Episode #154 Tips for Anesthesia Trainees To Help Keep Patients Safe, Part 2

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Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. We are continuing the conversation about tips and tricks for keeping patients safe for new anesthesia trainees. We are so excited to have Scott back on the show today for Part 2 in our series. Anesthesia trainees provide anesthesia care throughout their training and a foundation of patient safety right from the very beginning is critical to keep patients safe. We talked about medication safety, time-outs, checklists, and references on the show last week so make sure to check out Part 1 if you haven’t already. Today, we are talking about…well, I don’t want to spoil it!!

Before we dive into the episode today, we’d like to recognize Fresenius Kabi, a major corporate supporter of APSF. Fresenius Kabi has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Fresenius Kabi – we wouldn’t be able to do all that we do without you!”

And now let’s return to the conversation. Let’s move on to number five.

[Blaine] Yeah, the fifth tip and trick is one of my favorites, and that is to preoxygenate prior to induction of anesthesia so that you’re not rushed during your laryngoscopy.

[Bechtel] This is such a great tip. When you’re starting out in anesthesia or throughout your career, do you have any clinical examples to go along with this?

[Blaine] Yeah, I always make sure to make a point of this whenever I have either a medical student or a junior resident in the room. Um, I always make sure that we. Preoxygenate for three minutes. I let the patient breathe their regular tidal volumes prior to induction. And then I always kind of point out, you know, based on the patient’s comorbidities, but a young healthy person can go 5, 6, 7 minutes often without desaturating and. 5, 6, 7 minutes can be a lifetime when you’re moving down the difficult airway algorithm. Uh, should something like that arise.

[Bechtel] I love this one. I have been known to say I love preoxygenation in the operating theater. It is so important. This one belongs under the 10th APSF Patient Safety Priority Airway Management, which includes airway management, difficulties, skills, and overall management.

Anesthesia professionals need to be experts in airway management to help keep patients safe during anesthesia care. Making sure to effectively preoxygenate prior to induction of anesthesia and airway management provides additional time before desaturation. Did you know that the A S A updated the practice guidelines for management of the difficult airway in 2022?

The APSF reviewed the update in June, 2022, and we discussed it on this podcast for episodes number one 13 and number one 14. The updated guidelines highlight the importance of oxygen administration throughout the difficult airway algorithm, and this includes preoxygenation. You may provide care for a patient with an unanticipated difficult airway, and in this situation, preoxygenation may be life saving.

[Blaine] Absolutely. And I think another thing that I really like about procrastination is that when you are, uh, Deliberate and you can take your time with your laryngoscopy, you probably decreased the chances of either causing a nick or a cut on the lips damage to the teeth. These are things that we, I think I’ll mention in our preoperative evaluation to the patient, that there’s a, a chance of damage to the teeth or lips.

Um, but when you’re not rushed, I think you’re really able to take your time and, uh, be careful and avoid these types of, um, somewhat preventable. Harm to the patient.

[Bechtel] The other thing you can do while you’re pre oxygenating is to confirm that the patient is in the best position possible for, uh, laryngoscopy and intubation as well.

You have that three minutes where the patient is breathing oxygen, uh, and you’re confirming with your, that your monitors are all in place and working well. And then you can really look at the patient and say, do I have them in the best position? To be successful in that first attempt of intubation. And so you might want to change the bed height or put the uh, back up, elevate the head of the bed for the patient, or do any kind of maneuver so that they’re in the best position possible, and then now they’re well pre oxygenated and that really is the best time for induction of anesthesia and then proceeding with airway management.

All right, so moving on to number six.

[Blaine] Yeah. Number six is communicating both directly and specifically if you are going to have other professionals give medications and. What I mean by this is that other people might not know exactly what is going through your head if you don’t say it out loud. And so if you are either going to have a junior resident, give medications, a nurse, give medications, or anyone else stating both the drug name, using the generic drug name as well as the dosing that you would like to give the milligrams.

And I also like to say, The actual volume, because that’s often a more understandable and standardized way to say, uh, how much medication you would like to give.

[Bechtel] When would be a time when you would be communicating about somebody else giving a medication?

[Blaine] I had to learn this one the hard way, unfortunately is, and it is why it made this list, and I always try to remind junior residents of it, but I was doing obstetric anesthesia and I was called to assess a patient who was hypotensive after, uh, an epidural placement.

Uh, I went and saw her and her blood pressure was a little bit low and systolic in the eighties, and so I went into our cart and I grabbed a syringe of phenylephrine and was going to give a little bit of phenylephrine. The patient’s nurse was also in the room and she was standing on the opposite side of the bed to me, and the patient’s IV was over by her.

And so I asked the nurse, would you please give a hundred micrograms of phenylephrine and. I didn’t have much rapport with this nurse. You know, I was just there. I had just placed the epidural not too long ago and then left. And so I, the nurse hooks up the phenylephrine syringe to the iv and I watched her push the whole syringe, which was 10 mills as opposed to just one mill.

Uh, Thankfully, no harm came to the patient. Uh, but that was a hard lesson to learn from me in, uh, in effective communication. Uh, you know, I intended to give one milliliter and I should have specified the exact volume, which is why I always do that now, uh, because again, that’s much easier for everybody to understand what you mean.

[Bechtel] Yes, I agree that’s, it’s helpful, and you could say probably the dose and the volume too, just to be sure, but I, those kind of communication skills really are fundamental for anesthesia professionals, and you could see different areas where that would be important, not just on the maternity ward, but perhaps in the intensive care unit or in the pacu.

Or in the pre-operative area where you might have to ask somebody else to give a medication, and then you want to make sure that they’re giving the correct medication, the correct dose at the correct time too. The other thing I thought that this tip made me think about was just communication skills in general.

Communication skills are fundamental for anesthesia professionals. This is not just during medication administration, but also during handovers of care. This one falls back under the second A P S F priority of teamwork. I would like to mention another important resource, the Perioperative Multi-Center Handoff Collaborative, which was formed in 2015, and it is the special interest group supported by the A P S F.

The mission is to build the evidence base and implement strategies and tactics capable of eliminating unintended harms, attributable to poor communication and teamwork during perioperative handovers. The aims of the collaborative are the following. Understand the current state of perioperative handovers from all stakeholders.

Publish generalizable knowledge to advance perioperative handovers, organize and execute multi-center studies with human factors and implementation, and develop training material for medical education at the. Undergraduate, graduate and licensed practitioner levels. I will include a link for more information in the show notes as well.

[Blaine] Yeah, I think this is a really important thing to bring up here. And a lot of errors do come from handoffs. Uh, you know, we spend, you know, a couple hours with the patient in the operating room and really get to know the physiology and the procedure that the patient just have had, and then we go to hand them off to somebody else who hasn’t been with the patient for these hours and, you know, wasn’t there for every step of the procedure.

And I think. Uh, this is a time when a lot of error can be introduced. Uh, we actually worked on an electronic version of a handoff between our operating rooms and our cardiothoracic ICU. We were able to make a note and kind of a handoff checklist that was integrated into the electronic medical record and.

We are still actually collecting some data to, to look at any type of adverse events that, you know, arose before this checklist was implemented and, and after. Um, but I do think that handoffs are a, uh, an a very important time to try to reduce error when handing over a patient’s care.

[Bechtel] When you think about your handoffs, let’s say from the operating room to the PACU team, have you felt like you, they have improved over the course of your training and what was something that has helped make them better?

[Blaine] Yeah, I hope they have improved over time and I think one of the things I really try to do is similar to in med school when we were taught to, you know, ask. The review of systems questions in a head to toe manner so that you can be sure to cover all your bases. I do something similar with my anesthesia handoff to the pacu.

Um, you know, I’ll kind of go back through the procedure in a sequential order and kind of remember what we did and I’ll give that handoff in order. Uh, you know, so I will say, The IVs that the patient has, because I remember that I placed the IVs first when the patient was in pre-op, and then I’ll, we will say what kind of airway they had.

And then, because I mentioned the airway, I’ll remember this is the type of reversal that I use for their neuromuscular blockade. And then I’ll mention things, you know, like the medications that I gave for. P n v prophylaxis, and I’ll just kind of go in that sequential order. Uh, and I try to do it the same way every time.

Again, going back to one of our previous points of checklists, uh, and kind of doing things in the same manner every time. It makes it, it allows for much less mental energy to be expended. Trying to remember the order of things. If you just do it the same way every time, you don’t have to think as hard about the exact order.

Uh, and I think it makes you much less likely to forget something.

[Bechtel] I totally agree. Checklists and handovers definitely go hand in hand. Alright, and can you tell us a little bit about number seven?

[Blaine] Number seven I think is one of the more important ones, and that is, especially when you’re starting out as a new trainee, you should.

Say something if you are not comfortable with the procedure. And what I mean by this is, I think especially in med medical education, uh, we kind of have this sense as, as trainees that you want to be, you, you, you know, you want to be better, you want to be competent. And it’s really hard when you’re learning how to do all these new things and, you know, nobody wants to look like they don’t know what they’re doing.

Uh, that can, that can be uncomfortable kind of admitting. That you don’t know what you’re doing. But I think when you look at it through a lens of patient safety, it should be, it shouldn’t, it shouldn’t be hard to admit that you are not comfortable with the procedure if you have only done one central line.

Say that out loud to the attending so that they know, uh, that, you know, you might know the steps, uh, but they should remind you of every step or, you know, take extra care to, you know, kind of walk through that procedure with you. I think the worst thing you can do is. Pretend like you know what you’re doing when you might really not, and then the attending might kind of read into your body language and think that you don’t need any help.

And then, uh, I think that’s when, when errors can happen and, and harm can reach the patient.

[Bechtel] That’s a really good one. And it, and it’s hard too, I think if you keep patient safety as. One of the priorities as an anesthesia trainee and an anesthesia professional throughout your career, then it makes calling for help or saying that you’re not comfortable or.

Trying to get more information, just part of your mission, to keep patients safe and not something that reflects on your knowledge base or skill base. I think you’re absolutely right, right from the very beginning to being comfortable with saying something if you’re not comfortable and asking for help is really important.

If your goal is to keep patients safe and it should be,

[Blaine] Absolutely, and I love that you brought up the calling for help too, because I, I really, really, really, really try to think of this through a patient safety lens and that, you know, at the end of the day, it, this is not about us. This is not about our ego of not wanting to look like we don’t know what we’re doing or not calling for help.

Oh, I can take care of this myself. It’s not about us, it’s about the patient being safe and having a safe anesthetic. And so, uh, I think we should all, uh, feel comfortable asking a colleague, uh, calling for help when we need it. And like you said, if you know they, by the time someone shows up, the it’s all better.

You know that, uh, all, all the better.

[Bechtel] Absolutely. This is related to culture of safety, teamwork, and clinician safety. The A P S F covered a similar topic in February, 2022 in the article by Lynn Reed fostering a learning culture that supports a trainee’s wellness. Here is the article summary. Personal and professional wellness are the foundation of vigilant and safe perioperative practice and patient care.

Developing a comprehensive learning culture strategy for successful implementation and continuous improvement will foster clinician and trainee or learner wellbeing for patient and provider safety. Reid describes the following scenario for trainees, quote, imagine for a moment that you are a trainee student or learner from one of the many perioperative professions entering some phase of care to begin your clinical experience.

As a trainee now, or when you were a trainee, you are entering a place where your only experience other than reading about your chosen profession and perhaps shadowing for a few hours, might be a place where you or your family or friends have had a procedure that was. Filled with many unknowns. Now you are entering a very complex system, grounded in science and policy with many professional languages, traditions, and standards of care.

As a trainee, you may be concerned about how you will be perceived. You hope to be perfect and realize that in the end, perfection and looking good is just not possible. You may internalize the following questions. Will your faculty have time or interest to connect what you have learned in the classroom and simulation lab with actual practice?

Who will partner with you and how will you be supported for your personal safety and wellness so that you can learn without harming your patient or yourself? Additionally, many first days occur across a healthcare education program with changing faculty teams, specialty rotations, and new facilities, each with their own learning culture or environment, making self-efficacy and confidence even more challenging.

Does this resonate with you? We hope that you are in a training program that fosters a learning culture that supports your wellness, and we are, you are comfortable to say something if needed. Well, thank you so much to Scott for taking time out from your anesthesia training to be here on the show with us today.

Do you have anything else you want to add before we wrap up?

[Blaine] Yeah. Thanks for having me, Dr. Bechtel. This has been great. Uh, I, you know, I really try to emphasize all these points to junior residents whenever I have the chance to work with them. Uh, and as you know, in June we’ll have a, a new batch of residents coming through.

And so I think topics like all of these, uh, can go a long way to setting up a new trainee for success in their career.

[Bechtel] Absolutely, and there’s probably more tips and tricks that we missed. So if there is something else that you think we should be discussing on the Anesthesia Patient Safety Podcast, please email [email protected].

Or you can tag us on Twitter using the hashtag A P S F podcast and tagging us at AP s f org. We would love to hear from anesthesia, trainees, and anesthesia professionals on any tips and tricks that helped you right when you were starting out in your anesthesia career. Thank you so much to Scott for being with us on the show today, and good luck as you complete your anesthesia training this year.

To all of the anesthesia trainees listening to this podcast, welcome to the field of Anesthesiology. We hope that as you progress through your training, you remain committed to improving patient safety. You might be a future recipient of an A P S F research grant, or a future author of an A P S F newsletter article, and we might be talking with you right here on this podcast.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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