let's now think about phrase three so phase three treatment as it is like i mentioned is can
be pretty simple it's something that we've done regularly and it's something that we've drilled
at doing many times over the last you know decade or so let's take this kind of situation a 35 year
old female for a lap appendisectomy you're in a small suburban hospital four theaters no icu
you induce this otherwise well 30 year old with no allergies for an open appendisectomy one
minute after induction the blood pressure drops to 60 the patient is difficult to ventilate with
pressures of 40 centimeters only delivering 100 mils tidal volume so i want you to take
about a minute or so tell your partner what you would do uh given this information
um i'd be pissing a buzzer because this is a crisis uh i'll be asked to be mh sorry the
anaphylaxis trolley given the clinical scenario that'll be my number one diagnosis sounds good
i'd stabilize the patient by giving a small dose of metaraminol and giving 500 mils of crystalloid
and asking for the anaphylaxis box and then decided roles as for the anaphylaxis cards
that's good and i want you to keep going let's say you do that blood pressure for next cycle is
17 cycle after that is 50. you instituted the management you've said what would you do next
uh then i'm going to try and rule out other causes of potential differentials as well but
i'll be assigning tasks to try and stabilize the blood pressure by getting someone to try
and get lines in yeah but also drawing out the journal and saying the general intuition
what i'm going to try and give attention to here is um the fact that i think we all we've all heard
of crm uh you know crm is all of the non-technical skills uh required for effective teamwork in a
crisis and i think you know this is something that i you know i started medicine medical training in
the year 2000 i hadn't heard about this until i was a fourth year anaesthetic trainee in 2012
and the funny thing is now i think it's just you know the most important thing that i know is is
crm it's also something that's being more tested in you know examinations in the sim sessions that
we run and i expect that it will be something that will be examined in the vivers in some in some
method so how can you assess this in the viva if you remember the crm principles it reminds you to
mention key management points in your answer and i'll also go through this concept that of you know
of linear versus parallel parallel management threads which really help in not only just
highlighting the points of difference of a crisis and the priorities in groups of a crisis but also
helps you allocate you know allocate people to above roles in real life so crisis resource
management so i think you mentioned quite a few of these things in your answer as well which is which
is great so calling for help early participating planning setting priorities dynamically leadership
teamwork communicate effectively use all available information you're getting that anaphylaxis box
allocating attention wisely distributing the workload mobilizing resources cognitive aids
re-evaluating managing fixation errors knowing the environment cross-checking so obviously these are
a whole bunch of words and i you know i really hate just words for no reason so if we move this
into into an actual practical way of doing this i feel like there's a lot of things that we can add
to crisis management when we explain especially reviver to come across sounding very real life
and very organized so phase one very similar this is very concerning figuring on the pulse
scanning the patient surgery monitors i confirm the reading and i love that you actually said
look this is most likely anaphylaxis i'm going to call for help straight away because that's really
fair blood pressure 60 difficult ventilation that is anaphylaxis unless proven otherwise
phase two is pretty much already done you call from the naphtha anaphylaxis box and just state
what you're going to be doing again you're allowed to make these assumptions and progress through the
plan and the it's really the examiner's job to say that actually no the blood pressure
has result resolved it's completely fine if it's not anaphylaxis it's your it's their job to make
you see that so i'm very happy that you called in netflix and started managing it what i then
suggest is to state my priorities my priorities are ceasing the trigger oxygenation volume
recess adrenaline and maybe lines and other things acting as leader i allocate my team to these tasks
i then try to complete a story for each priority and just realize that whenever i've examined
people in crises crises seem like a very big deal but when you break it up into the different
priorities they're really just telling a story about each threat of management you know in that
parallel fashion for example oxygenation is really intubated if they're not intubated oxygenate 100
oxygen hand ventilate you know adjust your pressure control and your eye erosion
ratios to something that's reasonable and give ventilate adrenaline reassess
adrenaline is 50 to 100 mic boluses repeatedly re-evaluating and then starting an infusion with
three milligrams and 50 mils of dextrosal saline and running an infusion at you know 10 to 20 mics
per minute fluid is two liter stat reassessing putting a line in and pumping that in and giving
more fluid as required knowing that they can drop two liters extra for sale in the first ten minutes
and access so and so on i then check these task cards real value repeatedly
ask for a second opinion ensure nothing is missed and avoid fixation errors and then mindful of
the resources of the hospital call out retrieval service now this is obviously a lot of words that
i've said but i'm really just doing this i've got my crm principles on the left-hand column there
which are all a great bunch of words but they're just words but practically speaking what are the
actions that i'm going to say in real life or say in the vibe and do in real life and all of
them are quite common you know you always press the emergency buzzer or get help you lead the
situation you allocate staff to roles it's just what we do um there's there's always some kind of
cognitive aid or box or trolley for whatever situation you have so i would mobilize that
because that's exactly what you do in real life it's a it's a thing it's an ask a document
and you know if anything i know about the college they they love their documents so why not mention
what they put so much effort into and what is really worthwhile i then confer with a colleague
for a second opinion and i think about where i'm going do i need a call for a retrieval in a
hospital that's small um do i need a call for ecmo do i need to call for more dantrilling supplies
whatever it is you can think about that i want you to pay particular attention to the fact that
the theme of this whole series of lectures was that we want to look at the point of difference
and that's and i'd argue that everything is roughly the same except for stating these
multiple priorities so this section here that is a big deal so stating the multiple priorities will
be the point of difference of all the different crises you have and each of those priorities
will allow you to tell a full story the other thing that i've experienced when i examine
people on crises is that they're not sure how far to go with each story like how much do you
offer with adrenaline i'd just say that to give more information quickly is a lot quicker than
to give some information and wait so you could say i'd give 50 mikes of adrenaline and pause
wondering what to say next or you could in two seconds say i'd give repeated 50 microgram boluses
reassess start an infusion of three milligrams and 50 mls titrated to whatever the blood pressure is
done you know it doesn't take any more effort than a few extra seconds to just get it out and
it sounds professional sounds proficient sounds very polished to do so so i'd encourage you to
tell a full story of each priority or each parallel thread do the same thing with this
you