Working in the ED has probably changed forever thanks to COVID-19. I’ve found the experience peculiar, frightening, and relentlessly interesting. I’m sure we all have.
It goes without saying that the provision of reliable education and guidance in a crisis like this must be left to the experts and grey bearded leaders among us. However, I thought an EM trainee like me might add some value by sharing some of the stuff I’ve been trying to do in order to make myself as useful as possible for my department.
“When” not “if”
We know at least a handful of sick COVID patients will arrive on most shifts. This will surely be the case for months to come. And perhaps at some point we’ll see a “second wave”.
At the time of writing I’ve just finished one of the quietest stretches of nights I can remember in terms of the total number of patients seen in the department. However, the sick COVID patients needing immediate escalation or palliation kept trickling in. It was, and will continue to be, a guarantee.
During the day there seems to be a predictable pattern of chilled mornings and busier afternoons/evenings. It appears others are experiencing the same. When this all kicked off, I regularly took the opportunity to treat myself to an extra coffee in our new ProjectWingman café after morning handover. It quickly became apparent that I could use that time, along with the unnerving downtime overnight, more wisely.
We have started running regular COVID-centric in-situ simulations. Sure, we did the occasional sim before COVID, but all of a sudden we’ve managed to bang out several in quick succession with ample “buy-in”. We’ve debriefed outside in the ambulance bay so participants and observers can practice social distancing, and a post-sim email has then been fired out to the entire department with key learning/action points later that day. We are indebted to Virchester and #EM3 for their leadership on the sim front.
It cannot be overstated how useful we have found these sessions for flagging lurking stumbling blocks and shining the spotlight on key skills that require purposeful practice at the individual and team level.
Currently, ED management of the COVID sickies appears to be predictable – a stepwise approach to increasing oxygen support and keep your wits about you for alternative diagnoses (are the headliners… of course there is other stuff). Invariably, after a sim in the morning, we will do it for real in the afternoon. That has given an urgency and engagement to our preparations because it’s “when” not “if” a real patient requires, for example, CPAP and awake proning on that shift. There is an educational buzz about the place which is cool.
To purposefully practice you must:
– Deliberately target specific skills during shifts, seizing opportunities to drill or do them for real.
– Push yourself out of the comfort zone.
– Seek immediate feedback or self-reflect on stuff that can be tinkered with to improve the next attempt.
The following are the skills I/we have needed to get a lot better at recently:
– Making CPAP happen
– Doffing full PPE
– Closed loop communication
– End of life conversations (#havetheconversation)
Making CPAP happen
In the past I’ve tended to leave it to the nurses and respiratory physios to set up the NIV machine and fit the facemask. Now that we are limiting personnel entering a room full of aerosols, I’ve rapidly needed to get my act together on this front.
At my place our CPAP delivery options are a few Oxylog ventilators and one Trilogy NIV machine. As my knobology familiarity was embarrassingly poor, even the process of turning the machines on and dialling in the appropriate initial settings (PEEP/CPAP 10, FiO2 100% of course) required a bit of drilling. I’ve found this especially true for the Oxylog which I had previously only used for delivery of invasive ventilation.
Fitting the NIV facemask is the step which dictates how long a patient might be subjected to no oxygen and, as we’ve all seen, they can desaturate scarily quickly. We are using the Pulmodyne Maxshield facemask. It’s an intuitive and user-friendly piece of kit, but it quickly becomes a banana skin if a team is un-practiced in fastening it to the patient’s head.
I found this instructional video very useful in guiding my purposeful practice. It’s not exactly the same product (it’s for home CPAP in OSA patients) but the facemask and strapping are pretty much identical.
Key points with fitting (these particular) NIV facemasks:
– Try and be as calm and communicative as possible throughout to maximise patient tolerance.
– Place appropriately fitted mask on face (the “cushion” of the mask should contact the face just above the eyebrows and just below the bottom lip).
– Pull headgear over back of head. To facilitate this one person will need to gently lift the patient’s head off the bed/ask the patient to do it.
– Snap the lower headgear clips to the bottom of the mask.
– Only now can you adjust the length of the top and bottom straps (the velcro bits).
A crucial step in the process (and an easy detail to forget) is the inclusion of an HME filter at the patient end of the breathing circuit. It is attached to the “elbow” of the NIV full face mask.
Another stumbling block we’ve found is swapping the oxygen flow metre for the high flow oxygen hose (for CPAP). This isn’t necessary if you have an oxygen splitter at the wall. Following a sim where the patient was without oxygen for several minutes as we stumbled our way through the swap-over, we have managed to get hold of a couple of splitters for our AGP rooms.
Of course, every department will be different in terms of the equipment they have available and the experience of their staff on a given shift. This is just what our team have been purposefully practicing with regards to CPAP and of course there are some local quirks. It’s the principle of breaking down the process of making CPAP happen, shining a light on each component, and asking the question “how can we get better” that matters.
Doffing full PPE
This is obviously a high stakes procedure. Yet it still feels like loads of people think they know how to do it properly… but actually don’t. I was in that category at the beginning of March and definitely cocked up my first few attempts, potentially exposing myself to a decent dose of virus. It’s fiddly.
I have watched the useful PHE instructional videos multiple times and since volunteered myself to demonstrate the technique to colleagues regularly. I take every opportunity to watch/coach people as they doff. I’ve got so enthusiastic about solid PPE practice that I signed up for the shiny (and now “hibernating”) London Nightingale Hospital teaching faculty and have taught the PPE station. What was once outside my comfort zone is now firmly inside.
An issue with drilling this procedure is that it eats into dwindling PPE supplies. One clever solution is using mental practice/visualisation, which was excellently proposed over at emcrit last week.
Watch videos. Do demos. Mentally practice. Use a buddy system.
Closed Loop Communication
This old chestnut has never been so important. It turns out full PPE and walkie talkies make effective communication bloody difficult. A recap:
– Sender delivers communication to receiver in a clear and concise format.
– Receiver acknowledges receipt by a read-back of the information.
– Sender acknowledges the accuracy of the read-back by saying “that’s correct”.
e.g. Adam is team leader in full PPE in cubicle, Henry is the runner outside…
Adam (via walkie talkie): ‘Henry I need you to get me a bigger NIV mask’
Henry: ‘You need me to get you a bigger NIV mask’
Adam: ‘That’s correct’
Initially it feels weird to make a point of doing this constantly during a sim/case. To the untrained ear it can sound contrived and even patronising. But I’ve found it has become “normal” quite quickly because I’ve tried to practice it with whoever I’m working with.
The great thing about purposefully practicing this is you can do it/coach it to your hearts content in pretty much any workplace scenario. It doesn’t require equipment.
As I’ve heard many times before, if it’s good enough for the McDonalds drive thru, its good enough for a resus room (or AGP cubicle).
End of life conversations
This pandemic has served up some extraordinarily cruel moments for these happily hypoxic patients deemed not for escalation. They have so often been significantly younger than the patients we are used to having the conversation with, and therefore completely blindsided when confronted by their own mortality. And then they must die alone.
I am miles away from mastery when it comes to skilfully and compassionately explaining to a patient or a family the DNACPR/ceiling of care decision. When nervous I tend to ramble, sound rushed, and use too much medical jargon. I can remember several cases in the past where I have left my patients confused where clarity has never been so important for them.
It is impossible to accurately simulate the intensity of explaining to someone they are about to die. Instead, I have tried to be purposeful in my consumption of the abundant educational material. I have found the RCEMLearning COVID hub and this RSM Lecture from Rachel Clarke particularly useful.
I am ashamed to say that this has been the first time I have actively engaged with this subject matter in my training (apart from when I was half-heartedly revising for my MRCEM OSCE). I’ve realised that prior to the pandemic I was largely winging it. A legacy of this experience for me personally is that I will never underestimate the importance of this skill again.
I have created this simple checklist for myself (for talking to patients or families over the phone):
– Have a stop moment before going in.
– What do they understand about the situation?
– Must use the “D word” (death or dying). Tell the patient they are very likely to die from this disease.
– Talk about what we ARE doing (oxygen, analgesia etc).
– Make distinction between CPR and treatment. DNACPR does NOT mean no treatment.
– Explain that this decision helps us get our priorities right – making sure they are completely comfortable and looked after.
– This discussion isn’t about permission. This is a medical decision, and we just want to them to be fully informed and answer any questions they might have.
– Finish by trying to facilitate the patient seeing family remotely via a screen.
I am also planning to start printing off this letter written by intensivist Matt Morgan and giving to patients at the end of our conversation (as per RCEMLearning). It is simple and beautifully worded. Here is an excerpt:
“We will continue to use all of the treatments that may work and may get you back to being you again. We will use oxygen, fluid into your veins, antibiotics, all of the things that may work. But we won’t use the things that won’t work. We won’t use machines that can cause harm. We won’t press on your chest should your heart stop beating. Because these things won’t work. They won’t get you back to being you.”
“We don’t rise to the occasion; we fall to our level of training”Lt. Col. Dave Grossman
It’s been awesome to see how fired up people are getting in the effort to defeat this new enemy. The flow of world class education on an almost daily basis is a joy to behold.
However, I am regularly reminding myself to purposefully practice the bread-and-butter basics. The skills I’ve discussed in this post are raw fundamentals that will continue to be crucial regardless of new knowledge yielded by science. I believe that being perfect at the basics is the beating heart of emergency medicine.
At the beginning of March, I remember proudly saying to friends and family “this is what I have trained for”. I don’t think I was being completely truthful. How can any of us feel like we trained for a phenomenon so brutal and uncompromising as this? To say “this is what I am training for” is more accurate.
Thanks for reading.