You’re running a cardiac arrest and you notice the provider on the airway is struggling to deliver effective ventilations. You start trouble shooting and realize there isn’t an OPA to aid you. You hand him the OPA and ask one of the firefighters to provide a thumbs up technique + jaw thrust. You now note that the patient is ventilating appropriate during your brief 30:2 pause.
Why did this happen? Everyone knows airway adjuncts are necessary in cardiac arrest and BLS management, but you skipped right over this step and began to ventilate with just a BVM.
Maybe you forgot to suction before shooting that bolus of vomit down the airway with your BVM.
Providers shoot themselves in the foot on every call because they’re not organized like a resuscitationist.
In this blog I would like to discuss my thoughts on organizing our equipment with consideration to human error and adaptations to stress.
A Resuscitationist is..
In all actuality some of the characteristics of a resuscitationist
-Purposeful, intentional, and conscious
-Deep, visceral understanding of fundamental principles
-Application of Evidence Based Medicine
-Cool, calm, collected
A resuscitationist is purposeful to prepare themselves to be physically fit and mentally straight, intentional about their movements and process as well as conscious of their faults. Resuscitationist are first exemplary followers that are accountable, teachable, and humble. They reach a point where they have an unquenchable burning to better themselves and medicine. This fire develops into a passion where they must create change to work in an environment that provides maximally aggressive care.
Resuscitationist construct an environment where they craft space between their ears to allow for critical thinking and execution of procedures that make a difference in their patients. Resuscitationist do this through cognitive offloading.
Cognitive Offloading
Risko and Gilbert (2016) defined cognitive offloading as “The use of physical action to alter the information processing requirements of a task so as to reduce cognitive demand.”
Did you tilt your head (or your phone)? If so you performed a cognitive offload. Your brain wants the picture in the correct orientation so you turn your head so you can ‘see’ the picture easier instead of your brain thinking about it.
We cognitively offload every day by putting appointments in our calendar, set a timer while the brownies are in the oven, and write a grocery list. This is usually the extent to which people cognitively offload on an intentional basis and often revert to “I’ll remember that later.” How many times has your spouse asked you to pick up bread from the grocery and came home with everything but the bread? (Side note we can become more productive and dependable by using task management software like OmniFocus to have a program to remember it for us.)
This happens in everyday life, we don’t cognitively offload easy task, get wrapped up in that email our boss sent us and then forget to do simple task. This is magnified 10x while under stress and resuscitating a patient.
Our cognitive bandwidth can become shrunk down to the task immediately in front of this and have an almost complete loss of situational awareness (Weingart, 2014). During resuscitation this can mean forgetting to place an OPA in, pull off the IV band, or spending what seems like forever finding that one piece of equipment that is right in front of your face. As resuscitationist we must set ourselves up for the best chance at success by becoming extremely intentional about our equipment set up and location to better optimize our ability to practice under stress. This process of cognitively offloading will prevent the loss of precious moments during a resuscitation.
Organize Like a Resuscitationist
Organization and bag selection is a contentious topic among providers, or at least I am. Organization and equipment needs will differ among providers and agencies. Consensus may be difficult to reach sometimes and will need to differentiate between protocol and technique. Debate protocol and respect provider’s technique.
Organize in a way that follows an order of operation. Following an order of operation allows providers to move in a logical stepwise fashion that takes incremental steps with equipment in the way the procedure/protocol needs to be performed.
These are some examples of the way our major medical bag is organized at an agency. There’s a plethora of intentional organization that was implemented. These are just two examples.
For example inserting an EZ-IO, there’s a movement to insert the IO in the humeral head because of the flow rate, proximity to the heart, and cabin orientation (Lairet et al, 2013).
The equipment needed to place a humeral head IO is the prep kit, needle, flush, drill, and stabilizer. After identifying the site we need to prep it and let dry. During this dry time we can open the needle, flush the line, open the stabilizer, then attach the needle and go to town.
To cognitively offload this task we can organize the needles in yellow (largest) on top, then stabilizers (if packaged separately, then blue (adult), and pink for peds on the bottom. We organize in this way because the yellow should be the most commonly used IO and peds the least common.
But where’s the pressure bag?
The pressure bag is with the IV fluids because the pressure bag is applied to the fluids, not the IO itself.
A well-managed basic airway is far superior than a crummy intubation attempt (Pozner, 2019). Providers often noticed they didn’t have suction on and they forgot to place an OPA during a cardiac arrest. The suction machine was placed inside the major medical bag, creating one less thing to carry, and in front of the BVM and NPA/OPAs. This prevents providers from going straight to the BVM because they have to physically touch the suction machine and OPAs to get to the BVM. By doing this it creates an order of operation so the provider can take the first step in suctioning the airway, placing the OPA, and ventilating with the BVM.
A great way to discover issues prospectively is to use simulation to validate and test various organizational techniques and devices. Using simulation allows providers to try new things, make mistakes and learn without negatively impacting patients. This is also an environment that we can film and make use of multiple observers.
Another technique is to use a visualization technique to walk through the steps in a procedure and think how you can organize equipment.
Being a resuscitationist means that we’re purposeful, intentional, and conscious about the details that matter. To better utilize the space between our ears we need to give ourselves room to critically think by offloading seemingly innocuous task to a flow that is easy and automatic.
What intelligent designs have you created to compensate for human error?
-Adam LaChapelle
References:
https://www.ncbi.nlm.nih.gov/pubmed/27542527
https://emcrit.org/emcrit/emcrit-book-club-on-combat-by-grossman/
https://www.ncbi.nlm.nih.gov/pubmed/23331182
https://www.uptodate.com/contents/advanced-cardiac-life-support-acls-in-adults