The non-intubation checklist

June 17, 2013 by  
Filed under All Updates, ICU, Resus

no-sm

Scenario:

A 79 year old previously well female presents with loss of consciousness, having been found unresponsive by her daughter who saw her well one hour previously.

Examination reveals a GCS of E1V2M3 = 6 and reactive pupils with no lateralising signs. She is hypertensive. A VBG reveals a normal glucose and sodium and a pCO2 of 60 mmHg (7.9 kPa).

The emergency physician’s plan is to intubate and get a CT scan of her brain. This is explained to the daughter.

A no-brainer? You’d think so.

A consistent issue that recurs during discussions with UK emergency medicine colleagues is that of having to rely on anaesthesia and/or ICU colleagues for intubation of their patients in the ED. The pain comes not from disagreeing about who does the procedure or what drugs to use, but rather on the decision to intubate.

The refusal to intubate can stall or halt a resuscitation plan, delay care, result in risky transfers to the imaging suite, and even deny potential outcome-improving therapy (for example post-ROSC cooling). It can undermine team leadership and disrupt the team dynamic.

There are often different ways to ‘skin a cat’ and it is frequently helpful to invite the opinion of other critical care specialists. However, it is clear from multiple discussions with frustrated EM colleagues that the decision not to intubate is often influenced by non-clinical factors, most often ICU bed availability. Other times, it appears to be that the ‘gatekeeper’ to airway care (and to ICU beds) does not share the same appreciation of the clinical issues at stake. Examples here include the self-fulfilling pessimism post-ROSC based on inappropriate assignment of predictive value to neurological signs, and the assumption of non-treatable pathology in elderly patients presenting with coma.

The obvious solution to this is that the responsibility for managing the ‘A’ of ABC should not be delegated to non-emergency medicine personnel. Sadly, this is not achievable 24/7 in all UK departments right now for a number of awkward reasons.

So what’s a team leader to do when faced with a colleague’s refusal to intubate? The best approach would be to gently and politely persuade them to change their mind by stating some clinical facts that enable a shared mental model and agreed management plan, and to ensure the most senior available physicians are participating in the discussion.

Sometimes that fails. What next? Here’s a suggestion. This is slightly tongue-in-cheek but take away from it what you will.

It is imperative that the individual declining intubation appreciates the gravity of his or her decision. They must not be under the impression that they’ve done you (and the patient) a favour by giving their opinion after an ‘airway consult’. They have declined a resuscitative intervention requested by the emergency medicine team leader and should appreciate the consequences of this decision and the need to document it as such.

Perhaps say something along the lines of:

I see we haven’t managed to agree on this. We’ll just need you to complete the non-intubation form please for our quality improvement process. This will also help prevent your point being forgotten or misunderstood if we’re unlucky enough to face any complaints or litigation. I can fill it in on your behalf but I suspect you’d want to represent yourself as accurately as possible when documenting such a bold decision

And here’s the form. It is provocative, cheeky, and in no way should really be used in its current form:

nonintubationchecklistsm

Comments

16 Responses to “The non-intubation checklist”

  1. Jo Deverill on June 17th, 2013 08:30

    Appalling but true. When I worked in the NHS (last century) resus teams used to send a runner to ICU to find out if there were any beds, before intubating. I had hoped that someone had put an end to this entirely crass practice. Suggested solution: intubate the patient yourself. If ICU consider this inappropriate, they can extubate. It is only a piece of plastic after all. Go on – if it was such a bad idea – just pull it out.

  2. Anonymous on June 17th, 2013 23:43

    Perhaps an extra couple of checklists boxes are required.

    Reasons for requesting intubation:
    1) I’m too busy with other accident and emergency patients that if I can get this patient intubated then it becomes an anaesthesia / ICU problem, including all the necessary examination, investigation requests, therapeutic interventions and end of life care.

    2) 4 hour wait time left…

    Reasons for declining to intubate:
    1) The moment the decision is made to intubate all A/E interest clinical and physical in the patient is lost, including collateral history from family, decision making and specialist team referral and palliative care when appropriate.

    2) Because a tube isn’t going to save any aged patient with 5 acutely failing organ systems on the background of 5 chronically failing organ systems who lacks the appropriate physiological reserve to survive one ICU intervention, but “just had to let you know anyway”.

    Would have though that these A/E qualifications at the bottom of the checklist would have required some degree of intelligence and common sense to achieve.

    Oh and err…intubation the patient yourself, but if ICU consider appropriate…extubate YOURSELF! Take some ownership of your patients.

  3. Graham Johnson on June 18th, 2013 07:21

    Superb. Just superb.

    I’m putting these in resus.

  4. Alex James on June 18th, 2013 09:39

    Go on then. I’ll bite.

    “However, it is clear from multiple discussions with frustrated EM colleagues that the decision not to intubate is often influenced by non-clinical factors, most often ICU bed availability.”

    Really? I’ve never worked in a department where this was a serious consideration if someone really needs an ICU bed. When you’ve got more patients than beds one of us (God-willing, the SHO) gets in the back of an ambulance and turfs someone out to somewhere that’s not full. Or they go to recovery / theatre.

    If they’re a borderline case for admission then it might have an influence (since overspilling to recovery / transferring out is not without risk) but for barn-door sick people it isn’t really a common problem is it?

    “Other times, it appears to be that the ‘gatekeeper’ to airway care (and to ICU beds) does not share the same appreciation of the clinical issues at stake.”

    Well, that is understandably frustrating if they’re wrong and where it arises it should of course be sorted out at a level higher than mine. If this sort of thing is going on regularly then it suggests a pretty dysfunctional relationship between ED and ICU/Anaesthesia that needs sorting out.

    “The obvious solution to this is that the responsibility for managing the ‘A’ of ABC should not be delegated to non-emergency medicine personnel. Sadly, this is not achievable 24/7 in all UK departments right now for a number of awkward reasons.”

    I very much enjoy working with my colleagues in EM. I find the clinical stuff interesting as well as the human factors. Also, it seems to me that EM registrars and consultants are the product of rather aggressive natural selection – you’ve got to be pretty impressive to withstand the stuff that your workload / work pattern / college(?) throw at you. Indeed, one of the best doctors I’ve ever worked with is an EM reg (although, disappointingly it would seem that he’s about to start putting these up in resus).

    Most of the time in our region the specialties seem to complement each other and work very well together. I think – as Dr Reid’s post suggests we ought to – that by and large we do discuss things together and reach sensible conclusions.

    However, I’d hope that our contribution is valued by those that we work with and that we are not seen simply as a necessary evil that can be done away with as soon as they have the resources to provide the service we do.

    Now, finally, this may be me being a bit over-sensitive. I can chuckle at the bit at the end of the checklist. I really can. But talk of “refusal” (?to follow an order) and “delegating to non-emergency” (?inferior / subordinate) personnel does get my back up a bit.

    I can take that on the chin this time and at present I’m quite happy to be called ‘the anaesthetist’, ‘Alex’, ‘gasman’, ‘venflon-bitch’ or whatever you like, really. But if this sort of language continues I will be insisting that from now on I’m referred to as an Anaesthetic Physician when I’m in the ED.

    Love and hugs

    Alex
    Anaesthetic Reg in the UK

  5. Cliff on June 18th, 2013 11:34

    Alex thanks for taking the time to comment. The post is one sided and tongue in cheek and you have taken it in the spirit intended so thank you.
    The best resuscitations happen when colleagues work together with the patient’s best interests at heart, which I’ve no doubt you have.

    But yes, REALLY. You are lucky not to have worked in such an environment. When we discuss these issues amongst an audience of 30-40 senior ED docs on the Making Things Happen course almost everyone has such a story to tell, some of which would make your toes curl. I have seen it many times myself in the UK. A consultant on for ICU coming to resus and literally pulling out a tracheal tube of a post-ROSC patient (in her 60’s) on the grounds of unreactive pupils without having bothered to make any further assessment. A refusal to see a patient in resus because “we’ve got no beds”. Several occasions of “send the [comatose, hypercapnoeic] patient to scan and if there’s something treatable on it then we’ll come and intubate”. Two cases of airway obstruction in burns patients following refusal to intubate. The list really does go on and on and I promise you this is happening every week all around the UK.

    My personal opinion is that this is much less prevalent in hospitals with full time intensivists. Just about every example I personally have seen come from DGHs where the on call anaesthetic staff are required to cover out of hours, but have no day time commitment to critical care outside the operating room. Resources are a major issue, since if the SHO is sent on an interhospital transfer (another issue I have with the system) and the registrar is tied up in obstetrics / theatre / ICU / ward emergencies then the consultant has to come in for the next problem, which some simply refuse to do.

    “Non-emergency” personnel did not imply inferior, just non-ED-based, and therefore not always immediately available, and very often subject to other service pressures.

    I have no problem calling you an Anaesthetic Physician – it sounds cool.

    Hugs back

    Cliff

  6. Chris Cole on June 18th, 2013 13:44

    Hehehe…. Love it. :-)

    Perhaps we could have one for interventional cardiologists who decline urgent PCI for patients post-AMI/arrest who are “too unstable for the cath. lab.”, too??

    On a more serious note, why would we be asking someone from another dept to come intubate the patient, anyway? Certainly there are rare cases with every risk factor in the known universe for a predicted difficult/failed intubation for which me might invite our friendly neighbourhood anaesthetist to the party, but they are few and far between (the cases, not the anaesthetists… we happily have lots of those!). Surely you’d just intubate the patient yourself??

    Also, for better or worse, the time-honoured adage of “it’s easier to obtani forgiveness than permission”, having an already intubated patient can often result in the miraculous procurement of an ICU bed that would otherwise be “unavailable”.

  7. Anonymous on June 18th, 2013 17:28

    I think it is entirely reasonable in anticipation of finding a catastrophic intracerebral pathology, not to anaesthetise, intubate and ventilate a hypercapnoeic and comatose patient, or a moribund patient with multiorgan failure and no reserve etc..

    Now clearly thee are some ulterior motives, anecdotes etc…that are always going to be present.

    But; sometimes the risks of the procedure outweigh the benefit, and as the GMC guidance suggests, there is no obligation to provide treatment that is deemed futile or burdensome.

    …or don’t you learn that on your FCEM/FACEM/FESEM courses anymore?

  8. Cliff on June 18th, 2013 19:14

    Mr Anonymous, it is impressive how often the suspicion of catastrophic intracerebral pathology is not confirmed on CT. It is also impressive how confidently colleagues assume futility on very little information and no definitive diagnosis. Clearly there are cases when it is possible to conclude palliation is the best course for the patient. That’s what Box B on the form allows.

    I’m not sure I see the reasoning behind: “sometimes the risks of the procedure outweigh the benefit” when we’re talking about intubation in patients for whom securing the airway is indicated as part of their resuscitation or stabilisation.

    Those specialist fellowship qualifications aren’t courses.

  9. Alex James on June 18th, 2013 20:35

    Cliff

    I enjoy a bit of needling, provocation and debate as much as the next obstreperous trainee anaesthetist.

    I’ve no doubt these things do really happen when it comes to ICU admissions – I’m just not sure about the importance of the resource / bed problem as a factor. I think there are very few places now that have a proper ED with ICU covered by anaesthetists with no daytime critical care sessions. I’ve only worked at one such DGH and my experience there was that the non-intensivists had a lower threshold for admitting people and dealing with the aftermath the next day. Also, in 5 years of anaesthetics on-call I’ve never once known a consultant refuse to come in when asked (told!).

    I think your other point about clinical appreciation is probably the key one and that’s always going to be a problem with any interface between different specialties. We’re better than the “what’s the GCS?” lot, surely?

    I’m sure I’m preaching to the converted here but the other point I’d make is that if you got 30-40 anaesthetists in a room and asked them about Making Things Happen in the ED I think you’d probably get a pretty skewed view of UK emergency medicine! Which is not to say that it wouldn’t identify themes for us (and you?) to consider as your exercise has done for me.

    Best wishes

    Alex

  10. Alex James on June 18th, 2013 20:43

    To Dr Cole,

    I assume you don’t practice in the UK (apologies if I’m wrong) so, to put things in context, hopefully this is a reasonably balanced explanation that won’t prompt an off-topic debate or slanging match!

    It is rare for emergency physicians to be performing anaesthesia in UK EDs. As Dr Reid has alluded to there are a number of reasons for this.

    The first is tradition – in the UK emergency anaesthesia has ordinarily been performed by anaesthesia / ICM (which in practice used to be a subspecialty of only anaesthesia though this is slowly changing). The consequence of this is that in the UK the there are relatively few emergency physicians with ongoing experience and expertise in emergency anaesthesia (which I’d differentiate from the act of sticking the tube in). By contrast UK anaesthesia as a body has lots of experience because we do most of the ED and ICU workload and also anaesthetise emergencies in theatre.

    Again as a consequence of this traditional set-up, anaesthesia in most places is resourced to provide outreach to the ED and to the wards in order to respond to emergencies. By contrast recruitment, retention and resourcing in emergency medicine seems, at least to an outsider, to be much worse. So in the hospitals I work in it is expected that the anaesthetic/ICU on-call team will be deployed to ED regularly and there are usually two on-call consultants who come in if we’re shorthanded (or if it looks like we might soon be). Whereas in our ED if one of the ED team were to commit themselves one-to-one to anaesthetise a patient and manage them for an hour or two their department would come crashing to a halt.

    This is, of course, not the case for some departments and individuals where a combination of skill mix, experience, supervision and resources mean that the emergency physicians do this work. But I think it is fair to say that it is uncommon.

    http://emj.bmj.com/content/early/2012/11/07/emermed-2012-202023.full

    As someone who really enjoys resuscitation I quite like our collaborative model of managing these patients. I think the patient gets the benefit of at least two doctors with different but overlapping skill sets looking after them and we get involved early with patients who mostly end up coming to us anyway (to theatre or to ICU). From the other side I know that lots of emergency physicians would disagree.

  11. Anonymous on June 18th, 2013 23:48

    Ah yes, intubation and ventilation rather than proper history and collaterals.

    Granted intubation may buy you time to gather this information, but if we are just allowed to quote personal anecdotes then I shall say that the referrals for the obese, blue, nonagenarian who has slept in a chair for the last 8 years are exactly what this form seems to obviate…common sense decision making prior to referral.

    And no that is not age bias, it is physiological reserve bias.

    It is impressive how often the confirmation of a definitive diagnosis of a “totally reversible” condition leads to curative care and discharge from hospital to previous functional status.

    Reductio ad absurdum; Should we also have to document the need not to intubate when a patient has been assessed as fit, well and normal ready to be discharged home following a minor injury such as a burn to the finger? Just because the form exists…

  12. Cliff on June 19th, 2013 06:30

    You do seem to have missed the point entirely.

    “Ah yes, intubation and ventilation rather than proper history and collaterals”

    – nope, thorough evaluation prior to declining intubation was my point, and is written pretty clearly

    “Should we also have to document the need not to intubate when a patient has been assessed as fit, well and normal ready to be discharged home following a minor injury such as a burn to the finger? Just because the form exists…”

    – no, since the form was only suggested for patients in whom intubation was requested

  13. Tim Leeuwenburg on June 19th, 2013 10:58

    Guys, lighten up – this was (I think) meant as a humorous post and should be considered as such

    It also raises issue of how to deal with conflict in the resus room…

    Anecdote-sharing is one way of doing this.

  14. Chris Cole on June 19th, 2013 11:34

    Hi, Alex James!

    I’m afraid I must admit to a degree of antipodean colonial parochialism here, as while I have ventured to the northern hemisphere several times, it has always been in a recreational rather than professional capacity, and while I recently experienced my first ever “Is there a doctor on the plane?!” episode (with two casualties/patients within 5 minutes of each other, and both within 5 metres of my seat), happily neither of them required intubation. :-)

    So yeah… the idea of “outsourcing” emergency anaesthetic management is (literally) a foreign concept to me. We do invite our anaesthetists to come and play, but it’s usually for particularly complex or weird cases, where certain anaesthetic ninja skills and/or toys are required (e.g. awake fibreoptic expeditions, etc.). In my hospital, the anaesthetic registrar is automatically paged whenever we have a “trauma code” but they are rarely required, and typically after hours the evoked response is “Hi, I’m in theatre with a patient on the table, but do you need me to call my boss in for you?”. We partake of their kindly offered services in perhaps < 5% of such cases. It is, however, nice to know they're there and willing to plunge in when truly tricky stuff is afoot (and I have certainly requested their assistance on many occasions).

    And of course we invite them down when there's stuff that's just too cool not to share (steak knife through trachea, etc.), and they'd get all stroppy when they found out afterwards and they didn't get to come and play. ;-)

    Thank you for outlining the way things work in the UK. It seems to an outsider as if the situation there is largely a result of historical professional role delineation (and the relatively recent birth of emergency medicine as a specialty; indeed, many countries still have no such thing), though I can't help but think factors such as the 4-hour target probably contribute to an environment that is not conducive to UK emergency physicians using and maintaining emergency anaesthetic skills. As you rightly point out, removing a senior clinician from the ED for an indeterminate length of time to look after a ventilated patient can be functionally crippling to an already under-resourced, overcrowded, access-blocked department.

    We certainly do spend a fair amount of time battling with other teams to do something (or not do something…. not-going-to-start-on-about-lysing-strokes-in-ED… not going to… not going to…) for our patients. Happily, trying to convince someone else to come intubate our patient for us is not an issue we have to deal with. :-)

  15. Anonymous on June 19th, 2013 17:32

    Thorough evaluation prior to declining intubation was my point, and is written pretty clearly…

    Sure…the decision making part of your case history…”A no-brainer? You’d think so”

    Now then, this could continue indefinitely.

    The truth of the matter is that airway management is far more than just intubation as a reflex reaction.

    It is potentially a life changing therapeutic intervention as well as part of a resuscitation algorithm. Definitive investigation and treatment should not be delayed in anticipation of intubation.

    There are many patients I am called and literally instructed to intubate. Usually, I come to the A/E department. I discuss the history, I briefly speak to the family. I look at the available investigations and such on the computer system. If I think that intubation is not indicated then I will write a full entry into the notes, by hand, including a signature and a contact if further concern sub-section.

    If the intubation request was for a scan, I usually accompany the patient into scan myself.

    There are times however, when the anaesthetist is legitimately tied up, either peri-operatively, or carrying out a procedure or just in a hospital location 15min from A/E.

    In those cases, calling in the boss from home 20mins away, or waiting 15min for the anaesthetist to arrive/finish procedure when perhaps all that was needed was a quick trip to scan when eg the GCS had first started to drop seems non-sensical just to be presented with this form.

    DOI Work experience includes A/E, GenMed, Anaesthesia, and ICM

  16. The decision to intubate - Emergency Medicine Ireland on June 23rd, 2013 05:55

    [...] [This has been floating about as a draft post here for ages, but Cliff has finally inspired me to put it out there and have the discussion following his recent post on The tongue-in-cheek non-intubation check list] [...]