Exam Intelligence

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Whilst I was revising for my exam, I did not really take much note of the college Bulletin, which comes with the “Blue Journal” every other month.  I have started reading it again, and in doing so came across several references to an article from March 2008, written by an airline pilot, about the death of his wife under anaesthesia for an attempted ENT operation.  It is quite a tragic case, from which he hopes anaesthetists will learn.

In summary, she had no medical or anaesthetic conditions of major concern, there was slightly reduced neck movement which wouldn’t have worried anyone, airway assessment did not indicate a potentially difficult airway.  The procedure was a straightforward endoscopic sinus surgery and septoplasty.  The plan was to use an LMA which unfortunately could not be inserted at induction, and tracheal intubation proved extremely difficult.  She became hypoxic and could not be ventilated and was eventually allowed to wake up, but unfortunately had had a prolonged episode of hypoxia, and died with extensive brain damage on an intensive care unit 13 days later.  Now this is a grossly simplified summary, and I highly recommend you read the article on page 17 of issue 48 of the RCOA bulletin along with a summary of the case written by Prof Michael Harmer (former president of the AAGBI) at the Clinical Human Factors Group website for more details.

The reason I am writing about it is because it is another one of those safety issue questions that might come up, and something that everyone should be aware of.  I have never been unfortunate enough to be in a “Can’t Intubate, Can’t Ventilate” situation myself, but have become involved in a case where a QuickTrach has been inserted immediately prior to my arrival (without which that patient would certainly have died).  I can tell you that the danger of “fixation” that the pilot talks about is a real danger, and one which I have seen happen to people, and if I’m honest, has happened to me when trying to solve problems, at least outside of work!

My thoughts on this are that whenever you encounter serious difficulties, you should summon assistance, preferably of at least the same level of skill as you, but failing that, any other pair of eyes, hands and a different perspective on the situation can help.  (An aside here:  sometimes, when you can’t figure out something, it’s worth “brainstorming”, but in a non-judgmental way, by which I mean you brainstorm everything, and don’t disregard it immediately out of hand because you judge it to be a bad idea.  The reason for saying “non-judgmental” here, is that you may be fixated on the problem being one thing, but actually it is another, so you throw away a solution without consideration, because you’re looking for a solution to the wrong thing.  Never forget to listen to people.  Sometimes their ideas will be stupid and silly, but sometimes they will come up with a gem…)

Secondly, when you get into difficulty, take a few seconds to think about what you are ACTUALLY trying to achieve.  Are you really trying to intubate, or are you really trying to oxygenate?  Are you trying to save someone’s life by decompressing their tension pneumothorax, or trying to practice your sledinger chest drain insertion?

Thirdly, always look back at what you did, preferably with someone who wasn’t there (though this may be impossible) who can understand the situation (no point talking it through with the diabetes clinic HCA in this instance, is there), and try to figure out what went wrong, what could have been done differently, and why it wasn’t done differently.  The most important thing is that there should not be any attempt to apportion blame. It’s not about “It was your fault.  You didn’t do this or that”.  It’s about “Next time we should make sure that the following things happen…”.

Anyway, back to the point, after all, this is a website about passing the FRCA, right?

There are a number of guidelines and protocols out there about how to manage a failed or difficult intubation, but for the purposes of the UK exam, I suggest you stick to the ones you can find here at the Difficult Airway Society.  Other countries have slightly different guidelines, but the bottom line is, that the idea is to get oxygen in by whatever means is necessary, with the two ultimate (more desirable) outcomes being  a surgical airway, or a spontaneously breathing awake patient (never forget that an awake patient is a possibility for getting yourself out of trouble!).

Sassy speaks again:

Sorry for the long break in communication, I know it’s been quite a while since I last wrote. I really haven’t been up to that much….I would like to say that I’ve been busy reading up about the effects of ranitidine on physiological deadspace (I think she’s taking the Micky about one of the MCQ questions from April here… - Ed.), but I haven’t!

Since the changeover, the last couple of weeks I have mainly been wishing the old gang of doctors would come back. No one likes change and ICU nurses are no exception.  “Come back, all is forgiven!”  I like to think that we’re not fickle but I know we are, and at the moment we wish we had the old guys back.  Give it a year, though, and we won’t want them to leave.  At the moment they are generally receiving what has been termed the “cuff pressure look” ( Me neither - Ed.)  Funnily enough it was the EX who coined that look.  It was the “cuff pressure look” that brought us together and since then my many looks have made me pretty well known.  Sometimes I hardly need to utter a word, because a single look is enough.  I heard an FY1 saying something about a colleague of mine the other day, all completely untrue.  I didn’t speak to him, he knew by my face that he had said the wrong thing!! Poor boy, he’s not been the same since, but he’ll never do it again, so I’ve probably saved him from upsetting the next lot of nurses that he encounters.

So back to dealing with exam stress. My advice now looking back on our time together would be, book time to be together.  Yes I know this sounds like I’m suggesting you give in and be second best to medicine and the timetable, but by booking time, you know you will get it (unless another book on propofol comes out!) and you can look forward to it.

I think I need to comment on the second best bit.  I am not suggesting that you let yourself be second best or that you should adopt that role, but as I came to understand you need to realise how important medicine is to doctors.  They spend years at med school and then years after that studying for post-graduate exams, so it’s bound to be.  To be honest as much as I really longed for time together I was very proud of him and his dedication.  Did I ever say that??? I hope I did and if you ever read this and guess I’m talking about you, I was.

I also think booking either a holiday or weekend break just before the timetable kicks in is a great idea.  When your schedules allow eat lunch or dinner together, at least you get some time to talk and catch up.  Learn to enjoy time on your own, catch up on things you have let slide.  Exercise together; we ran together and he helped me train for a marathon.  One thing I never did was tell him that all the studying occasionally got to me and that I missed my lovely boyfriend, I wish now I had said it.  I’m not saying you should go on about it but everyone is human and I think in an adult relationship you should say what you think or what’s on your mind.  Once he’s finished reading the geeks guide to cardiac output…OF COURSE.

Oh and get yourself on Facebook….if you are that way inclined.  I most certainly am not and cannot understand what anyone sees in it.  Virtual food fights…please tell me all you adult readers what on earth is all that about??  I may dig again about facebook but will try to refrain, you’re lucky I’ve stopped myself thus far!  Oh and one more thing, just don’t try and help him study, even if you are a doctor, its just not helpful, be there when he needs you and when your window in the timetable comes along.

So the exams ended (well that round). I was elated and even more so when he passed. We never got the holiday because I then became the EX.  It was sad, really.

Would I go out with a doctor again…..not if I could help it and he wouldn’t go out with a nurse I am sure.   Even if I met another doctor and even if he was like Mc Dreamy.  (Get it?? Grey’s anatomy?? No? Perhaps it’s a girl thing).  I would probably make an exception for Mc Dreamy, after all Meredith did time and time again.

Anyway, I’ll be back again soon,

XX

To be continued…

Apart from the video for “Girlfriend” by Avril Lavigne, this is the most viewed video on youtube.com, and if you watch it, I think you’ll see why…

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Back in April of this year, just around the time of the SAQ, those pleasant people at NICE published new guidance on Perioperative Hypothermia (Inadvertent).  It didn’t make it into the last exam, because it was published too late, but it strikes me that because maintaining a patient’s temperature during anaesthesia and surgery is a fairly straightforward thing to do, is relatively inexpensive in the grand scheme of things, and has so many potential benefits, that it has a high chance of coming up in the exam this time around.

There is also an article in this month’s Anesthesiology about Temperature Monitoring and Perioperative Thermoregulation by Daniel Sessler from the USA, who has a special interest in perioperative thermoregulation and has been studying it for about 22 years.

CEACCP published Thermoregulation and mild peri-operative hypothermia, an article about mild perioperative hypothermia and its effects, in 2003.

Remember also, that you may be asked in viva voce about methods of temperature monitoring and how the devices used work, and that HME filters are also a possible topic for questioning.

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