so this is one of my favorite topics it's obviously a really big topic
um and i remember one of the jokes the uh one of my consultants used to ask me during vive training
was where's the most dangerous place in this size someone causes survivor because everyone seems to
arrest or have some kind of catastrophe so crisis management what i really love about this is uh so
this took me a while to really come up with but i i found that this three-phase kind of approach
really really helped me to talk through any part of the viva so the crisis can be
a real massive spectrum of presentations and questions of survivor and so take take from
this talk what you will these three phases can be interchanged any different part of the exam that
you might get so crisis management framework a crisis occurs or some kind of problem occurs phase
one is really just safety and optimization to kind of get you into into the realm of talking safely
about something phase two is about the cause and phase three is treatment often a lot of these will
happen simultaneously but it doesn't mean that you can't have a structured approach to this as well
so there's a lot of problems with crises in survivor and i think we've all if we've done vivas
in the past we could we've all seen how this happens you don't have all the visual cues it's
easy to forget some small details whilst you're trying to say and describe and consider and manage
everything so you know it can be really tricky and examiners may pick on something that you think is
pretty minor and that you would have obviously done so it's really hard to mind read what
the examiner is thinking plus show everything that you do in a complex situation when in real
life you'd be in that situation managing it but the good thing is that it isn't real uh it isn't
real the skills you have are what you say you have so you may be completely terrible at putting out
lines or central lines or managing a crisis but it doesn't matter because you can fake it in this
in this exam so what i think is the right method and approach can solve any problem and you know
one of those things if you can fake the language that i'll hopefully give you here um it will i
think it'll really help you to you know actually practice this in real life as well that said
you may have your own method so please you know this is only this is my approach it's completely
non-evidence-based but just really helps me to talk through the complexity of what happens in the
vibe but also real life so please um you know take it for what it is it's just really just opinion
now just to start off with some tips so examiners so again uh when i came up with this course over
the years i talk to examiners a lot about what they want and what they what they're really
examining on and one of one of the examiners who i asked about crisis in particular said the
examiners want to test you on small changes so just to know that not everything is a crisis a
small change in blood pressure isn't a crisis it isn't particularly stressful it happens every day
in almost you know every patient they get a lot more out of small change than what you do with
small deviations from normality than a complete arrest think about what that means this whole time
i've been talking about what is normal and what is um you know not a point of difference or not
discriminative between candidates if you put if you arrest every single patient that's just als
guidelines and that's very easy to follow but if you make subtle changes with with a certain amount
of nuance and you know a lack of an arrest then it differentiates between people's decision-making
far better than something that's a guideline if something is a crisis it is important to say so
but also if it isn't a crisis you can vary your phrasing to reflect the urgency so you know just
just again get comfortable using different words to make things not a cliche this is an emergency
there's a crisis this is concerning this is troubling i'm generally worried about this
and try to vary a phrasing as it happens to you in real life um in this fiber so the first phase
let's let's talk about this case uh 61 ml nil past history mesa allergies 10 minutes into the carotid
endotherectomy the patient becomes hypertensive at 200 millimeters mercury my i recognize this
as concerning blood pressure in this situation my um immediate management is to confirm the reading
and communicate to the surgeons i confirm the reading by looking at the transducer and
transducer and flushing the arterial line a temporary situation by policing uh checking the
airway confirming that confirming my monitors entire co2 et cetera and bolstering a um
protocol red invention uh which is what i'd like to be using for mine yeah fantastic so again you
said a lot of really important things there and i just want to highlight this this is definitely
a bit of a statement that i say so take from it what you will that's relevant to each situation a
few things are probably often always relevant um so i've just said with a finger on the pulse if
something's really dire like you know perio rest i'd probably want to have a finger on the pulse
just to make sure that i can always be identifying and arrest and then proceed with als if that's
irrelevant that's often not going to be something you do so just take that with a grain of salt
i always want to say something along the lines i'm scanning the patient the surgery and all monitors
or my environment i'm scanning that because that's what you would do in real life and i've had that
instance where someone says oh well you know you didn't say that you looked at the co2 and so i
think it's really great to be able to just go i'm broadly looking and doing a general inspection of
the environment um again i really like that you said confirm the reading like you know a lot of
our ability to detect problems is to you know read our monitors and our monitor simply monitors and
they're as good as um the you know the i guess the the accuracy of of the of their reading so
if your transducers fall in this situation or if your pulse oximeter is is shaking or your
end tile is lost because of a blockage you really aren't treating the right thing so you absolutely
need to confirm that reading and that's what i was getting at with this particular situation
i then you know at different levels of you know if you're a really junior person you'd
call for help straight away but as you get more senior you probably one of the things
that will come up is you may feel like you need to call for help when the blood pressure goes
to 80 on a normal induction so you know just to reflect on that and realize that you know
chances are you probably won't call for help until something is actually really dire
in your you know in your senior practice now and to just appreciate that realism
i like the fact that you said temporize i think that's always the next step you've
you know you scanned everything you've confirmed the reading you've sent the help if relevant
and most of us will temporize measures or optimize i've called here but temporised with a bit of
fluid and aramine or a bit of profile and remy or paralysis and bag bag ventilation and increasing
the oxygen so we do some very familiar steps that are very real and i would always talk through
this because that's exactly what i do in real life and that's what the examiner is asking me
um i then assess the patient and treat so phase one is simply just getting quickly
through these and i wouldn't take much more than a few seconds to get through this because again
they're not they're not necessarily points that differentiate you from other candidates
um but i think they're absolutely necessary because that's what i do in real life so
i can't like you know i can't fake this by not mentioning it so phase two is the cause again
this can this can occur in isolation and often occurs simultaneously i'm talking about causes
as i'm differentiating things as well as managing each cause that i go through but just to break it
up and just to give you a bit of a suggestion on how to really you know tackle causes and how to
talk to through them really efficiently to get to the point that the examiners want to get to i've
just got this this approach um anyway so let's go through this a 60 year old male heavy smoker
with copd from emergency laparotomy desaturates during the case what do you think is causing this
i think that this could be a multi-factorial cause um however moving methodically
um there's potential for reversible uh bronchostasis so a ocuspastic component
they could have atelectasis and basal collapse during their laparotomy
and in addition to that there could be increased plugging and mucous formation in the presence of
being an atmosphere yeah that's good and you gave me a really real a real answer right so
the stuff that you mentioned is literally what would happen time and time again day in day
out for a copd patient having hypoxemia now so what i'd say is that you've done
you know in the first part we talk about systematic categorized answers but these
are slow and i think in real life so you know this is an exam of real life in real life experts use
probability gambits um but we can combine that with a systematic exclusion of differentials and
this would be born out in a lot of the um in know crisis management literature out there so so i
would say something pretty similar to you i would preface it with the these phrases but i think this
is most likely x so the serious differentials i must rule out are these and you're likely
to show a lot of clinical acumen by doing those first two statements but if you're wrong if the
examiner isn't satisfied by that you can always go through your systematic review or differential
if you're prompted to so in that example i could have gone yep great it's probably bronchospasm you
auscultate the lungs let's go let's manage it or maybe i'm unsatisfied with what you've said
and i'll just be like and and what else and what else then you can take a step back and you can go
okay so you're not happy with my this is most likely you're not happy that i've looked at all
the really serious stuff that obviously i need to rule out urgently great hypoxemia can be fi
hyperventilation shunt bq mismatch or diffusion abnormality the detail of these that i'll rule out
systematically is blah blah blah so i'm trying to get you to have your cake in here in a sense that
you can get to the answer quickly but again like everything else we get to the point of difference
but we also are able to give the full gamut of a completely systematic and thorough answer
if required but i suspect that most of the time the survivor you will get through with that
with that point of difference that critical you know the critical issue or the most likely
diagnosis um someone in the chat just asked about that the phrase simultaneously diagnose and treat
and everything i know about examiners you you that is definitely a true statement that you do that
um but i'd say that you could now because that's the thing that's said so often it's a thing that's
known it's a thing that everyone understands that we do i'd say that that's probably just a waste of
words is my personal opinion because if you were to say i would simultaneously diagnose and treat
you could save the time by saying for this hypoxia i'm going to rule out bronchospasmo
you know i check the circuit auscultate the lungs if there's any bronchoscopes and treat with
el ventilline atrovent and you can just you know you can literally do the simultaneous diagnosing
and treating without actually needing to say the words simultaneously diagonalism treats so
my opinion probably don't need to say it probably a waste of breath if you're really
if you're really smooth with this kind of crisis management talk you'll end up
doing exactly what you said you're going to do without using those extra words
quick summary crisis occurs your phase one is safety and optimization or temporarization steps
so you check your reading doctor's abcs your phase two is phrased literally it is most likely this
the serious differentials i must rule are these and if the examiner is unhappy or unsatisfied with
those differentials then i can go through my whole list of stuff and you'll learn in your workbooks
i've i've just got my tables that i've listed of all the different common problems that i'd see
and i think the biggest part of that was to just write out my own table so you know you can you
know obviously you can use those tables i i found it really useful to to to have those but i reckon
you know everyone's got a slightly different way of thinking about these problems and so i think
one of the great biggest things i did for this exam was to actually draw the tables up myself
so i've processed the table and made decisions about how i categorize things
and how i diagnose and approach things so i'd say use the tables but drop your own tables as well
and yeah make it make it your own phase three which we'll go through is treatment for the next
exercise let's go through some diagnostics so this occurs a 24 year old for appendisectomy the blood
pressure is say maybe 80 is a bit bit higher than maybe a bit too normal let's go with the
blood pressure 70 post induction and you do a very standard deduction with 200 profile 100 of sucks
for this otherwise fit fit person and say 100 or 200 of fentanyl blood pressure is 70 post
induction you would do all the normal things which we won't need to go through but definitely in your
practice practice though so you know finger on the pulse i just scan my monitors my surgeon
the patient uh check my reading maybe recycle the blood pressure and give some fluid and
aramine as temporarization steps and then i think this is you know go through your
diagnosis this is hypertension most likely post reduction these differentials are must roll out
septic shock yeah sounds good and that's good if it's directly post-induction i completely agree
with you it's most likely to the anesthetic agents and imagine yourself in the viber
you don't want to get into that pattern of over calling everything you know just un
just be very comfortable in thinking that this is probably normal i would temporize things and
then i would look for other bad things and that's probably what you do in real life
on the second cycle of that blood pressure and depending on what what part of the surgery it is
it's anything from anaphylaxis sepsis to lap cord injury those are the really bad things i want to
look at and if i'm wrong about those if the if the examiner is unsatisfied i've got all my causes of
hypertension take whatever classification you want preload rate rhythm contractility afterload or
distributive obstructive cardiogenic hypovolemic shock classifications whatever you want at least
you've got your backup if you're wrong about those two let's try the next one 40 year old patient for
a lap collie becomes tachycardic on incision so my first thought will be that this is erection to
the pain and i will give the anastasia and if the patient doesn't respond consider other possible
diagnosis like anaphylaxis or electrolyte disturbances hypovolemia okay good so again
i think most of us would agree this either pain or light anesthesia pretty common uh but i really
care about ruling out things like anaphylaxis or you know have they gone into some kind of svt or
vt depending on how fast the heart rate is again in that situation you have a lot of indicators but
being able to go straight to what's really bad about this situation is vital good next one you