Clinical Brain Training

Outline for Surgical Airway Lecture

Jun 22

Posted by Jeff Young, MD in Podcast | No Comments

For my lecture on airways, and surgical airways. Go back to airway podcast for more information.

Airway

Tactical thinking
- Can the air get into the trachea?
- Can the air in the trachea get into the lungs?
- Do the lungs work?
- Can the air get in?
  - Open the airway
  - Use an adjunct to open the airway
    - Oral, nasal, fingers if necessary
Obstructions
- Suction
- Get large objects out, but be careful not to push them farther in (dont blindly sweep)
- Hold large tissue defects open to allow air passage
- Remember the tongue is the most likely item to obstruct
Bask mask technique
- Remember do not push the mask down on the face causing the tongue to obstruct
- Try not to blow vomit into the airway, if you hear noisy respirations you need to suction, or might need to get a definitive airway
- Can the air get from the trachea into the lungs?
  - Problems
    - Large obstructions
      - Mucus plugs, blood, teeth
  - Transections of trachea
    - Huge neck
    - SQ emphysema
    - When ventilating neck looks like its expanding with each breath
    - Air comes back out of mouth with each ventilation
  - Perforation of trachea with airway device
    - Mass in neck
    - Symptoms of tracheal transection
    - Must get airway, less important to treat perforation
      - If you can maneuver tube past perforation, do that, and we’ll worry about perforation later.
      - Do whatever you need to do to get airway, most things can be fixed
      - Do the lungs work?
        
        Massive aspiration
        
        Unable to get sats up despite good airway (color change, see tube pass through cords)
        
        Very important – in hyperurgent situation, if all data looks like tube is in, do not pull it out until you have ruled out other things. You may not get that airway back.
Pneumothorax
- Dart chest, or chest tube
- Remember need to keep path open or with positive pressure pneumo will reaccumulate quickly
Hemothorax
- Not much can be done pre-hospital
- Hemothorax should not cause tension situation
  - Other lung should function normally
  - Darting will not help
  - Only chest tube will help
  - Airway
    - Should be prepared for surgical airway at every intubation
      - I have seen normal intubations turn into catastrophes that requires surgical intervention – you can not predict when it will happen…
At the least, someone should have their hand on a
- Knife
- Tube
- Tracheal hook
  - (or crich kit)
When the sats are dropping, you do not want to be tearing apart bags, or sending people back to the unit to get equipment
Better idea – if you have time, get the airway in the back of the unit
- Lighting
- Better bed height
- Better suction
- Can run if you need to

In my opinion, you should try to do EVERYTHING in the back of the ambulance (you are one step closer to the hospital if things go south)

Crich (you dont do traches in the field)
- Make sure you find the cricothyroid membrane
  - It is VERY easy to think you are in the right place when you are not
  - In some patients it is higher that it looks, in some lower
  - Procedure
    - Find thyroid cartilage FIRST (gull winged cartilage)
    - Move down until you feel first tracheal ring (will usually be prominent)
    - then slide finger up and in to space between first tracheal ring and thyroid cartilage
    - In some people, this space may be small, but it can be widened.
  - Tube
    - If you dont have a tracheostomy tube, use an ETT
    - The ETT should be one entire size smaller than you would use endotracheally
      - In the average adult, I will use a 6.0 ETT for a crich
        
        It is better to get a smaller tube in than be unable to get a bigger tube in
        
        You can usually vent through anything down to a 4-4.5 tube in an adult, and even then you will probably do fine with pO2, the pCO2 may rise but who cares, its short term.
        
        I recommend an NG tube as a guidewire if you are not using a crich kit
        
        You need to know which NG tube you need and it should be readily available, or taped to the ETT or trache
        
        It is OK to have one too small (a 12F will usually work)
  - Technique
    - Find the spot
    - Make a vertical cut at LEAST one inch deep (make darn sure you are into the trachea)
    - Make a MUCH bigger skin incision than the diameter of the tube (at least a half inch wider on each side)
    - DO NOT MAKE HORIZONTAL CUTS
      - You can make your vertical and then turn your knife 90 degrees and stab but do not cut laterally (anterior jugular veins are in variable positions)
      - If you can see into the trachea or you can put the tip of your finger into the trachea, then gently place the tube in with a 45 degree angle heading to the feet
      - If you can see in, or air is not blowing out with bagging, you will need a guidewire, or you will need to widen the hole. To do this you will likely need to cut a tracheal ring
      - Dont push the tube in too far
        
        Very easy to do
        
        Push it till you cant see the balloon, blow the balloon up (if you then see the balloon, deflate and push at least 2 inches farther in, the inflate and gently retract. Once you get the balloon seated, no one EVER lets go of the tube (best) or you use suture (our method) or you securely tie it in (usually does not work)
        
        Best to secure it with trache tie (tube holder will NOT work), and continue to keep your hand on it until a respiratory therapist at the hospital takes it out of your hand.
Pitfalls
- Tube can go north
  - Air will come out of mouth
  - Tube can go to sides or through trachea
    - See signs on tracheal disruption or perforation
  - If you think tube is in wrong place, make certain its in the right place (if you need to shove your pinky into trachea, to make sure path is clear, than do it)
    - Check end tidal
    - Listen to lungs and stomach
  - Right main stems are VERY EASY with crichs

Complications and Rescue

Jun 15

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching, EMS, Hospital | No Comments

Very interesting paper in New England Journal of Medicine (NEJM 2009;361:1368-75, Variation in hospital mortality associated with inpatient surgery) that hospitals have widely variable mortality rates, but surprisingly very similar complication rates. What seems to differentiate great hospitals from good ones, is the ability to rescue patients from complications, not preventing complications.

This is a very important finding, because rescue, in hospitals, is often neglected. We assume that the same nurses and staff that perform routine daily medical care, can immediately transition into providers that can handle the rapidly changing variables present in a patient who is declining or crashing. Often saving a patient with a major complication requires aggressive resuscitation, thorough and rapid search for a cause, and immediate intervention. Another problem is that these patients often look “sick” but dont look like they are “dying”. By the time they look like they are dying, it is often too late to effectively intervene.

Also you could gather 10 patients with sepsis, and they will all have different symptoms, vital signs, and lab data. It takes an experienced caregiver, with a very healthy paranoia, to intervene correctly in these situations. Another maxim of rescue (in hospital and out) is the acceptance of over-reaction. I have talked about this before in that the fire-ems community accept a rather large percentage of calls where they “over respond” based on the eventual facts of the situation. Hospitals are only now learning the importance of over-reaction, and the fact that if you are going to catch the 5 patients who are dying from a complication, you may need to vigorously intervene on the 20 patients who just “look like something is wrong”. Waiting until those 5 patients declare themselves as “really sick” will likely eliminate your opportunity to save all of them. Thus, over-reaction will save lives.

Overdiuresis

Jun 10

Posted by Jeff Young, MD in Clinical Pearls, Hospital | No Comments

In my ICU, the intensivists agree about almost everythig, except aggressive diuresis. I am happy diuresing people, as long as I know that they are euvolemic. Diuresing a hypovolemic patient will not do any good, because you will end up giving the fluid back (and more) once their pressure drops.

This is why a simple , minimally invasive blood volume monitor is the Holy Grail in many ways. Swan Ganz Catheters will usually give you a valid impression of fluid status, but it is invasive, and crazy in the recoveing patient who’s fluid status is unknown. A test of Lasix is reasonable, but what do you do if you give 20 of Lasix to a diuretic naive patient and get a poor response? Do you double the dose, or do you conclude the patient’s fluid status may be poor and their kidneys are saying “dummy, enough with the Lasix”.

So, if you see someone with low urine output and hypotension, fluid is the treatment, but I just want to make sure you look at the I’s and O’s, you look at the weight, you look at the BUN/Creatinine. A lot of times they get a contraction alkalosis that causes confusion. I’ve seen patients pH get in the 7.5 range solely through diuresis, and though you will never see a good randomized study of this, it cant be good for the patient.

The Febrile ICU patient (from a War Game Lecture)

Jun 10

Posted by Jeff Young, MD in Clinical Pearls, Clinical Teaching | No Comments

When you’re doing an infectious investigation, and we’re all guilty of not doing this, you really do need to look everywhere. The kinds of patients that we get in the unit continue to be febrile, continue to have white counts, we don’t know why. You need to look at every IV site, you need to do a rectal, make sure they don’t have peri-rectal, turn them to make sure they don’t have an infected decubitus. I can forgive anybody that the first time through you get a chest x-ray, they’ve got an obvious pneumonia, productive sputum, it’s not a big deal if you didn’t strip them and look at everything, but once you’ve had someone who’s been treated for 3 to 4 days with a presumptive diagnosis, they’re still sick, they’re still febrile, they’ve had a big drop in their white count (and remember, a big drop in the white count is consistent with sepsis not with getting better). You need to say, I’d strip them, look all over their skin, I’d look at their old sites. Look at the IV sites, do a rectal, make sure they don’t have peri-rectal, look at them, look at their back and make sure they don’t have a decubitus

Website

Jun 10

Posted by Jeff Young, MD in Information | No Comments

I’ve been remiss about keeping posts going on the website, even though I’ve been pretty steady with a weekly podcst. I will try to put more stuff on the site to read, starting today.

Scenario Training: How to get the most out of it…

Jun 1

Posted by Jeff Young, MD in Clinical Teaching, EMS, Hospital, Podcast | No Comments

This podcast follows the latest blog entry. How do you get the most out of scored evaluation and training scenarios. This training and testing mechanism has become the most important tool in most organizations for teaching and evaluating students and new employees. Using this teaching tool optimally is incredibly important to both the person being evaluated, and to the organization. I present my thoughts on how to get the most out of the process.

Also have parts of an original song I wrote and performed at the beginning and end. Please tell people who you think may enjoy the podcasts and site, up to 18,000 downloads and want to reach as many people as we can.

Thanks.

Podcast: Play in new window | Download

Scenario Training: How to Teach Them and How to Make Sure People Learn From Them

May 29

Posted by Jeff Young, MD in Clinical Teaching, EMS | No Comments

Teaching How to Do Scenarios and How to Learn From Them (BACKGROUND FOR THIS WEEK”S PODCAST)

While checklists are good, teaching people to perform medicine where 100 proscribed motions and words are delineated may or may not be good. While seemingly contradictory to what I’ve said before, here are the reasons:

Memorization sucks from a safety perspective

Things are memorized in patterns, when you break the pattern everything shatters to the ground and its very difficult to recover
So, memorization is good if you can sit there, clear your mind, concentrate without interruption, and regurgitate the components – rarely happens in an emergency

Memorization is a bad way to teach

Things are learned in chunks (5-7 individual items) that are then bonded together by transitions
- Airway transitions to breathing exam after you do X, breathing to circulation when you do Y
- That way all you need to remember under pressure are the transitions, the chunks will be there for you if you learned them properly (repetition)

People who are not good teachers (or think they are good teachers) teach neophytes by pointing at the list of checkboxes and say “look, dummy you didn’t do this one”. The learner then gets nervous and goes “shoot, I better remember to do that one” this then makes it hard for them to remember the previous step or the one following since they now fixate on the one they missed.
Checklists are NOT FOR MEMORIZATION. They are safety tools to be used during, or around the heat of the moment to create a situation where you can collect data, analyze, and implement. When you don’t have to memorize, you can go one level deeper into information gathering and analysis, which is usually good (but could be bad if you are not diligent about going back to your checklist and making sure you got everything).

So if you have a checklist why learn anything?

Because you need to understand the physiology, the presentation, the sequence of signs and symptoms, the safety considerations, the techniques for care (IV’s, intubation and such) and you need to learn how to properly rank priorities and form and carry out a treatment or rescue plan that works.
The checklist merely allows you to not forget essential safety components

My take on how to teach this:

Make certain the learner understands the background on everything (what it looks like, what its components are, etc.)

What respiratory failure is
What an unsafe environment is
What shock is, etc.

Next, insure they understand why the steps in the algorithm are where they are?

Why is airway first
Why do we listen to the lungs
Why do we check peripheral pulses first
Why do we wear PPE
Why is an unsafe scene a problem, even when the patient is dying and needs help right away

Next, ONLY practice the individual steps.

Do those until you can see the person understands what they need to do and why, and why the algorithm is the way it is..

Don’t even think of going to step B until they have a grasp on step A
- Example: don’t move to breathing evaluation until the learner is checked out on airway, and so on

After learning all the steps (airway, breathing, circulation, vital signs, etc.)

Use YOUR experience and knowledge to help them link the steps
- Everyone does this a little different, and often there is no right way
- Will go over in podcast

When you are preparing to test, don’t make them go through the whole evolution if they are screwing up – STOP! You must correct them when they muck up a step or a transition

How you prepare someone for testing is where your ability as a teacher comes out. It is at this step you can make or break learning and retention
Remember, in these sorts of things, if they do it wrong once and their mind grabs that bad process, it will take a lot of work (usually 5 perfect repetitions) to eradicate it
Stop, tell them what they did, and go back at least 2 steps, so they need to practice the step, and the transition in the flow of the problem.

Finally, testing probably needs to be less strict

I know this is contrary to a lot of what I say, but if someone is getting nervous at the same step in the test over and over again, and they clearly understand the material, and they do everything else right, they probably are competent and shouldn’t be failed. If they are horrible all the way through, get rid of them before they hurt someone.

Medical Decision Making Lecture at Virginia Society for Repisratory Care

May 22

Posted by Jeff Young, MD in Clinical Teaching | No Comments

This is the lecture I gave this past week at the Virginia Society for Respiratory Care in Virginia Beach, VA on May 21. Hope you enjoy it.
Thanks for listening.
JY.

Podcast: Play in new window | Download

Respiratory Failure

May 19

Posted by Jeff Young, MD in Podcast | No Comments

Discussion of respiratory insufficiency and failure, treatment, and some information on ventilator management. The podcast is available at Clinical Brain Training on iTunes.
Thanks for listening.
JY

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Leadership and Improving Clinical Care

May 13

Posted by Jeff Young, MD in Podcast | No Comments

In this podcast, I try to tackle the issue of leading clinicians to safer and more effective care. I give no answers, but my take on the process from my experience in quality and patient safety. Whether you are a leader or are objecting to being led, I think you will get something out of it.
Music from Tom Jolly and I from the album “On Call” from our old group Nightbreeze.
Thanks
JY