We have all heard of the "sterile cockpit." This is a practice that crews on aircrafts follow during critical phases of flight (like take-off and landing). During these critical phases of flight, nothing is spoken of except the safety of the crew and the task at hand. This means no talking about your weekend while the pilot is trying to land in the middle of a neighborhood. This practice should be applied to more than just flight. Distractions can cause us to miss important things about our patients during assessment as well. More focus on the task at hand instead of trying to multitask may improve our performance. What do I mean?
It's not uncommon that I'm asked unrelated questions while performing important tasks. How can we stop interruptions? I would like to push for something called "OAAT" (pronounced 'oh-at'). This stands for "One At A Time." This is a term that could be blurted out loud when you start a task. This lets your team know that you either need them to assist, or at the very least, not interrupt. What kind of tasks would this be appropriate for?
Reading the ECG
When you are handed an ECG, it shouldn't be delivered with a side of questions that are unrelated to the ECG. It's important to be able to stand there and take a solid one minute to look at the ECG. One minute seems like a short amount of time if you were taking an exam and had to answer a question about an ECG, yet in real like we usually glance at the ECG for about 10 seconds because other tasks are breathing down our necks. It's time to take back the habit of methodically reading each ECG. When is the last time your thoughts or words mimicked the following when you read an ECG?
"Sinus rhythm, rate of 70"
"There are no ectopic beats"
"No abnormal P wave axis or notching"
"Normal R wave axis, looks like positive 60"
"R wave progression looks normal, I have a biphasic V3"
"No AV or hemi blocks"
"I don't see any T wave abnormalities"
"All ST segments look even with the PR segments"
"Measurements are all within normal limits"
"Alright... I don't see any immediate life threats on this ECG, I'll write down this interpretation and move on "
You can do all of that quickly if you have no interruptions. Maybe the next time you anticipate being interrupted during your ECG read, you can simply tell your team: "OAAT."
Calculating Vent Settings
Figuring out vent settings involves usually only a few calculations, but interruptions can really throw a wrench in them. Hopefully you are using ideal body weight for all of your vented patients. So your sequence of events would go something like:
"This a male patient, height of 5'10", so I am going to take 10x2.3 and then add 50, this gives me 73 KG IBW"
"73x6 since there is no history of obstructive or restrictive lung disease. This gives me 438mL, I'm going to use 450mL"
"The rate is going to be 20/min for an adequate vT, there is no known acidosis"
"Since we just did RSI, let's begin at 1.0 fio2 and then titrate down"
"I'm going to use 10 of PEEP to start, since that is what the patient was on prior to intubation"
"Setting the I time 0.8"
"I:E ratio will be at least 1:2, again there is no known obstruction"
"Checking a Pplat, 14"
"Calculating the driving pressure, we have 9"
"Flow waveforms looks normal"
"I do not currently have any alarms"
"Let's watch the patient's sedation level when the rocuronium wears off and be prepared to decrease the I time, switch to SIMV, and increase sedation as well as analgesia"
Getting someone's vent settings right is extremely important and warrants no interruptions from teammates, unless they are helping with the task at hand.
Obtaining IV/IO Access
Obtaining IV or IO access can be extremely easy, or extremely difficult. It becomes difficult for several reasons. Crappy veins, practically no veins, obesity, low perfusion states, etc, can all cause stress and difficulty when trying to obtain IV access. IO Access may also prove difficult when boney landmarks are obscured by adipose tissue. It has been my experience that everyone expects everyone else to get the IV or IO access on the first attempt, and with little effort. This kind of thinking invites interruptions because the task is perceived as easy. Perhaps the fix to this is turning it into a mentally sterile procedure. Taking a few moments to collect your thought, lay out your equipment, and perform a thorough assessment of the vein/bone anatomy will likely increase your first attempt success. I've seen more than a few IV lines pulled out or dropped because of poor communication (secondary to distraction) between the provider placing the line and the person assisting them.
"I have all my equipment laid out. Tegaderm, tape, extension set is primed with a flush and cap."
"I'm using a 20 G"
"I've just prepped the site with a couple alcohol preps"
"We will be placing this IV in the cephalic right here on the wrist"
"I need you to hold the arm just like this"
"I have good flash and the catheter advanced easily"
"Good blood return"
"10 mL's in, no sign of infiltration.
"I am going to hold the arm and IV in place now, you can let go"
"Now place the tegaderm over the hub of my IV"
"Let's tape here, here, and here"
This task may seem simple, but I believe we take it too lightly. I suspect distractions and rushing plays more of a part in missing on the first attempt than we think it does.
Dosing Medications
A medication dosing error is NOT something you want to have to put in your report/chart. There are many hospitals that have put in place protocols for a mentally sterile environment for this already. This is in an attempt to reduce errors. When drawing up a medication, no one should be throwing out numbers for other parameters in the same room (vitals, vent settings, urine output, etc.). This is like screaming out random numbers while someone is trying to count their money, it will almost surely make the task much harder. Drawing up medications should also always be at least a two person task.
Person 1: "I have 2 vials of amiodarone, 150 mg in each, with a concentration of 50mg/ml"
Person 2: "I confirm"
Person 1: "I am going to draw up 5ml for 250 mg, 3 ml out of one vial and 2 out of the other "
Person 2: "I confirm"
Person 1: "Placing 250 mg into this 250 mL bag of D5W for a concentration of 1:1, 1 mg to each mL"
Person 2: "I confirm"
Person 1: "Placing the pump at 900 ml's / hour with a total volume to be infused of 150 to deliver 150 mg over 10 minutes"
Person 1: "I confirm"
It is easy to grab a wrong vial or mix up a dose when your environment is not conducive to critical thinking. Make sure your teammates know, OAAT!
Patient Movement
I've never personally seen it happen, but I've heard horror stories about chest tubes, ET tubes, PICC lines, and all kinds of other things getting yanked out while moving a patient. This is a critical event that could kill a patient, and it would simply be due to pure inattention and rushing. I am usually the person holding the ETT and head during a draw sheet transfer from one bed to another. Every single time, I ask everyone touching the draw sheet: "Are any lines going to get caught? Is the foley up? Is there enough slack on the IV? Are The beds locked? Is everyone ready?" NEARLY EVERY TIME... The person at or near the feet will start counting while everyone is still checking if it's actually safe to move the patient!! It drives me insane! In what world do the people down at the feet live in?? The person at the head always counts! BTW, counting is actually bad (or so I've heard). You should be saying "ready, set, go." This apparently avoids confusion with people who think you're going to say "one, two, three, GO." If you work in EMS, there is another mentally sterile procedure you should be aware of as reguards patient movement. What is it?
Loading the patient in and out of the ambulance! My partner and I (@FOAMedic1) have been doing a mentally sterile environment with this for a long time now. Once the cot gets to the back of the ambulance, we ensure nothing is hanging on either side. Then, we make sure the cot is securely locked in. We then both grab the cot no matter how light the patient is (we try to do this the exact same way every time). Whoever has controls will say "I have controls," and then start to count "ready, set, go!" I have confidence that we will never drop a patient as long as we continue to follow this habit. During movement of the cot we are also in constant communication about safety hazards. If something even seems slightly unsafe, we will come up with a better plan for whatever obstacle we are trying to overcome.
It Can't Be Rude
There are many other procedures that are important to keep mentally sterile. Intubating, a rapid trauma assessment, assessing lung sounds or heart tones, ultrasound exams, etc. The bottom line is that you need to have open and clear communication with your team about when it is completely inappropriate to interrupt a provider during a task. There will obviously be times when tasks need to be interrupted. If you're busy reading the ECG and the nurse tells you that the patient just lost a pulse, that probably wouldn't be the smartest time to respond with "OAAT!" Is the OAAT idea silly? Maybe. Or, maybe it could become a non-offensive way to let people know that you will be right with them as soon as you take care of this important intervention. It could be a way of politely saying 'patient care first, hang on.' Whatever way you choose to communicate a mentally sterile environment, it has to be polite, non-offensive, and effective. There should be an understanding between the team that cutting off the person who is doing the interrupting is not rude, it is just part of effective patient care.