work in

When confronted with a critically ill patient, it is easy to focus on the scenario in front of us (there is usually quite enough to think about there!) and accept the physical environment as it is. By going a step further and ACTIVELY managing our environment to improve logistics and ergonomics we can increase our chances of a good outcome. This can occur both BEFORE we are confronted with a patient (eliminating the latent hazard above, for example) and DURING a resuscitation. This is particularly important in the pre-hospital setting, where both the relatively unforgiving helicopter and roadside environment provide a range of challenges not encountered in a resuscitation bay. As doctors I believe we have a lot to learn from our paramedic colleages in this area.

(NB – if someone becomes angry because that restocking checklist mysteriously disappears this week, I had NOTHING to do with it, nothing at all)