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Operational Readiness- Pressure Lines

In the heat of a stressful moment, we seldom rise to the occasion but rather sink to the level of our training. I was reminded of this last week when my partner and I were setting up for the intubation of a hypotensive septic patient the other day. The two of us are often conducting clinical simulation scenarios in our free time, but usually they are focused on the management of trauma patients. In my local service area, the vast majority of our flight requests are for trauma evacuations. While our intubation followed all standards and we achieved the DASH1-A, or definitive airway sans hypoxia/hypotension on 1st attempt (credit to Dr. Weingart @EMcrit), we felt ourselves shaking off a little rust as we prepared for the management this particularly sick medical patient. In our debrief later in the evening we both concluded that the outcomes would have been the same, but our on-scene time could have been improved significantly. Thankfully at my service, on-scene times are not the metric we are judged upon rather the overall quality of care.

As a preceptor of new nurses in the ED, I always loved recruiting nurses of differing years of experience to participate in training exercises. It offered everyone a chance to "shake off the rust" and identify areas for improvement. This strategy also highlighted the importance of maintaining operational readiness for newly graduated nurses transitioning to practice. Precepting also afforded me the opportunity to sit back and observe nurses performance at times, as opposed to always being in the trenches. This gave me some good insight to the skills that were most lacking within our department. I quickly realized that ED nurses in my hospital hadn’t the slightest clue how to properly set up an arterial line transducer. I doubt I will forget the moment when that reality was apparent. Our team was resuscitating a hypotensive patient receiving a massive transfusion. It was impossible to get digital blood pressures so the physician opted to insert a central line. He inserted the line and reached for the transducer, only to find 3 skilled and seasoned ED nurses fumbling over the tubing. He then asked for something that gives me chills to this day… “Call up to the ICU and get me one of their nurses down here”. For all my ED clinicians out there, you know what a slap in the face that is as ED and ICU are still fighting the greatest healthcare civil war, the likes of which has no end in sight.

It’s vital as emergency and critical care clinicians to be at our best when it comes to the use of our own equipment as there is nothing more embarrassing or frustrating than fumbling with your gear when the crucial moment comes. The above interaction is what sparked my interest in creating a way for nurses to prepare for the insertion of pressure monitoring lines in a simulated environment, where mistakes can be made and lessons can be learned without affecting patient care.

Simulation has gained a deserving foothold in the healthcare setting but remains expensive unless some creativity is applied. Here is my method for creating a pressure line simulator applicable for monitoring CVP, PAP, PAWP and peripheral/central arterial lines.

Equipment for the simulator: Equipment for the pressure