There has been an exponential rise in COVID-19 cases. There is no doubt we’re feeling the effects of that all over the world. Many people, especially it seems, the lay public and politicians, have a hard time understanding the meaning of ‘exponential’.
The scariness of exponential growth shown here with E.coli
Image by Stewart EJ, Madden R, Paul G, Taddei F (2005) / CC BY-SA
But can exponential rise continue? If cases double every 3-4 days, then based on today’s figures from the Johns Hopkins Dashboard (1st April) by May 6 there will over 8.7 billion people infected, which is more than everyone on the planet, and clearly impossible.
This means the rise must tail off eventually. In fact, the more people there are who are infected, the harder it is to find someone to infect with the virus who hasn’t already got it. Also, spread should be limited by the social distancing and other measures (such as handwashing).
This actually gives rise to a LOGISTIC curve, rather than an EXPONENTIAL curve. This is an S-shaped curve that describes population growth (in both viruses and people) as well as other phenomena in economics and science(1).
Notice in the above curve the mid-point marked 0.5. This is the inflection point when the rate of increase in cases stabilises before declining. Specifically, the ‘Growth Factor’, or number of new cases in one day divided by the number of new cases the previous day, equals 1. Note at this point cases are still increasing – the virus is still spreading – but it’s not accelerating, and therefore no longer on an exponential trajectory.
This isn’t the only model to describe pandemics and none is perfect(2). We still can’t predict what will happen with SARS-CoV-2 and we absolutely need to continue to enforce strict containment measures. But having a basic understanding of the data gives us ways to visualise it that allow comparisons, and show which countries have ‘fallen off’ the exponential rise curve.
Since in most places, we are still on the exponential part of the curve, it is imperative to educate as many people as we can on the benefits of strict isolation and hygiene measures:
The best brief explanation of the above, which prompted me to write this brief post, is by the brilliant minutephysics
Take a few minutes to watch the video below:
Please note all the caveats at the end of the video. And one final one – I’m not an epidemiologist or mathematician. I’ve just been wrestling with what the endpoint of exponential rise would be and found these resources helpful.
One of my nursing colleagues was telling a story the other day about one of the first resuscitations we did together in the ED several years ago. It demonstrates the principle of establishing control of a sub-optimally coordinated team by using some form of attention grabber. She kindly agreed to write down her recollection for me to share here:
I have finally found 2 minutes to sit down and write you the story I was telling you about the other week…. We were in the middle of a resus in the ED, it was chaotic, loud and messy.
I remember you calling out in a commanding voice for everyone to stop (can’t recall what you actually said) but when we all looked up and fell silent you lifted up one leg, let a rather loud large fart out and then very calmly proceeded to take control of the situation. Everyone was so stunned, and slightly amused that the whole situation just settled right down and we all cracked on with the resus in a much more organised fashion.
I don’t know if you know I own a first aid training company. I tell this story when I am teaching. I explain to people that an emergency situation can be chaotic and stressful and someone has to take control. Sometimes you need to take a second to get a grip of yourself and others before you can be of any help to the person in need.
By telling your story it makes people realise you can stop for a second to gather yourself, take stock of what is needed then crack on. Sometimes it takes extreme measures such as dropping a fart to get people to get back on track.
You have given me many stories over the years but the fart one has got the most traction so far.
See you at work
I accept that some people may find this offensive or consider it inappropriate or unprofessional. Please consider:
All mammals produce flatus.
Holding on to flatus can be uncomfortable and can distract a resuscitation team leader, potentially adversely affecting outcome.
The performance had its desired effect, helping the resuscitation.
The patient was intubated and therefore not at olfactory risk
This video shows the mechanism for dislodgement and deformation of humeral intraosseous needles and how to avoid this.
In summary, if you need to abduct the arm (eg. for thoracostomy), keep the thumbs down (ie. have the arm internally rotated at the shoulder). Otherwise the IO catheter may bend or fall out.
Occasionally we step out of the resuscitation room feeling like a case should have gone better, but it can be hard to put our finger on just where it went wrong. In my last post I discussed the STEPS approach to analysing resuscitation cases: Self, Team, Environment, Patient and System.
Occasionally you can get a case where the STEPS seem to be aligned but things still feel bad. In which the outcome was unsatisfactory because the plan was wrong, or the team wasn’t able to execute the plan. Consider the following case.
1. A patient with a past history of DVT no longer on anticoagulants presents with chest pain and syncope.
She is severely hypotensive with a raised jugular venous pressure and a clear chest x-ray. A working diagnosis of pulmomary embolism is made.
Discussions ensue regarding empirical fibrinolysis and a respiratory physician is consulted, who over the phone cautions against treating without a CT pulmonary angiogram.
The patient is given heparin and transferred to the CT scanner where she arrests. Intravenous rtPA is given during CPR but no return of spontaneous circulation is achieved and she is pronounced dead after 30 minutes of resuscitation.
On this occasion the team worked efficiently and communicated well under clear leadership. Everyone knew the plan and shared the mental model. The environment was well controlled and the patient had been swiftly moved to CT within 20 minutes of arrival. Thanks to simulation training the well rehearsed cardiac arrest resuscitation was conducted with precision and the team was able to rapidly access the thrombolytic and knew the correct dose.
By a quick STEPS analysis, this case appears to have gone as well as could be expected. Perhaps there is nothing to learn. Some you win, some you lose, no?
No. Autopsy revealed type A aortic dissection with pericardial tamponade.
The management may have been efficient but it failed to be effective. In other words, things were done right, but the right things weren’t done; they did the wrong things right.
This might be an example where STEPS is inadequate, and instead we should evaluate the clinical trajectory. The cognitive bias that led to a lack of consideration of alternative diagnoses might be classifiable under ‘self’ or ‘team’ but I find it more helpful to consider it under a failure of strategy. What is strategy? Strategy in my mind is another word for plan. The plan is based on a particular resuscitation goal, and will consist of the procedures & skills required to action the plan. We can thus break down an attempted clinical trajectory into:
Goal (what are we trying to achieve) Strategy, or Plan (what’s our plan to get there?) Tactics, or Actions (what procedures will be required to execute the plan) And, at more granular level: If we’re failing at the procedural level, the components of procedures, namely Skills & Microskills. So, as we zoom in from macro to micro in setting the clinical trajectory, we can look at Goals, Plan, Actions, and Skills:
In the above case it appears the following was applied, in terms of Goal-Plan-Actions-Skills:
G – resuscitate hypotensive patient P – give fibrinolysis for likely PE A – consult respiratory physician, get CTPA S – request scan, give heparin, transport to CT
The goal was appropriate, but the plan was ineffective.
The following approach would have been more effective.
G – resuscitate hypotensive patient P – identify cause of undifferentiated hypotension and initiate treatment in the resus room A – thorough bedside assessment in patient too sick to move: history, physical, CXR, ECG, labs, POCUS S – Basic cardiac ultrasound
By planning to identify and treat the cause of hypotension in the resus room, the more appropriate investigation would have been selected (cardiac ultrasound) and the correct diagnosis is much more likely to have been made.
Let’s look at some other cases:
2. An 88-year-old male presents by ambulance to the ED with dizziness. He is hypotensive, pyrexial, hypoxic and confused.
His chest x-ray shows likely bronchopneumonia. He has appropriate initial resuscitation and ICU is consulted. Soon he is intubated and on high dose vasoactive medication with escalating doses despite ongoing hypotension, anuria, and a lactate of 11 mmol/l, increased from 8 on arrival.
As he is being wheeled off down the corridor towards ICU his distraught and frail wife arrives. She is taken to the quiet room where she explains that her husband would never want to be ‘on a life support machine’ and asks ‘can’t you just keep him comfortable’?
G – the goal – to provide maximally aggressive resuscitation – was not in keeping with the patient’s wishes. If the goal had been to provide care in accordance with his wishes, the plan could have included attempts to ascertain these sooner while providing initial treatment. Upon gaining sufficient information, a new goal can be established: maximising the patient’s comfort and dignity.
3. An obese 30-year-old female presents with syncope. At triage she is pale, tachycardic & hypotensive. Clinical and sonographic assessment, including free intraperitoneal fluid and a positive urine HCG, is suggestive of ruptured ectopic pregnancy.
The gynaecologist and anaesthetist ask the ED team to bring the patient straight to the operating room. The ED team spends 20 minutes struggling to obtain intravenous access, eventually placing a 22G intravenous catheter in the patient’s hand and a humeral intraosseous needle.
Her shock is considerably worse on arrival in theatre, despite attempts to transfuse O negative blood en route.
Goal – get her safely to the operating room Plan – vascular access, cross match blood, start haemostatic resuscitation, go to OR as soon as possible Actions – peripheral and/or intraosseous cannulation attempts Skills – vascular access skills
Here the failure was at the actions and skills level. Better vascular access could have been attained using ultrasound guided peripheral cannulation, or central vascular access, or earlier intraosseous insertion.
4. A 120kg 32-year-old male with a history of deliberate self harm presents on the night shift with coma due to mixed benzodiazepine and venlafaxine overdose.
The decision is made to intubate for airway protection. After rapid sequence induction direct laryngoscopy is attempted by the emergency registrar who obtains a grade 4 view. Cricoid pressure is removed resulting in a grade 3 view.
The registrar asks for a bougie which she passes and then railroads the tracheal tube over it. The cuff is inflated, capnography is connected, and the self-inflating bag is connected and squeezed while the chest is auscultated.
The abdomen distends, the capnograph remains flat, and gastric contents are seen to pass upward through the tube into the self-inflating bag. The tube is immediately removed and bag-mask ventilation is attempted. The oxygen saturation is now 78% and the airway is soiled. The airway is suctioned and repeat attempts to bag-mask ventilate fail. A successful cricothyroidotomy is performed and the patient subsequent has full neurological recovery.
Goal – Provide supportive care and minimise complications from overdose Plan – Airway protection and admit to ICU for monitoring Actions – Rapid sequence intubation, ICU referral Skills – Pre-, peri- and post-intubation oxygenation techniques; patient positioning; rapid sequence induction of anaesthesia; direct laryngoscopy; bougie handling techniques; external laryngeal manipulation
In this case the patient was not placed in the ramped position and no nasal cannulae were applied for apnoeic oxygenation. A tube was railroaded over an oesophageal bougie, which arguably should not occur if ‘hold up’ is sought when the bougie is placed.
Although the goal, plan and actions were appropriate, the team did not demonstrate adequate skill in this procedure. Likely due to a failure of training, standardised procedures, and checklists (or their application), this could also be identified as a ‘system’ problem in STEPS. It is also possible that the intubator forgot her training under stress – a problem classifiable under ‘self’. Alternatively other members of the team may have had knowledge but didn’t speak up or cross-check their colleague, which would be a ‘team’ issue.
Limitations of this approach This sort of analysis is retrospective and subjective and at risk of hindsight bias (e.g. distortion due to projection, denial, or selective recall). However, these limitations do not negate the value of the learning exercise, particularly if we are aware of them and strive to minimise their impact (e.g. write down the details of a cases as soon as possible afterward). It at least provides a structure for individuals and teams to begin the conversation about where and how things may have been suboptimal.
Goals may be multiple and may change according to incoming information, and for each goal there may be several viable alternative plans. STEPS and GPAS may overlap, eg. team failures may result in inappropriate goals and strategies, or in failed procedures.
Summary These models may prove helpful as a means of dissecting a case in a structured way. Put simply, STEPS offers a structure for identifying efficiency improvements (“doing things right”) and GPAS can help us assess effectiveness (“doing the right things”).
Another way of looking at it is that STEPS provides the components of a resus at any point in time, and GPAS defines the trajectory: where the resus is going and how to get there.
I use this structure to analyse cases in my own clinical practice and in my teaching. I would be interested to hear from others’ experience. Do you find this approach useful in identifying areas for improvement in those cases that you feel should have gone better?
Thanks to Chris Nickson for his comments and improvements to this post
A resuscitationist agonises. These words, expressed by Scott Weingart during a podcast we did together, ring true to all of us who strive to improve our practice. Driven by the passionate conviction that we should never lose a salvageable patient through imperfect care, we relive cases and re-run them through our mental simulators to identify areas for improvement.
In the search for actionable items though, we occasionally exit this process empty-handed. Something about a case felt wrong although ostensibly all the clinical interventions may have been appropriate. It is in these cases that it can be helpful to have a structure to aid analysis.
I, along with an international, interdisciplinary faculty of resuscitationists, have previously proposed an easily remembered system for optimising the clinical and non-technical components of resuscitation immediately before and during a patient encounter, dubbed the ‘Zero Point Survey’ (ZPS)(1), so called because first contact with a patient is rarely ‘Time Zero’ for a prehospital mission or hospital resuscitation case; there is invariably time for preparation of oneself, one’s team, and the environment (including equipment) prior to the primary survey and commencement of resuscitation. Following the assessment and management of STEP (self, team, environment & patient), the team should be regularly Updated on patient status and informed of the Priorities.
But ‘self, team, environment and patient’ isn’t just a useful system for case preparation. It can also be used for case analysis. I have found by discussing many ‘unsatisfactory’ cases over the years with participants in human factors workshops that STEP can help us identify where the issues lie. Accompanying all these factors is another ’S’: the system in which they interplay – the organisational rules, processes, policies, resources and deficiencies that may facilitate or obstruct an effective resuscitation(2).
Using STEPS to analyse cases The following (genuinely) hypothetical resus cases demonstrate how the application of this framework – Self, Team, Environment, Patient, System – might help identify correctible factors for future resuscitations:
1. Cardiac arrest in the bathroom on the orthopaedic ward – “it was chaos, there were too many people, and the resus trolley wasn’t properly stocked”.
STEPS analysis: Team – Leader needed to assign roles and allocate tasks Environment – Crowd control needed, lack of equipment System – Adequate checks for resus trolley not in place
2. 19-year-old male stabbed in the chest and arrested on arrival in hospital. CPR provided but went from PEA to asystole. Team leader discontinued resus after 20 minutes. Resident: “I thought he needed a resuscitative thoracotomy but no-one was willing to do it. No-one even mentioned it”.
STEPS analysis: Self – Lacked confidence to speak up, doubted own knowledge or influence Team – Lack of team situational awareness or knowledge or skill regarding required intervention System – Insufficient training and preparation for penetrating traumatic cardiac arrest scenario
3. 30-year-old mother with abdominal wound and her 2-year-old daughter with massive open head injury, both due to gunshot wounds, having been shot by husband/father who killed himself on scene. Child arrests in the ED, without ROSC, witnessed by mother before mother is taken to operating theatre.
STEPS analysis: Patient(s) – tragic case with upsetting circumstances and compounded psychological distress for patient and staff. The best resuscitation team in the world is not going to feel good about this one.
4. 46-year-old previously healthy male with VF arrest achieved ROSC after prehospital defibrillation and brought to the ED of a non-cardiac centre comatose and intubated. Further refractory VF in ED. Received multiple shocks, antiarrhythmics, double sequential external defibrillation. No on-site access to mechanical CPR, cardiac catheterisation, or ECMO. Patient declared dead in ED.
STEPS analysis: System – Prehospital team gave excellent care but brought the patient to a hospital ill-equipped to manage his ongoing needs, due to lack of ambulance service policy regarding appropriate destination hospital for cardiac arrest cases.
Summary You can see from the above cases how STEPS may be applied to make some sense of where a resus has gone wrong. Note that I am not recommending this as a way of structuring a team debrief or formal incident investigation – many institutions already have processes for conducting these and various rules and sensitivities have to be accommodated. Rather, this is a format I’ve found helpful in applying during informal discussions that aim to get the nub of where things could or should have gone better.
Occasionally, you can get a case where the STEPS seem to be aligned but things still feel bad – in which the outcome was unsatisfactory because the plan was wrong, or the team wasn’t able to execute the plan. In my next post I’ll discuss another way of analysing cases that can accompany STEPS.
I find clinicians are quick to consider sepsis and hypoperfusion/ischaemia as causes of a raised lactate, but slow to include other causes in their differential.
Although an elevated lactate has been shown to be associated with worse outcomes in numerous studies, not all causes of a raised lactate are sinister. It’s therefore important to diagnose the cause both to allow the right treatment and to avoid assuming an inappropriately poor prognosis.
This 12 minute video offers an approach to diagnosing the cause of elevated lactate based on an understanding of lactate physiology using a simple visual aid – a ‘lactate map’ and a memorable acronym.
AS A MEMBER OF THE MEDICAL PROFESSION:
I SOLEMNLY PLEDGE to dedicate my life to the service of humanity;
THE HEALTH AND WELL-BEING OF MY PATIENT will be my first consideration;
I WILL RESPECT the autonomy and dignity of my patient;
I WILL MAINTAIN the utmost respect for human life;
I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing, or any other factor to intervene between my duty and my patient;
I WILL RESPECT the secrets that are confided in me, even after the patient has died;
I WILL PRACTISE my profession with conscience and dignity and in accordance with good medical practice;
I WILL FOSTER the honour and noble traditions of the medical profession;
I WILL GIVE to my teachers, colleagues, and students the respect and gratitude that is their due;
I WILL SHARE my medical knowledge for the benefit of the patient and the advancement of healthcare;
I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard;
I WILL NOT USE my medical knowledge to violate human rights and civil liberties, even under threat;
I MAKE THESE PROMISES solemnly, freely, and upon my honour.
Have you deviated from any of the above?
Can you resolve not to in future?
What help do you need from your employer or your colleagues to allow you to adhere to them?
Can you think of colleagues who might benefit from being shown this pledge?
Please reflect on this line:
I will attend to my own health, well-being, and abilities in order to provide care of the highest standard
It is ABSOLUTELY RIGHT to prioritise these so you can be maximally effective for your patients.
If there are changes you need to make in this area, make them.
“What’s your leadership style Cliff? How do you like to run the emergency department?”
Our new fellow had asked a reasonable question. Although I’d never had to summarise it before, my reply came immediately: “I see my role as doing the most for the most by reducing the sum total of human suffering in the ED – both patients and staff”.
I hadn’t really reflected on this before. Obviously my clinical priority is resuscitation, but the reality is that resuscitation only contributes to a small proportion of ED workload. And when our resources and attention are prioritised to the resus room, the department fills with other patients in pain or distress, and their anxious relatives and parents(1).
Examples of the suffering, in patients, relatives, and staff, include:
Emergency departments really can be melting pots of human suffering, but there is so much we can do to reduce or relieve that suffering.
We just need to expand our view of our role from ‘diagnose and treat illness’ to ‘care for patients and their families’.
I believe an emergency physician can do much to reduce the ‘area under the curve’ – from listening to the nurses, buying a round of coffee, making sure rest breaks happen; to relieving pain, thirst and cold; to trying to prevent illness and injury from claiming someone’s loved ones; to being understanding to an admitting specialty colleague; to taking the time to explain to parents and relatives what is going on, and that you are taking their presentation seriously.
I also believe this approach provides some protection from burnout.
It is easy to be concerned with the difficult aspects of our job that are outside our control, which can result in stress and a sense of powerlessness. But there are so many things WITHIN our control that can make such a difference, that this is where our attention should focus.
This is the ‘Circle of Influence’ described by Steven Covey in “The 7 Habits of Highly Effective People”, in which he argues that the first habit, Proactivity, is demonstrated by people who work on problems within their circle of influence, rather than wasting time on those things outside it. Not only will this provide us with more satisfaction and sustainability in our career, it should also make us happier people, since expressing kindness for other people is a key component in the recipe for human happiness (which I describe here).
Of course, the other staff can also make a massive difference. However as the emergency physician clinically in charge of the floor, I have a responsibility to lead by example, and can exert far greater influence than more junior staff. As summarised recently by Liz Crowe and colleagues(2):
“EM doctors as the leads of the ED often set the ‘tone’ for the interdisciplinary staff within the team. Each EM doctor can choose to actively contribute to building a safe and supportive culture of collegial support, professional development and learning through high quality communication, humour and creating a sense of team within their departments.”
So let’s ALL set the tone. Support our teams, and show kindness to them and our patients. We can all help reduce the Area Under the Suffering Curve.
1. Body R, Kaide E, Kendal S, Foëx B. Not all suffering is pain: sources of patients’ suffering in the emergency department call for improvements in communication from practitioners. Emerg Med J. 2015 Jan;32(1):15–20.
This guest post from a fellow retrieval clinician contains a powerful message for us all. We have a responsibility to recognise the inevitability of clinician error, and to develop systems within our organisations to support those involved to avoid the ‘second victim’ phenomenon.
– 0:01: Error – Noun – A mistake
I was the picture perfect hire, I had tailored most of my career for our line of work: retrieval.
I was a senior FRU Paramedic with a background including the hottest terms: “clinical development”, “ultrasound”, “research”, “educator” and the useless alphabet soup that one inevitably acquires through enough time in healthcare. My CV was mint, printed on subtly thick paper to give a subliminal message of “excellence” – calculated moves for a calculated outcome.
I knew the protocols, policies, procedures before stepping through the door. With a fantastic orientation behind me, I was fucking awesome. I was in the stratosphere of awesome. Flightsuit, the smell of Jet A, podcasts blaring. I approached the one-year mark in retrieval feeling at home. Being granted complete clinical autonomy, I found my work deeply rewarding, stimulating. Nitric Oxide, ECMO, Ketamine, DSI/RSI, TXAblahblahblah. The buzz of Twitter was my daily work.
“Error” was a word, a noun. Error was a picture of crashed airplanes or derailed trains. Droning Powerpoints featured the Swiss cheese model and non-sequitur diagrams with abstract buzz-words. If you sucked, you crashed and burned. If you were good, you landed on the goddamn Hudson River.
+ 0:01: I am Error
Through an error in medication transitions, a young girl died under my care. Regardless of the slew of contributing factors, the latent errors – I am Proximate Cause. That is a title that is hard to shed. That is a title that follows you through day and night, wakefulness and sleep, at work, in the car, in the shower, in bed.
Having lost my desire to return to work, I drafted a curt letter of resignation and began the search for work elsewhere where I might be free of consequence. I was filled with dread waiting for my pager to go off, whispering a prayer for an easy tasking. I lacked the organizational or personal tools to process the slew of emotions I felt – incompetence, inadequacy and guilt. Just as easily as I had woven myself into who I was, I came undone.
+ 0:02: “Error-Free” – Adjective – Containing no mistakes
Despite our best attempts to adopt the lessons of aviation, aerospace and high-stakes systems into our craft, we in retrieval are primed for error throughout the work we do every day. We dive into the currents of diagnostic momentum, wading through the thoughts of others. The chaos swirling around us leads to erosion of situational awareness and the interruption of processes. The unforgiving physiology of the critically ill also force us to tread close to the edge. The margins are razor-thin, the consequences are great.
Just like we prepare for the risks involved with a complex machine such as the helicopter, we must train for the consequences of the complexities of medicine, such as error.
Our teams train for the very remote risk of over-water ditching through egress training yet little time is spent on a constant danger to our teams and our patients. The injection of simulated error through misdiagnoses, human factors and poorly labeled vials can not only prime the team for the capture of potential error but also the very real emotions that can result from mistakes – simulated or not. Much discussion has been had on resiliency training as of late, much of its focus on preparing teams for success in the midst of crisis. We must train for events such as an error like mine to prepare the individual clinician for the crisis that follows.
Yet the burden should not fall squarely on the individual clinician. As high performing organizations we have a duty to put in place transparent processes that can provide clinicians with support following a mistake as well as a clarity about “what comes next” following a mistake. As I consider my subsequent hardship following the death of this child, much of it took root in the lack of support from my organization and a lack of clarity about what would happen as a result of all this. More damaging than anything else is the solitude that comes with being unable to share one’s experience. A “second victim” left to their own devices to cope with their mistake is a victim of a system that has failed them.
We are equally primed for injury. One of your greatest strengths becomes your Achilles heel. We pursue our passions and find that resus and retrieval is the medicine that stimulates the cortex. This work inevitably becomes a fundamental part of who we are. The pursuit of excellence under the demanding conditions of our work is all-consuming, leading to this work become the very mesh of our being – “The Retrievalist” “The Resuscitationist.”
Following error, we experience an unraveling of who we are. The hard fall to the bottom is hard to recover from. I write this to let you know that it gets better and that you’re not alone. The resignation letter is deleted, the bottles stop emptying, the sleep comes more easily and you accept that in our craft, “error-free” is just a word, an adjective and that “error” is a noun and does not define you.
This is a guest post from Dr Per Bredmose, anaesthetist and retrieval medicine physician in Norway, also known as Viking One
I struggle to ventilate the patient in the resus room, airway pressures are high, the bag doesn’t empty properly. In my mind I plan ahead for the next step. Through my mind goes the thought – is this the one, the one that I cannot ventilate? Statistically it is not likely to be, but I am prepared to add two-person technique, airway adjuncts like nasopharyngeal or oropharyngeal, or supraglottic devices that I use frequently in theatre. I feel confident in the use of these methods, and (in the worst case) in cricothyroidotomy. I have practiced that numerous times on our live-tissue course on anaesthetised pigs. However – before I start any of these actions.. I routinely, almost as a reflex from theatre turn the patient’s head 45 degrees to the left, and then the bag suddenly empties easily – and I can ventilate the patient.
Some people think that time with TIVA in theatre has little value for emergency medicine and advanced prehospital care. I strongly disagree. This is some of the most relevant and valuable time I have for keeping and optimising my practical skills. Bag-valve-mask (BVM) ventilation is an essential core skill for any prehospital provider. In theatre this manoeuvre is well known and frequently practiced. It is my impression that this head rotation is less used, and even maybe less well known outside theatre, and especially in the prehospital field. Therefore this is a reminder of an old technique.
When to do it: When encountering difficulties in conventional BVM ventilation, either when you cannot ventilate or when it’s just difficult to ventilate.
How to do it: Keep a firm one hand grip and gently rotate the head 45 degrees towards the side of the hand with the jaw grip. At the same time, one can try to optimise the one-hand-jaw thrust that goes along with BVM ventilation. Occasionally one needs to extend (dorsiflex) the neck a bit further to fully open the airway. The technique can also be used as a two-person technique, although this is rarely needed.
Opposition: Frequently I hear that I cannot transfer practice from theatre to the prehospital field. Well, this seems to work well in theatre, in ICU and in the field – airways are airways!!
Recently an article in European Journal of Anaesthesiology by Itagaki et al(1) with a cross over design showed an increase in tidal volume when the patients were ventilated in a head rotated position compared to neutral position with the same airway pressure. Their conclusion was as follows: Head rotation of 45° in anaesthetised apnoeic adults significantly increases the efficiency of mask ventilation compared with the neutral head position. Head rotation is an effective alternative to improve mask ventilation if airway obstruction is encountered. Therefore – this is a useful tool that one always should have in the “practical toolbox”. It is not always the solution, but occasionally it saves you (and the patient) a lot of trouble.
Thoughts from Dr Cliff Reid I haven’t used this approach and wasn’t aware of previous research showing an increase in the retroglossal (but not retropalatine) spaces in (awake) patients with head rotation(2).
The mechanism is thought to be gravitational. It is also possible that neck rotation increases upper airway wall tension that reduces collapsibility of the lumen.
In this elegantly designed new study, a two handed BMV technique was used, similar to that advocated in my prehospital & emergency medicine environments. The rotation was always to the right, although the authors comment that they would expect the same results on the left. The increased tidal volume effect with head rotation occurred mostly in younger patients and patients with Mallampati classification I. Such patients are unlikely to be difficult to mask-ventilate, limiting the applicability of these findings to patients who are difficult to ventilate. However having one more option to employ to improve BMV efficacy (after two person technique, optimising ear-to-sternal-notch positioning, and inserting oro- and/or nasopharyngeal airways) may be useful, and the experience and perspective of my anaesthetic colleague Viking One is definitely food for thought. Obviously one should avoid this if there is potential neck injury so I won’t be trying it my trauma patients.